This is archive material for research purposes. Please see
PDPFinder.com or
MAFinder.com for current plans.
2022 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2022 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
|
Align Connect (HMO C-SNP) (H3274-003-0) Benefit Details 
 | ||||||
| This plan is available in Los Angeles County, CA Click on a letter below to view the Align Connect (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 | ||||||
| 30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
| Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $2.00(E) | $2.00(E) | $2.00(E) | $6.00(E) | $6.00(E) | $6.00(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% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $2.00 | $2.00 | $2.00 | $6.00 | $6.00 | $6.00 |
| Tier 2: Generic: | $15.00 | $15.00 | $15.00 | $45.00 | $45.00 | $45.00 |
| Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $135.00 |
| Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | $95.00 | $285.00 | $285.00 | $285.00 |
| Tier 5: Specialty Tier: | 25% | 25% | 25% | 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 | ||||
| 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 Align Connect (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 | ||||||