2019 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Moda Health HMO Enhanced + RX (HMO) (H8506-003-0) Benefit Details | ||||||
This plan is available in Lake County, OR Monthly Premium: $203.00 Rx Deductible: $120 Initial Coverage Limit: $3,820 Click on a letter below to view the Moda Health HMO Enhanced + RX (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 | ||||||
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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $2.00 | $2.00 | n/a | $6.00 | $6.00 | $6.00 |
Tier 2: Generic: | $20.00 | $20.00 | n/a | $60.00 | $60.00 | $60.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | n/a | $135.00 | $135.00 | $135.00 |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | n/a | $300.00 | $300.00 | $300.00 |
Tier 5: Specialty Tier: | 30% | 30% | 30% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 63% Generic and 75% Brand Donut Hole Discount applies | ||||||
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 | ||||
Go to the Moda Health HMO Enhanced + RX (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 |