2014 Medicare Advantage Prescription Drug Price Information | ||||||
AHM Opal (HMO-POS) (H5774-014-0) Benefit Details | ||||||
Monthly Premium: $33.00 Rx Deductible: $0 ICL: $2,850 Click on a letter below to view the AHM Opal (HMO-POS) 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 | ||||||
Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE | ||||||
Plan’s average negotiated retail drug price in in LAJAS, PR: CMS MA Region 30, includes: PR | $5.32* 30-Day Supply $11.50* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier #1: Preferred Generic | |||||
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: | 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: | ||||||
$5.00 | $8.00 | n/a | $15.00 | $24.00 | $10.00 | |
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: | ||||||
$5.00 | $5.32 | n/a | $11.50 | $11.50 | $10.00 | |
Your Estimated Cost in Gap if Drug is Generic (28% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$2.53 | $2.53 | $2.53 | $5.46 | $5.46 | $5.46 | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$2.55 | $2.55 | n/a | $2.55 | $2.55 | $2.55 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$5.32 | $5.32 | n/a | $6.35 | $6.35 | $6.35 | |
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: | ||||||
$5.00 | $8.00 | n/a | $15.00 | $24.00 | $10.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$5.00 | $5.32 | n/a | $11.50 | $11.50 | $10.00 | |
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 $5.00. | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (28% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$2.53 | $2.53 | $2.53 | $5.46 | $5.46 | $5.46 | |
--- 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): | ||||||
$2.55 | $2.55 | n/a | $2.55 | $2.55 | $2.55 | |
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 $5.32 = $0.27. Since $0.27 is less than $2.55, you would pay $2.55 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): | ||||||
$5.32 | $5.32 | n/a | $6.35 | $6.35 | $6.35 | |
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 $5.32 = $0.27. Since $0.27 is less than $6.35, you would pay $6.35 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. However, since the negotiated retail drug price ($5.32) is less than your cost-sharing amount ($6.35) and since you never pay more than the negotiated retail price, your cost-sharing would be $5.32. | ||||||
AHM Opal (HMO-POS) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
September, 2014: | $5.32 | $11.50 | ||||
June, 2014: | $5.11 | $10.87 | ||||
March, 2014: | $5.37 | $11.31 | ||||
January, 2014: | $5.46 | $11.54 | ||||
October, 2013: | $5.52 | $11.74 | ||||
January, 2013: | $12.95 | -- | ||||
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 Medroxyprogesterone Acetate 5mg/1 500 TABLET BOTTLE prices that the AHM Opal (HMO-POS) has negotiated with each of the retail pharmacies in the plan’s service area (in LAJAS, PR: CMS MA Region 30, includes: PR). In other words, when you use the AHM Opal (HMO-POS) to purchase Medroxyprogesterone Acetate 5mg/1 500 TABLET 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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