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2017 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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2017 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
UnitedHealthcare Dual Complete ONE (HMO SNP) (H3113-012-0)
Benefit Details        
This plan is available in Allegheny County, PA

Monthly Premium: $35.00
Rx Deductible: $400
Initial Coverage Limit: $3,700

Click on a letter below to view the
UnitedHealthcare Dual Complete ONE (HMO SNP) 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*
Initial Deductible Phase Cost Sharing
All Formulary Drug Tiers: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: : $0.00 $0.00 n/a $0.00 $0.00 n/a
Tier 2: : $0.00 $0.00 n/a $0.00 $0.00 n/a
Tier 3: : $0.00 $0.00 n/a $0.00 $0.00 n/a
Tier 4: : $0.00 $0.00 n/a $0.00 $0.00 n/a
Tier 5: : $0.00 $0.00 n/a $0.00 $0.00 n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 49% Generic and 60% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 51% 51% 51% 51% 51% 51%
All Formulary Brand-Name Drugs: 40% 40% 40% 40% 40% 40%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.30 The greater of 5% or $3.30
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.25 The greater of 5% or $8.25
Go to the UnitedHealthcare Dual Complete ONE (HMO SNP) 2017 Formulary Browser by choosing a letter below:
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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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