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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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AR Blue Cross - Medi-Pak Rx Basic (PDP) (S5795-003-0) Benefit Details 
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| This plan is available in CMS PDP Region 19 Monthly Premium: $43.10 Rx Deductible: $310 Initial Coverage Limit: $2,850 Qualifies for LIS: No Click on a letter below to view the AR Blue Cross - Medi-Pak Rx Basic (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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $4.00(E) | $4.00(E) | $4.00(E) | $8.00(E) | $8.00(E) | $8.00(E) |
| Tier 2: Non-Preferred Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 5: Specialty Tier: | 100% | 100% | 100% | 100% | 100% | 100% |
| Initial Coverage Phase Cost-Sharing | ||||||
| Tier 1: Preferred Generic: | $4.00 | $4.00 | $4.00 | $8.00 | $8.00 | $8.00 |
| Tier 2: Non-Preferred Generic: | $15.00 | $15.00 | $15.00 | $30.00 | $30.00 | $30.00 |
| Tier 3: Preferred Brand: | 22% | 22% | 22% | 22% | 22% | 22% |
| Tier 4: Non-Preferred Brand: | 41% | 41% | 41% | 41% | 41% | 41% |
| 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 | ||||
| Notes: *The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. (E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible. | ||||||
| Go to the AR Blue Cross - Medi-Pak Rx Basic (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 | ||||||