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2020 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Security Blue HMO-POS Standard (HMO-POS) (H3957-045-1) Benefit Details 
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| This plan is available in Allegheny County, PA Monthly Premium: $200.50 Rx Deductible: $0 Initial Coverage Limit: $4,020 Click on a letter below to view the Security Blue HMO-POS Standard (HMO-POS) 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: : | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: : | $13.00 | $13.00 | n/a | $39.00 | $39.00 | $32.50 |
| Tier 3: : | $44.00 | $44.00 | n/a | $132.00 | $132.00 | $110.00 |
| Tier 4: : | $100.00 | $100.00 | n/a | $300.00 | $300.00 | $250.00 |
| Tier 5: : | 33% | 33% | 33% | 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 Security Blue HMO-POS Standard (HMO-POS) 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 | ||||||