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2014 Medicare Prescription Drug Plan Cost-Sharing Details
| 2014 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Symphonix Rite Aid Value Rx (PDP) (S0522-022-0) Benefit Details 
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| This plan is available in CMS PDP Region 15 which includes: IN KY Monthly Premium: $33.60 Rx Deductible: $310 Initial Coverage Limit: $2,850 Qualifies for LIS: Yes Click on a letter below to view the Symphonix Rite Aid Value Rx (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 |
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| 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 | $2.00 | $1.00 | $3.00 | $6.00 | $3.00 |
| Tier 2: Non-Preferred Generic: | $10.00 | $13.00 | $10.00 | $30.00 | $39.00 | $30.00 |
| Tier 3: Preferred Brand: | $34.00 | $39.00 | $34.00 | $102.00 | $117.00 | $102.00 |
| Tier 4: Non-Preferred Brand: | $85.00 | $95.00 | $85.00 | $255.00 | $285.00 | $255.00 |
| Tier 5: Specialty Tier: | 25% | 25% | 25% | 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 Symphonix Rite Aid Value Rx (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 | ||||||