2011 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
EnvisionRxPlus Gold (PDP) (S7694-065-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 31 which includes: ID UT Click on a letter below to view the EnvisionRxPlus Gold (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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Tier 1 Preferred Generics: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | $12.00 |
Tier 2: Tier 2 Non-Preferred Generics: | 25% | 25% | n/a | 25% | 25% | 25% |
Tier 3: Tier 3 Preferred Brand: | $25.00 | $25.00 | n/a | $75.00 | $75.00 | $75.00 |
Tier 4: Tier 4 Non-Preferred Brand: | 25% | 25% | n/a | 25% | 25% | 25% |
Tier 5: Tier 5 Specialty Drugs: | 25% | 25% | 25% | 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: Tier 1 Preferred Generics: | 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 EnvisionRxPlus Gold (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 |