2023 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Geisinger Gold Classic Essential Rx (HMO) (H3954-161-0) Benefit Details all covered insulin pay $35 or less | ||||||
This plan is available in Montour County, PA Click on a letter below to view the Geisinger Gold Classic Essential Rx (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* | |
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: | $3.00 | $3.00 | $0.00 | $7.50 | $7.50 | $0.00 |
Tier 2: Generic: | $20.00 | $20.00 | $0.00 | $50.00 | $50.00 | $0.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $117.50 | $117.50 | $70.50 |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | $100.00 | $250.00 | $250.00 | $150.00 |
Tier 5: Specialty Tier: | 33% | 33% | n/a | n/a | n/a | n/a |
Tier 6: Vaccines: | $0.00 | $0.00 | n/a | n/a | n/a | n/a |
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: | $3.00(A) | $3.00(A) | $0.00(A) | $7.50(A) | $7.50(A) | $0.00(A) |
Tier 6: Vaccines: | $0.00(A) | $0.00(A) | n/a | n/a | n/a | n/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 $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 | ||||
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 Geisinger Gold Classic Essential Rx (HMO) 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 |