2012 Medicare Advantage Prescription Drug Price Information | ||||||
Providence Medicare Extra Part B Only + RX (HMO) (H9047-013-0) Benefit Details | ||||||
Click on a letter below to view the Providence Medicare Extra Part B Only + RX (HMO) 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 | ||||||
Acyclovir 200mg/5mL 473 mL in 1 BOTTLE | ||||||
Plan’s average negotiated retail drug price in in Clackamas, OR: CMS MA Region 23, includes: OR | n/a* 30-Day Supply n/a 90-Day Supply (calculated) | |||||
Formulary (Drug List) drug tier: | Tier 1 | |||||
Does this plan offer any Gap coverage? | ||||||
Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. | |||||
Drug Usage Management Restrictions: | None | |||||
Formulary (Drug List) Tier Cost-Sharing Details | ||||||
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: | ||||||
$7.00 | $10.00 | $7.00 | $21.00 | $30.00 | $21.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 14%): | ||||||
86% | 86% | 86% | 86% | 86% | 86% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 50%): | ||||||
50% | 50% | 50% | 50% | 50% | 50% | |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.60 | The greater of 5% or $2.60 | |||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.50 | The greater of 5% or $6.50 | |||||
Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
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** | |
Your Estimated Cost Initial Coverage Phase: | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
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** | |
--- If you purchase during the Initial Deductible Phase --- | ||||||
This plan does not have an Initial Deductible: | ||||||
n/a | n/a | n/a | n/a | n/a | n/a | |
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
$7.00 | $10.00 | $7.00 | $21.00 | $30.00 | $21.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
--- If you purchase during the Catastrophic Coverage Phase --- | ||||||
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.60 | The greater of 5% or $2.60 | |||||
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.50 | The greater of 5% or $6.50 | |||||
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
TBD | TBD | TBD | TBD | TBD | TBD | |
Providence Medicare Extra Part B Only + RX (HMO) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
April, 2012: | n/a | -- | ||||
September, 2010: | n/a | -- | ||||
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the Acyclovir 200mg/5mL 473 mL in 1 BOTTLE prices that the Providence Medicare Extra Part B Only + RX (HMO) has negotiated with each of the retail pharmacies in the plan’s service area (in Clackamas, OR: CMS MA Region 23, includes: OR). In other words, when you use the Providence Medicare Extra Part B Only + RX (HMO) to purchase Acyclovir 200mg/5mL 473 mL in 1 BOTTLE, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. |
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