2014 Medicare Advantage Prescription Drug Price Information | ||||||
HumanaChoice H5868-009 (PPO) (H5868-009-0) Benefit Details | ||||||
Monthly Premium: $56.00 Rx Deductible: $310 ICL: $2,850 Click on a letter below to view the HumanaChoice H5868-009 (PPO) 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 | ||||||
SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM | ||||||
Plan’s average negotiated retail drug price in in ADAIR, IA: CMS MA Region 19, includes: IA | $173.46* 30-Day Supply $516.12* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier 3 This Tier has No Deductible. | |||||
Does this plan offer any Gap coverage? | Few Generics, Few Brands | |||||
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: | Quantity Limit:60/30Days | |||||
Formulary (Drug List) Tier Cost-Sharing Details | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Initial $310 Deductible Cost Sharing: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
Initial Coverage Phase Cost-Sharing: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 28%): | ||||||
79% | 79% | 79% | 79% | 79% | 79% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 52.5%): | ||||||
47.5% | 47.5% | 47.5% | 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 |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
Your Estimated Cost in Deductible Phase: | ||||||
$45.00 | $45.00 | $45.00 | $270.00 | $270.00 | $250.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
Your Estimated Cost in Gap if Drug is Generic (28% discount): | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (52.5% discount): | ||||||
$82.39 | $82.39 | $82.39 | $245.16 | $245.16 | $245.16 | |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): | ||||||
$8.67 | $8.67 | $8.67 | $25.81 | $25.81 | $25.81 | |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): | ||||||
$8.67 | $8.67 | $8.67 | $25.81 | $25.81 | $25.81 | |
Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order** | Preferred Pharmacy | Standard Pharmacy | Mail- Order** | |
--- If you purchase during the Initial Deductible Phase --- | ||||||
Initial $310 Deductible Cost Sharing: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
Your Estimated Cost in Deductible Phase: | ||||||
$45.00 | $45.00 | $45.00 | $270.00 | $270.00 | $250.00 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
This plan has coverage for all Tier 3 drugs during the initial deductible phase. Although this plan has an initial deductible, Tier 3 drugs have no deductible. So you play the same during the deductible phase ($45.00), 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: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$45.00 | $45.00 | $45.00 | $135.00 | $135.00 | $125.00 | |
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 $45.00. | ||||||
--- 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): | ||||||
$82.39 | $82.39 | $82.39 | $245.16 | $245.16 | $245.16 | |
--- 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): | ||||||
$8.67 | $8.67 | $8.67 | $25.81 | $25.81 | $25.81 | |
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 $173.46 = $8.67. Since $8.67 is more than $2.55, you would pay $8.67 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): | ||||||
$8.67 | $8.67 | $8.67 | $25.81 | $25.81 | $25.81 | |
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 $173.46 = $8.67. Since $8.67 is more than $6.35, you would pay $8.67 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. | ||||||
HumanaChoice H5868-009 (PPO) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
September, 2014: | $173.46 | $516.12 | ||||
June, 2014: | $173.47 | $516.12 | ||||
March, 2014: | $158.23 | $469.01 | ||||
January, 2014: | $158.12 | $470.68 | ||||
October, 2013: | n/a | n/a | ||||
January, 2013: | n/a | -- | ||||
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 SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM prices that the HumanaChoice H5868-009 (PPO) has negotiated with each of the retail pharmacies in the plan’s service area (in ADAIR, IA: CMS MA Region 19, includes: IA). In other words, when you use the HumanaChoice H5868-009 (PPO) to purchase SAVELLA TABLETS TITRATION PACK KIT 12.5;25;50MG;MG;MG 55 COUNT PKGCOM, 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. |
||||||
Return to the HumanaChoice H5868-009 (PPO) 2014 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 |