2012 Medicare Prescription Drug Price Information | ||||||
United American - Preferred (PDP) (S5755-017-0) Benefit Details | ||||||
Click on a letter below to view the United American - Preferred (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 | ||||||
THEOPHYLLINE TABLET ER 300MG (100 CT) | ||||||
Plan’s average negotiated retail drug price in CMS PDP Region 14, includes: OH | $19.42* 30-Day Supply $58.27^ 90-Day Supply (calculated) | |||||
Formulary (Drug List) drug tier: | Tier #2: Non-Preferred Generic Drugs This Tier has No Deductible. | |||||
Does this plan offer any Gap coverage? | No 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** | |
Initial $100 Deductible Cost Sharing: | ||||||
$9.00 | $9.00 | n/a | $27.00 | $27.00 | $21.00 | |
Initial Coverage Phase Cost-Sharing: | ||||||
$9.00 | $9.00 | n/a | $27.00 | $27.00 | $21.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 14%): | ||||||
86% | 86% | n/a | 86% | 86% | 86% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 50%): | ||||||
50% | 50% | n/a | 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 in Deductible Phase: | ||||||
$9.00 | $9.00 | n/a | TBD | TBD | TBD | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$9.00 | $9.00 | n/a | $27.00^ | $27.00^ | $21.00^ | |
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
$16.70 | $16.70 | n/a | $50.11^ | $50.11^ | $50.11^ | |
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
$9.71 | $9.71 | n/a | $29.13^ | $29.13^ | $29.13^ | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$2.60 | $2.60 | n/a | $2.91 | $2.91 | $2.91 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$6.50 | $6.50 | n/a | $6.50 | $6.50 | $6.50 | |
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 --- | ||||||
Initial $100 Deductible Cost Sharing: | ||||||
$9.00 | $9.00 | n/a | $27.00 | $27.00 | $21.00 | |
Your Estimated Cost in Deductible Phase: | ||||||
$9.00 | $9.00 | n/a | TBD | TBD | TBD | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
This plan has coverage for all Tier 2 drugs during the initial deductible phase. Although this plan has an initial deductible, Tier 2 drugs have no deductible. So you play the same during the deductible phase ($9.00), as you would in the initial coverage phase. This purchase would not count toward meeting your deductible. | ||||||
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
$9.00 | $9.00 | n/a | $27.00 | $27.00 | $21.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$9.00 | $9.00 | n/a | $27.00^ | $27.00^ | $21.00^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
The cost-sharing for purchases made during the initial coverage phase (ICP) would be a flat fee of $9.00. | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (14% discount): | ||||||
$16.70 | $16.70 | n/a | $50.11^ | $50.11^ | $50.11^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your cost is the negotiated retail price of $19.42 x 86%. | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (50% discount): | ||||||
$9.71 | $9.71 | n/a | $29.13^ | $29.13^ | $29.13^ | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your costs is the negotiated retail price of $19.42 x 50%. | ||||||
--- 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): | ||||||
$2.60 | $2.60 | n/a | $2.91 | $2.91 | $2.91 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $2.60. Calculating 5% of $19.42 = $0.97. Since $0.97 is less than $2.60, you would pay $2.60 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug. | ||||||
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): | ||||||
$6.50 | $6.50 | n/a | $6.50 | $6.50 | $6.50 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $6.50. Calculating 5% of $19.42 = $0.97. Since $0.97 is less than $6.50, you would pay $6.50 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. | ||||||
United American - Preferred (PDP) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
April, 2012: | $19.42 | -- | ||||
September, 2010: | $13.44 | -- | ||||
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 THEOPHYLLINE TABLET ER 300MG (100 CT) prices that the United American - Preferred (PDP) has negotiated with each of the retail pharmacies in the plan’s service area (CMS PDP Region 14, includes: OH). In other words, when you use the United American - Preferred (PDP) to purchase THEOPHYLLINE TABLET ER 300MG (100 CT), 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. ^If the cost-sharing for your 90-day supply is a percentage (co-insurance), your estimated cost shown in the table above is calculated based on the 30-day average retail price multiplied by three (3). Please keep in mind that some plans offer discounts for purchasing a 90-day mail-order supply. For example, if you purchase a 90-day mail-order supply of your medication, you may only pay for a 60-day supply, based on your plan coverage. However, such a plan-specific discount is NOT shown in the table above because this data is not provided to us in a usable format. You can telephone the Medicare prescription drug plan directly for more details. |
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