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2018 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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2018 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Premier Health Advantage (HMO) (H3233-001-0)
Benefit Details        
This plan is available in Auglaize County, OH

Monthly Premium: $0.00
Rx Deductible: $125
Initial Coverage Limit: $3,750

Click on a letter below to view the
Premier Health Advantage (HMO) Formulary
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  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
Tier 1: Preferred Generic: $3.00(E) $3.00(E) n/a(E) $9.00(E) $9.00(E) n/a(E)
Tier 2: Generic: $15.00(E) $15.00(E) n/a(E) $45.00(E) $45.00(E) n/a(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Tier 6: Select Care Drugs: $0.00(E) $0.00(E) n/a(E) $0.00(E) $0.00(E) n/a(E)
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $3.00 $3.00 n/a $9.00 $9.00 n/a
Tier 2: Generic: $15.00 $15.00 n/a $45.00 $45.00 n/a
Tier 3: Preferred Brand: $47.00 $47.00 n/a $141.00 $141.00 n/a
Tier 4: Non-Preferred Brand: $100.00 $100.00 n/a $300.00 $300.00 n/a
Tier 5: Specialty Tier: 30% 30% n/a n/a n/a n/a
Tier 6: Select Care Drugs: $0.00 $0.00 n/a $0.00 $0.00 n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
56% Generic and 65% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap
Tier 1: Preferred Generic: $3.00(A) $3.00(A) n/a $9.00(A) $9.00(A) n/a
Tier 6: Select Care Drugs: $0.00(A) $0.00(A) n/a $0.00(A) $0.00(A) n/a
All Formulary Generic Drugs: 44% 44% 44% 44% 44% 44%
All Formulary Brand-Name Drugs: 35% 35% 35% 35% 35% 35%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.35 The greater of 5% or $3.35
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.35 The greater of 5% or $8.35
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.
(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 Premier Health Advantage (HMO) 2018 Formulary Browser by choosing a letter below:
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