2013 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SmartD Rx Saver (PDP) (S0064-019-0) Sanctioned Plan ![]() ![]() ![]() | ||||||
This plan is available in CMS PDP Region 19 Click on a letter below to view the SmartD Rx Saver (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: Preferred Generics: | $0.00 | $10.00 | n/a | $0.00 | $25.00 | n/a |
Tier 2: Non-preferred Generics: | $20.00 | $33.00 | n/a | $50.00 | $82.50 | n/a |
Tier 3: Preferred Brands: | $30.00 | $45.00 | n/a | $75.00 | $112.50 | n/a |
Tier 4: Non-preferred Brands: | $77.00 | $95.00 | n/a | $192.50 | $237.50 | n/a |
Tier 5: Specialty: | 25% | 25% | n/a | 25% | 25% | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 21% Generic and 52.5% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 79% | 79% | 79% | 79% | 79% | 79% |
All Formulary Brand-Name Drugs: | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
Go to the SmartD Rx Saver (PDP) 2013 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 |