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2019 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2019 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Apollo @ Home Constellation Health (HMO) (H8266-004-0) Sanctioned Plan 
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| This plan is available in Toa Baja County, PR Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $3,820 Click on a letter below to view the Apollo @ Home Constellation Health (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* | |
| This plan does not have an Initial Deductible: | n/a | n/a | n/a | n/a | n/a | n/a |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Generic: | $5.00 | $5.00 | n/a | $15.00 | $15.00 | $15.00 |
| Tier 2: Preferred Brand: | $40.00 | $40.00 | n/a | $120.00 | $120.00 | $120.00 |
| Tier 3: Non-Preferred Brand: | $75.00 | $75.00 | n/a | $225.00 | $225.00 | $225.00 |
| Tier 4: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 33% |
| 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 1: Generic: | $5.00(A) | $5.00(A) | n/a | $15.00(A) | $15.00(A) | $15.00(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. (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 Apollo @ Home Constellation Health (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 | ||||||