2011 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
UA Medicare Part D Prescription Drug Cov (PDP) (S5755-024-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 21 Click on a letter below to view the UA Medicare Part D Prescription Drug Cov (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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Generic: | $10.00 | $10.00 | n/a | $28.00 | $28.00 | $26.00 |
Tier 2: Preferred Brand Name: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 3: Non-Preferred Brand Name: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Specialty: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Generic: | $10.00 | $10.00 | n/a | $28.00 | $28.00 | $26.00 |
Tier 2: Preferred Brand Name: | $45.00 | $45.00 | n/a | $113.00 | $113.00 | $90.00 |
Tier 3: Non-Preferred Brand Name: | $95.00 | $95.00 | n/a | $238.00 | $238.00 | $190.00 |
Tier 4: Specialty: | 31% | 31% | n/a | 31% | 31% | 31% |
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 UA Medicare Part D Prescription Drug Cov (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 |