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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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Optima Medicare Value (HMO) (H2563-008-0) Benefit Details 
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| This plan is available in Fairfax County, VA Monthly Premium: $0.00 Rx Deductible: $150 Initial Coverage Limit: $4,020 Click on a letter below to view the Optima Medicare Value (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 | ||||||
| Tier 1: : | $0.00(E) | $0.00(E) | n/a(E) | $0.00(E) | $0.00(E) | $0.00(E) |
| Tier 2: : | $12.00(E) | $12.00(E) | n/a(E) | $36.00(E) | $36.00(E) | $0.00(E) |
| Tier 3: : | $47.00(E) | $47.00(E) | n/a(E) | $141.00(E) | $141.00(E) | $117.50(E) |
| 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 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: : | $12.00 | $12.00 | n/a | $36.00 | $36.00 | $0.00 |
| Tier 3: : | $47.00 | $47.00 | n/a | $141.00 | $141.00 | $117.50 |
| Tier 4: : | $95.00 | $95.00 | n/a | $285.00 | $285.00 | $237.50 |
| Tier 5: : | 27% | 27% | n/a | 27% | 27% | 27% |
| 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 | ||||
| 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. | ||||||
| Go to the Optima Medicare Value (HMO) 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 | ||||||