2020 Medicare Advantage Plan Prescription Drug Cost-Sharing Details

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2020 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Peoples Health Choices Value (HMO) (H1961-018-0)
Benefit Details        
This plan is available in Acadia Parish, LA

Monthly Premium: $0.00
Rx Deductible: $300
Initial Coverage Limit: $4,020


Click on a letter below to view the
Peoples Health Choices Value (HMO) Formulary
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  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
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: : $10.00(E) $10.00(E) n/a(E) $30.00(E) $30.00(E) $0.00(E)
Tier 3: : $45.00(E) $45.00(E) n/a(E) $135.00(E) $135.00(E) $135.00(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: : $10.00 $10.00 n/a $30.00 $30.00 $0.00
Tier 3: : $45.00 $45.00 n/a $135.00 $135.00 $135.00
Tier 4: : $100.00 $100.00 n/a $300.00 $300.00 $300.00
Tier 5: : 27% 27% n/a 27% 27% 27%
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) $0.00(A) n/a $0.00(A) $0.00(A) $0.00(A)
Tier 2: : $10.00(A) $10.00(A) n/a $30.00(A) $30.00(A) $0.00(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.
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