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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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2016 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
SelectHealth Advantage (HMO) (H1994-004-0)
Benefit Details        
This plan is available in Cassia County, ID

Monthly Premium: $45.00
Rx Deductible: $0
Initial Coverage Limit: $3,310

Click on a letter below to view the
SelectHealth Advantage (HMO) 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
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
This plan does not have an Initial Deductible:n/an/an/an/an/an/a
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $3.00 $3.00 $3.00 $9.00 $9.00 $6.00
Tier 2: Generic: $15.00 $15.00 $15.00 $45.00 $45.00 $30.00
Tier 3: Preferred Brand: $45.00 $45.00 $45.00 $135.00 $135.00 $135.00
Tier 4: Non-Preferred Brand: $95.00 $95.00 $95.00 $285.00 $285.00 $285.00
Tier 5: Specialty Tier: 33% 33% 33% n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 42% Generic and 55% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 58% 58% 58% 58% 58% 58%
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 $2.95 The greater of 5% or $2.95
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $7.40 The greater of 5% or $7.40
Go to the SelectHealth Advantage (HMO) 2016 Formulary Browser by choosing a letter below:
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