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2023 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2023 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Triple S Optimo Plus (PPO) (H4005-004-0) Benefit Details 
 all covered insulin pay $35 or less | ||||||
| This plan is available in Aibonito County, PR Click on a letter below to view the Triple S Optimo Plus (PPO) 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 | $5.00 | n/a | $0.00 | $10.00 | $0.00 |
| Tier 2: Generic: | $0.00 | $8.00 | n/a | $0.00 | $16.00 | $0.00 |
| Tier 3: Preferred Brand: | $25.00 | $40.00 | n/a | $50.00 | $80.00 | $50.00 |
| Tier 4: Non-Preferred Brand: | $40.00 | $55.00 | n/a | $80.00 | $110.00 | $80.00 |
| Tier 5: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | 33% |
| Tier 6: Select Care Drugs: | $0.00 | $3.00 | n/a | $0.00 | $6.00 | $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) | $5.00(A) | n/a | $0.00(A) | $10.00(A) | $0.00(A) |
| Tier 2: Generic: | $0.00(A) | $8.00(A) | n/a | $0.00(A) | $16.00(A) | $0.00(A) |
| Tier 6: Select Care Drugs: | $0.00(A) | $3.00(A) | n/a | $0.00(A) | $6.00(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 $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 Triple S Optimo Plus (PPO) 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 | ||||||