2021 Medicare Advantage Plan Prescription Drug Cost-Sharing Details

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2021 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
SOLIS SPF 002 (HMO D-SNP) (H0982-002-0)
Benefits & Contact Info        
This plan is available in Miami-Dade County, FL

Monthly Premium: $30.80
Rx Deductible: $0
Initial Coverage Limit: $4,130


Click on a letter below to view the
SOLIS SPF 002 (HMO D-SNP) 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*
This plan does not have an Initial Deductible:n/an/an/an/an/an/a
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: 0% 0% n/a 0% 0% 0%
Tier 2: Generic: 0% 0% n/a 0% 0% 0%
Tier 3: Preferred Brand: 0% 0% n/a 0% 0% n/a
Tier 4: Non-Preferred Brand: 25% 25% n/a 25% 25% n/a
Tier 5: Specialty Tier: 25% 25% n/a n/a n/a n/a
Tier 6: Supplemental Drugs: 0% 0% n/a 0% 0% 0%
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: Preferred Generic: 0%(A) 0%(A) n/a 0%(A) 0%(A) 0%(A)
Tier 2: Generic: 0%(A) 0%(A) n/a 0%(A) 0%(A) 0%(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 $3.70 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
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(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 SOLIS SPF 002 (HMO D-SNP) 2021 Formulary Browser by choosing a letter below:
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