2011 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
AmeriHealth Rx Option II (PDP) (S2321-002-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 6 which includes: PA WV Click on a letter below to view the AmeriHealth Rx Option II (PDP) 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 |
|||||
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: Tier 1: | $5.00 | $5.00 | n/a | $15.00 | $15.00 | $10.00 |
Tier 2: Tier 2: | $10.00 | $10.00 | n/a | $30.00 | $30.00 | $20.00 |
Tier 3: Tier 3: | $30.00 | $30.00 | n/a | $90.00 | $90.00 | $60.00 |
Tier 4: Tier 4: | $65.00 | $65.00 | n/a | $195.00 | $195.00 | $130.00 |
Tier 5: Tier 5: | 25% | 25% | n/a | 25% | 25% | 25% |
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: Tier 1: | n/a | |||||
Tier 2: Tier 2: | n/a | |||||
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 AmeriHealth Rx Option II (PDP) 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 |