2022 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Brandman Health Plan (Arise) (HMO C-SNP) (H7594-001-0) Benefit Details select insulin coverage $35 or less | ||||||
This plan is available in Los Angeles County, CA Click on a letter below to view the Brandman Health Plan (Arise) (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 MAPD plan may offer some forms of insulin as part of the
Senior Savings Model.
The Senior Savings Model stipulates that participating insulins will cost no more than $35
in the deductible, initial coverage, and coverage gap phases of your MAPD plan.
The Medicare provided information below reflects the normal cost-sharing, NOT the $35 copay. Please contact the drug plan for more details. | ||||||
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 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Tier 2: Generic: | $9.00 | $9.00 | $9.00 | $27.00 | $27.00 | $18.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $90.00 |
Tier 4: Non-Preferred Drug: | $90.00 | $90.00 | $90.00 | $270.00 | $270.00 | $270.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $0.00 | $0.00 | $0.00 | $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) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) |
Tier 2: Generic: | $9.00(A) | $9.00(A) | $9.00(A) | $27.00(A) | $27.00(A) | $18.00(A) |
Tier 6: Select Care Drugs: | $0.00(A) | $0.00(A) | $0.00(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 $3.95 | 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 | ||||
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 Brandman Health Plan (Arise) (HMO C-SNP) 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 |