2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
UPMC for Life Dual (HMO D-SNP) (H4279-001-0) Benefit Details | ||||||
This plan is available in Adams County, PA Monthly Premium: $35.60 Rx Deductible: $435 Initial Coverage Limit: $4,020 Click on a letter below to view the UPMC for Life Dual (HMO D-SNP) 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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $2.00 | $9.00 | n/a | $4.00 | $27.00 | $4.00 |
Tier 2: : | $8.00 | $15.00 | n/a | $16.00 | $45.00 | $16.00 |
Tier 3: : | $10.00 | $17.00 | n/a | $25.00 | $51.00 | $25.00 |
Tier 4: : | 46% | 46% | n/a | 46% | 46% | 46% |
Tier 5: : | 25% | 25% | 25% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
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 $3.60 | The greater of 5% or $3.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.95 | The greater of 5% or $8.95 | ||||
Go to the UPMC for Life Dual (HMO D-SNP) 2020 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 |