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2017 Medicare Prescription Drug Plan Cost-Sharing Details
| 2017 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
|
EnvisionRxPlus (PDP) (S7694-010-0) Benefit Details 
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| This plan is available in CMS PDP Region 10 Monthly Premium: $14.60 Rx Deductible: $260 Initial Coverage Limit: $3,700 Qualifies for LIS: Yes Click on a letter below to view the EnvisionRxPlus (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* | |
| Initial Deductible Phase Cost Sharing | ||||||
| Tier 1: Preferred Generic: | $1.00(E) | $14.90(E) | $1.00(E) | $3.00(E) | $44.70(E) | $2.00(E) |
| Tier 2: Generic: | $15.00(E) | $20.00(E) | $15.00(E) | $45.00(E) | $60.00(E) | $45.00(E) |
| Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
| Tier 4: Non-Preferred Drug: | 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: | $1.00 | $14.90 | $1.00 | $3.00 | $44.70 | $2.00 |
| Tier 2: Generic: | $15.00 | $20.00 | $15.00 | $45.00 | $60.00 | $45.00 |
| Tier 3: Preferred Brand: | 10% | 20% | 10% | 10% | 20% | 10% |
| Tier 4: Non-Preferred Drug: | 25% | 36% | 25% | 25% | 36% | 25% |
| Tier 5: Specialty Tier: | 27% | 27% | 27% | 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 | ||||
| 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 EnvisionRxPlus (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 | ||||||