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2021 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2021 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Heart & Diabetes (HMO C-SNP) (H3815-010-0) Benefit Details 
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| This plan is available in Los Angeles County, CA Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $4,130 Click on a letter below to view the Heart & Diabetes (HMO C-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* | |
| 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: Preferred Generic: | $0.00 | $7.00 | $0.00 | $0.00 | $7.00 | $0.00 |
| Tier 2: Generic: | $5.00 | $12.00 | $5.00 | $15.00 | $22.00 | $12.50 |
| Tier 3: Preferred Brand: | $30.00 | $37.00 | $30.00 | $90.00 | $97.00 | $75.00 |
| Tier 4: Non-Preferred Drug: | $75.00 | $82.00 | $75.00 | $225.00 | $232.00 | $187.50 |
| Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs: | $5.00 | $5.00 | $5.00 | $0.00 | $0.00 | $0.00 |
| 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: | $0.00(A) | $7.00(A) | $0.00(A) | $0.00(A) | $7.00(A) | $0.00(A) |
| Tier 6: Select Care Drugs: | $5.00(A) | $5.00(A) | $5.00(A) | $0.00(A) | $0.00(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 $3.70 | 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 Heart & Diabetes (HMO C-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 | ||||||