2017 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
SilverScript Choice (PDP) (S5601-050-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 25 which includes: IA MN MT NE ND SD WY Monthly Premium: $31.30 Rx Deductible: $0 Initial Coverage Limit: $3,700 Qualifies for LIS: Yes Click on a letter below to view the SilverScript Choice (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* | |
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: | $3.00 | $3.00 | $3.00 | $7.50 | $7.50 | $7.50 |
Tier 2: Generic: | $14.00 | $14.00 | $14.00 | $35.00 | $35.00 | $35.00 |
Tier 3: Preferred Brand: | $42.00 | $42.00 | $42.00 | $105.00 | $105.00 | $105.00 |
Tier 4: Non-Preferred Drug: | 48% | 48% | 48% | 48% | 48% | 48% |
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 -- 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 SilverScript Choice (PDP) 2017 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 |