2015 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Symphonix Rite Aid Premier Rx (PDP) (S0522-049-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in CMS PDP Region 01 which includes: ME NH Monthly Premium: $90.30 Rx Deductible: $0 Initial Coverage Limit: $2,960 Qualifies for LIS: No Click on a letter below to view the Symphonix Rite Aid Premier 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* | |
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: Preferred Generic: | $2.00 | $4.00 | $2.00 | $6.00 | $12.00 | $6.00 |
Tier 2: Non-Preferred Generic: | $4.00 | $6.00 | $4.00 | $12.00 | $18.00 | $12.00 |
Tier 3: Preferred Brand: | $30.00 | $35.00 | $30.00 | $90.00 | $105.00 | $90.00 |
Tier 4: Non-Preferred Brand: | $70.00 | $75.00 | $70.00 | $210.00 | $225.00 | $210.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 35% Generic and 55% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $2.00(A) | $4.00(A) | $2.00(A) | $6.00(A) | $12.00(A) | $6.00(A) |
Tier 2: Non-Preferred Generic: | $4.00(A) | $6.00(A) | $4.00(A) | $12.00(A) | $18.00(A) | $12.00(A) |
All Formulary Generic Drugs: | 65% | 65% | 65% | 65% | 65% | 65% |
All Formulary Brand-Name Drugs: | 45% | 45% | 45% | 45% | 45% | 45% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
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 Symphonix Rite Aid Premier Rx (PDP) 2015 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 |