2022 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Medicare Advantage HMO (HMO) (H8095-001-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in Shelby County, IA Click on a letter below to view the Blue Medicare Advantage HMO (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 | ||||||
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 | $10.00 | $2.00 | $0.00 | $30.00 | $6.00 |
Tier 2: Generic: | $10.00 | $20.00 | $8.00 | $22.00 | $52.00 | $24.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $49.00 | $109.00 | $139.00 | $111.00 |
Tier 4: Non-Preferred Drug: | $100.00 | $100.00 | $100.00 | $290.00 | $290.00 | $290.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | 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 $3.95 | The greater of 5% or $3.95 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $9.85 | The greater of 5% or $9.85 | ||||
Go to the Blue Medicare Advantage HMO (HMO) 2022 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 |