2023 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Texas Independence Health Plan, Inc. (HMO I-SNP) (H5015-001-0) Benefit Details all covered insulin pay $35 or less | ||||||
This plan is available in Live Oak County, TX Click on a letter below to view the Texas Independence Health Plan, Inc. (HMO I-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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | 25% | 25% | 25% | 25% | 25% | 25% |
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 $4.15 | The greater of 5% or $4.15 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $10.35 | The greater of 5% or $10.35 | ||||
Go to the Texas Independence Health Plan, Inc. (HMO I-SNP) 2023 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 |