2021 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Triple S Platino Ultra (HMO D-SNP) (H5774-025-0) Benefit Details | ||||||
This plan is available in Gurabo County, PR Monthly Premium: $0.00 Rx Deductible: $445 Initial Coverage Limit: $4,130 Click on a letter below to view the Triple S Platino Ultra (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: Preferred Generic: | $14.00 | $19.00 | n/a | $28.00 | $38.00 | $28.00 |
Tier 2: Generic: | $15.00 | $20.00 | n/a | $30.00 | $40.00 | $30.00 |
Tier 3: Preferred Brand: | $42.00 | $47.00 | n/a | $84.00 | $94.00 | $84.00 |
Tier 4: Non-Preferred Brand: | $95.00 | $100.00 | n/a | $190.00 | $200.00 | $190.00 |
Tier 5: Specialty Tier: | 25% | 25% | n/a | 25% | 25% | 25% |
Tier 6: Select Care Drugs: | $2.00 | $6.00 | n/a | $4.00 | $12.00 | $4.00 |
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 $3.70 | The greater of 5% or $3.70 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.20 | The greater of 5% or $9.20 | ||||
Go to the Triple S Platino Ultra (HMO D-SNP) 2021 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 |