2014 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SilverScript Plus (PDP) (S5601-005-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 2 which includes: CT MA RI VT Monthly Premium: $125.70 Rx Deductible: $0 Initial Coverage Limit: $2,850 Qualifies for LIS: No Click on a letter below to view the SilverScript Plus (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 | ||||||
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 | ||||||
Tier 1: Generic: | $0.00 | $7.00 | $0.00 | $0.00 | $21.00 | $0.00 |
Tier 2: Preferred Brand: | $17.00 | $24.00 | $17.00 | $42.50 | $72.00 | $42.50 |
Tier 3: Non-Preferred Brand: | $41.00 | $48.00 | $41.00 | $102.50 | $144.00 | $102.50 |
Tier 4: Specialty Tier: | 33% | 33% | 33% | 33% | 33% | 33% |
Coverage Gap (Donut Hole) Phase Cost Sharing 28% Generic and 52.5% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Generic: | $0.00(A) | $7.00(A) | $0.00(A) | $0.00(A) | $21.00(A) | $0.00(A) |
Tier 2: Preferred Brand: | $17.00(A) | $24.00(A) | $17.00(A) | $42.50(A) | $72.00(A) | $42.50(A) |
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 $2.55 | The greater of 5% or $2.55 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.35 | The greater of 5% or $6.35 | ||||
Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (A) Coverage Gap cost-sharing applies to all drugs on the designated tier. Drugs that are covered in the coverage gap also receive the donut hole discount. (P) Coverage Gap cost-sharing applies to only some of drugs on the designated drug tier. Drugs that are covered in the coverage gap also receive the donut hole discount. | ||||||
Go to the SilverScript Plus (PDP) 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 |