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Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2014 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
United American - Select (PDP) (S5755-103-0)
Benefit Details        
This plan is available in CMS PDP Region 32
Monthly Premium: $25.70
Rx Deductible: $310
Initial Coverage Limit: $2,850 Qualifies for LIS: Yes

Click on a letter below to view the
United American - Select (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
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 Generic: $1.00 $9.00 n/a $3.00 $27.00 $0.00
Tier 2: Non-Preferred Generic: $5.00 $13.00 n/a $15.00 $39.00 $36.00
Tier 3: Preferred Brand: $36.00 $44.00 n/a $108.00 $132.00 $119.00
Tier 4: Non-Preferred Brand: $95.00 $95.00 n/a $285.00 $285.00 $257.00
Tier 5: Specialty Tier: 25% 25% n/a 25% 25% 25%
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 28% 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 $2.55 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
Go to the United American - Select (PDP) 2014 Formulary Browser by choosing a letter below:
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