2011 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Medicare Plus Blue PPO Assure (PPO) (H9572-003-1) Benefit Details | ||||||
This plan is available in Allegan County, MI Click on a letter below to view the Medicare Plus Blue PPO Assure (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: : | $3.00 | $3.00 | $3.00 | $7.50 | $9.00 | $7.50 |
Tier 2: : | $40.00 | $40.00 | $40.00 | $100.00 | $120.00 | $100.00 |
Tier 3: : | $95.00 | $95.00 | $95.00 | $237.50 | $285.00 | $237.50 |
Tier 4: : | 25% | 25% | 25% | n/a | n/a | n/a |
Tier 5: : | 25% | 25% | n/a | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 7% Generic and 50% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | ||||||
All Formulary Generic Drugs: | 93% | 93% | 93% | 93% | 93% | 93% |
All Formulary Brand-Name Drugs: | 50% | 50% | 50% | 50% | 50% | 50% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.50 | The greater of 5% or $2.50 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.30 | The greater of 5% or $6.30 | ||||
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 Medicare Plus Blue PPO Assure (PPO) 2011 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 |