2024 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
EmblemHealth VIP Dual (HMO D-SNP) (H5991-012-2) Benefits & Contact Info all covered insulin pay $35 or less | ||||||
This plan is available in Albany County, NY Click on a letter below to view the EmblemHealth VIP Dual (HMO D-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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 2: Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 6: : | $5.00(E) | $5.00(E) | $5.00(E) | $15.00(E) | $15.00(E) | $15.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $15.00 |
Tier 2: Generic: | $12.00 | $12.00 | $12.00 | $36.00 | $36.00 | $36.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
Tier 4: Non-Preferred Drug: | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $300.00 |
Tier 5: : | 25% | 25% | 25% | n/a | n/a | n/a |
Tier 6: : | $5.00 | $5.00 | $5.00 | $15.00 | $15.00 | $15.00 |
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 | ||||||
All Formulary Drugs: |
$0 cost-sharing. The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||
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 EmblemHealth VIP Dual (HMO D-SNP) 2024 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 |