2019 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
PacificSource Medicare Essentials Rx 21 (HMO) (H3864-021-0) Benefit Details | ||||||
This plan is available in Bingham County, ID Monthly Premium: $75.00 Rx Deductible: $300 Initial Coverage Limit: $3,820 Click on a letter below to view the PacificSource Medicare Essentials Rx 21 (HMO) Formulary A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $3.00(E) | $8.00(E) | $3.00(E) | $9.00(E) | $24.00(E) | $6.00(E) |
Tier 2: Generic: | $12.00(E) | $17.00(E) | $12.00(E) | $36.00(E) | $51.00(E) | $24.00(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 6: Select Care Drugs: | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $3.00 | $8.00 | $3.00 | $9.00 | $24.00 | $6.00 |
Tier 2: Generic: | $12.00 | $17.00 | $12.00 | $36.00 | $51.00 | $24.00 |
Tier 3: Preferred Brand: | $37.00 | $47.00 | $37.00 | $111.00 | $141.00 | $74.00 |
Tier 4: Non-Preferred Drug: | 31% | 33% | 31% | 31% | 33% | 31% |
Tier 5: Specialty Tier: | 27% | 27% | 27% | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing 63% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 3: Preferred Brand: | $37.00(P) | $47.00(P) | $37.00(P) | $111.00(P) | $141.00(P) | $74.00(P) |
Tier 6: Select Care Drugs: | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) |
All Formulary Generic Drugs: | 37% | 37% | 37% | 37% | 37% | 37% |
All Formulary Brand-Name Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.40 | The greater of 5% or $3.40 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.50 | The greater of 5% or $8.50 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the PacificSource Medicare Essentials Rx 21 (HMO) 2019 Formulary Browser by choosing a letter below: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z 0-9 |