2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Aetna Medicare Premier Plan (PPO) (H5521-077-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in Broome County, NY Monthly Premium: $0.00 Rx Deductible: $200 Initial Coverage Limit: $4,020 Click on a letter below to view the Aetna Medicare Premier Plan (PPO) 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: : | $0.00(E) | $15.00(E) | $0.00(E) | $0.00(E) | $45.00(E) | $0.00(E) |
Tier 2: : | $10.00(E) | $20.00(E) | $10.00(E) | $25.00(E) | $60.00(E) | $25.00(E) |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
Tier 2: : | $10.00 | $20.00 | $10.00 | $25.00 | $60.00 | $25.00 |
Tier 3: : | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
Tier 4: : | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $300.00 |
Tier 5: : | 29% | 29% | 29% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | $0.00(A) | $15.00(A) | $0.00(A) | $0.00(A) | $45.00(A) | $0.00(A) |
Tier 2: : | $10.00(A) | $20.00(A) | $10.00(A) | $25.00(A) | $60.00(A) | $25.00(A) |
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 | ||||
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 Aetna Medicare Premier Plan (PPO) 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 |