2024 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2024 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Anthem I Carelon Medicare Advantage (HMO) (H4161-011-0) Benefits & Contact Info 
 all covered insulin pay $35 or less | ||||||
| This plan is available in Los Angeles County, CA Click on a letter below to view the Anthem I Carelon Medicare Advantage (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 | ||||||
| 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 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand: | $30.00 | $35.00 | $30.00 | $90.00 | $105.00 | $60.00 |
| Tier 4: Non-Preferred Drug: | $85.00 | $95.00 | $85.00 | $255.00 | $285.00 | $170.00 |
| Tier 5: : | 33% | 33% | 33% | n/a | n/a | n/a |
| Tier 6: : | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $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) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) |
| Tier 2: Generic: | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) |
| Tier 6: : | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(A) | $0.00(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 | ||||||
| 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. (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 Anthem I Carelon Medicare Advantage (HMO) 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 | ||||||