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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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Kaiser Permanente Senior Advantage Hawaii Island (HMO) (H1230-014-0) Benefit Details 
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| This plan is available in Hawaii County, HI Monthly Premium: $196.00 Rx Deductible: $445 Initial Coverage Limit: $4,130 Click on a letter below to view the Kaiser Permanente Senior Advantage Hawaii Island (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: Preferred Generic: | $6.00(E) | $6.00(E) | $6.00(E) | $18.00(E) | $18.00(E) | $12.00(E) |
| Tier 2: Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 6: Vaccines: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $6.00 | $6.00 | $6.00 | $18.00 | $18.00 | $12.00 |
| Tier 2: Generic: | $20.00 | $20.00 | $20.00 | $60.00 | $60.00 | $40.00 |
| Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $94.00 |
| Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $200.00 |
| Tier 5: Specialty Tier: | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 6: Vaccines: | $0.00 | $0.00 | n/a | n/a | n/a | n/a |
| 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 | ||||
| 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 Kaiser Permanente Senior Advantage Hawaii Island (HMO) 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 | ||||||