2014 Medicare Advantage Prescription Drug Price Information | ||||||
Triple-S Medicare Optimo Select (HMO) (HMO) (H4012-008-0) Benefit Details | ||||||
Monthly Premium: $0.00 Rx Deductible: $0 ICL: $2,850 Click on a letter below to view the Triple-S Medicare Optimo Select (HMO) (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 | ||||||
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies | ||||||
NEULASTA 6MG/0.6ML SYRINGE | ||||||
Plan’s average negotiated retail drug price in in VEGA ALTA, PR: CMS MA Region 30, includes: PR | $4,796.99* 30-Day Supply $13,952.10* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier #5: Specialty Tier | |||||
Does this plan offer any Gap coverage? | All Generics | |||||
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: | Prior Authorization | |||||
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: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 28%): | ||||||
79% | 79% | n/a | 79% | 79% | 79% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 52.5%): | ||||||
47.5% | 47.5% | n/a | 47.5% | 47.5% | 47.5% | |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.55 | The greater of 5% or $2.55 | |||||
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
The greater of 5% or $6.35 | The greater of 5% or $6.35 | |||||
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: | ||||||
$1,865.32 | $1,865.32 | n/a | $3,068.98 | $3,068.98 | $3,068.98 | |
Your Estimated Cost in Gap if Drug is Generic (28% discount): | ||||||
$3,789.62 | $3,789.62 | n/a | $4,959.63 | $4,959.63 | $4,959.63 | |
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$2,223.18 | $2,223.18 | n/a | $2,625.67 | $2,625.67 | $2,625.67 | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$239.85 | $239.85 | n/a | $697.61 | $697.61 | $697.61 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$239.85 | $239.85 | n/a | $697.61 | $697.61 | $697.61 | |
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: | ||||||
33% | 33% | n/a | 33% | 33% | 33% | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$1,865.32 | $1,865.32 | n/a | $3,068.98 | $3,068.98 | $3,068.98 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
The cost-sharing for purchases made during the initial coverage phase (ICP) would be $940.50 or ($2,850.00 x 33%). But since the retail drug price ($4,796.99) is greater than initial coverage limit ($2,850), the difference of $1,946.99 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase, you would pay an additional $924.82 or ($1,946.99 x 47.5% -- 50% of the discount counts toward TrOOP and the 2.5% paid by your plan does not count toward TrOOP). So, your total cost for this one purchase is $1,865.32 or $940.50 (ICP) + $924.82 (Gap) . | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (28% discount): | ||||||
$3,789.62 | $3,789.62 | n/a | $4,959.63 | $4,959.63 | $4,959.63 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your cost is the negotiated retail price of $4,796.99 x 79%. | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$2,223.18 | $2,223.18 | n/a | $2,625.67 | $2,625.67 | $2,625.67 | |
Since 97.5% this drug’s negotiated retail price ($4,796.99) is greater than the TrOOP limit ($4,550), in the donut hole phase, you would pay $2,216.67 (($4,550 / 97.5%) x 47.5% -- 50% of the discount counts toward TrOOP and the 2.5% paid by your plan does not count toward TrOOP) plus $6.52 in the catastrophic phase, (which is 5% of the remaining $130.32) because $6.52 is greater than the minimum catastrophic cost-share of $6.35. Although it rarely happens that you would be responsible for the entire $4,550 for a purchase in the coverage gap, it can occur, for example on an expensive generic drug with a $0 copay in the initial coverage phase. | ||||||
--- If you purchase during the Catastrophic Coverage Phase --- | ||||||
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: | ||||||
The greater of 5% or $2.55 | The greater of 5% or $2.55 | |||||
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$239.85 | $239.85 | n/a | $697.61 | $697.61 | $697.61 | |
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 $2.55. Calculating 5% of $4,796.99 = $239.85. Since $239.85 is more than $2.55, you would pay $239.85 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 $6.35 | The greater of 5% or $6.35 | |||||
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$239.85 | $239.85 | n/a | $697.61 | $697.61 | $697.61 | |
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 $6.35. Calculating 5% of $4,796.99 = $239.85. Since $239.85 is more than $6.35, you would pay $239.85 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. | ||||||
Triple-S Medicare Optimo Select (HMO) (HMO) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
September, 2014: | $4,796.99 | $13,952.10 | ||||
June, 2014: | $4,573.00 | $13,300.40 | ||||
March, 2014: | $4,578.41 | $13,312.10 | ||||
January, 2014: | $4,392.85 | $12,745.90 | ||||
October, 2013: | n/a | n/a | ||||
January, 2013: | $3,985.39 | -- | ||||
April, 2012: | $3,777.59 | -- | ||||
September, 2010: | $3,707.60 | -- | ||||
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 NEULASTA 6MG/0.6ML SYRINGE prices that the Triple-S Medicare Optimo Select (HMO) (HMO) has negotiated with each of the retail pharmacies in the plan’s service area (in VEGA ALTA, PR: CMS MA Region 30, includes: PR). In other words, when you use the Triple-S Medicare Optimo Select (HMO) (HMO) to purchase NEULASTA 6MG/0.6ML SYRINGE, 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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