2011 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Prescription Blue Option A (PDP) (S5584-001-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 13 Click on a letter below to view the Prescription Blue Option A (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 | ||||||
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* | |
Initial Deductible Phase Cost Sharing | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Tier 1: | $5.00 | $5.00 | $5.00 | $12.50 | $15.00 | $12.50 |
Tier 2: Tier 2: | $35.00 | $35.00 | $35.00 | $87.50 | $105.00 | $87.50 |
Tier 3: Tier 3: | $70.00 | $70.00 | $70.00 | $175.00 | $210.00 | $175.00 |
Tier 4: Tier 4: | 25% | 25% | 25% | n/a | n/a | n/a |
Tier 5: Tier 5: | 25% | 25% | n/a | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 7% Generic and 50% Brand Donut Hole Discount applies | ||||||
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 | ||||
Go to the Prescription Blue Option A (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 |