2019 Medicare Prescription Drug Price Information |
Express Scripts Medicare - Value (PDP) (S5660-114-0)
Benefit Details
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Monthly Premium: $30.20 Rx Deductible: $415 ICL: $3,820 Qualifies for LIS: Yes
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This Plan Uses Lower Cost-Sharing for Preferred Pharmacies |
SYMDEKO 100/150 MG-150 MG TABS  |
Plan’s average negotiated retail drug price in CMS PDP Region 12, includes: AL TN | $22,525.80* 30-Day Supply $68,237.90* 90-Day Supply
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Formulary (Drug List) Drug Tier: | Tier #5: Specialty Tier
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Does this plan offer any Gap Coverage? | No Gap Coverage |
Does this Drug have Gap Coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. |
Drug Usage Management Restrictions: | Prior Authorization and Quantity Limit:56/28Days
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Formulary (Drug List) Tier Cost-Sharing Details |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Initial $415 Deductible Cost Sharing: |
| 100% | 100% | 100% |
n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing: |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 63%): |
| 37% | 37% | 37% |
n/a | n/a | n/a |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%): |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: |
| The greater of 5% or $3.40 |
The greater of 5% or $3.40 |
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): |
| The greater of 5% or $8.50 |
The greater of 5% or $8.50 |
Your Estimated Cost for Purchases During Each Coverage Phase |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Your Estimated Cost in Deductible Phase: |
| $3,008.65 | $3,008.65 | $3,008.65 |
n/a | n/a | n/a |
Your Estimated Cost Initial Coverage Phase: |
| $2,762.92 | $2,762.92 | $2,762.92 |
n/a | n/a | n/a |
Your Estimated Cost in Gap if Drug is Generic (63% discount): |
| $5,537.10 | $5,537.10 | $5,537.10 |
$7,822.71 | n/a | n/a |
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): |
| $2,199.97 | $2,199.97 | $2,199.97 |
$4,419.15 | n/a | n/a |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): |
| $1,126.29 | $1,126.29 | $1,126.29 |
n/a | n/a | n/a |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): |
| $1,126.29 | $1,126.29 | $1,126.29 |
n/a | n/a | n/a |
Tier Cost-Sharing Details and Your Costs with Explanations |
|
30-Day Supply Cost-Sharing |
90-Day Supply Cost-Sharing |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
Preferred Pharmacy |
Standard Pharmacy |
Mail- Order** |
--- If you purchase during the Initial Deductible Phase --- |
Initial $415 Deductible Cost Sharing: |
| 100% | 100% | 100% |
n/a | n/a | n/a |
Your Estimated Cost in Deductible Phase: |
| $3,008.65 | $3,008.65 | $3,008.65 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
|
For a purchase of this drug made during the initial deductible phase,
you cross over into other phases of your plan’s coverage (straddle claim).
So you pay 100% of the drug cost up to your deductible of $415
and the remaining amount ($22,525.80-$415) (price - deductible) falls
into your initial coverage phase (ICP).
For the ICP portion of your coverage, your cost-sharing would be an additional $851.25
or $3,405.00 x 25%
(overage up to your remaining coverage limit
($3,405.00) * cost-sharing). Since the amount of the retail drug price falling into the ICP
$22,110.80 is greater than the remaining
initial coverage limit $3405 ($3,820 - $415),
$18,705.80 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase,
you would pay an additional
$1,008.88
or ($4,035.53 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP assuming this is a brand-name drug). Since the portion of the costs that fell into the coverage gap
$18,705.80 x 95% exceeds the amount
of TrOOP left ($3,833.75),
$14,670.27 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase, you would pay an additional $733.51 or (5% of $14,670.27) since it is greater than the minimum catastrophic cost-share of $8.50. |
--- If you purchase during the Initial Coverage Phase --- |
Initial Coverage Phase Cost-Sharing: |
| 25% | 25% | 25% |
n/a | n/a | n/a |
Your Estimated Cost Initial Coverage Phase: |
| $2,762.92 | $2,762.92 | $2,762.92 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| The cost-sharing for purchases made during the initial coverage phase (ICP) would be $955.00 or ($3,820.00 x 25%). But since the retail drug price ($22,525.80) is greater than initial coverage limit ($3,820), the difference of $18,705.80 rolls into the coverage gap phase. For the portion that falls into the coverage gap phase,
you would pay an additional
$1,090.79
or ($4,363.16 x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP). The portion of the costs that fell into the coverage gap $4,363.16 exceeds the amount of TrOOP left ($4,145.00) so you only pay in the gap on the amount within the TrOOP. The excess over TrOOP, $14,342.64 falls into the catastrophic coverage phase. For the portion that falls into the catastrophic coverage phase,
you would pay an additional $717.13 or (5% of $14,342.64) since it is greater than the minimum catastrophic cost-share of $8.50. So, your total cost for this one purchase is $2,762.92 or $955.00 (ICP) + $1,090.79 (Gap) + $717.13 (Cat.Cov.). |
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- |
Your Estimated Cost in Gap if Drug is Generic (63% discount): |
| $5,537.10 | $5,537.10 | $5,537.10 |
$7,822.71 | n/a | n/a |
|
Since this drug’s negotiated retail price ($22,525.80) is greater than
the TrOOP limit ($5,100), in the donut hole phase, you would pay
$5,100.00 ($13,783.78 x 37%)
plus $437.10 in the catastrophic phase, (which is 5% of the remaining $8,742.02) because $437.10 is greater than the minimum catastrophic cost-share of $3.40. Although it rarely happens that you would be responsible for the entire $5,100 for a purchase in the coverage gap, it can occur, for example on an expensive generic drug with a $0 copay in the initial coverage phase. |
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): |
| $2,199.97 | $2,199.97 | $2,199.97 |
$4,419.15 | n/a | n/a |
|
Since 95% this drug’s negotiated
retail price ($22,525.80) is greater than
the TrOOP limit ($5,100), in the donut hole phase, you would pay
$1,342.11 (($5,100 / 95%) x 25% -- 70% of the discount counts toward TrOOP and the 5% paid by your plan does not count toward TrOOP)
plus $857.87 in the catastrophic phase, (which is 5% of the remaining
$17,157.38)
because $857.87 is greater than the minimum catastrophic cost-share of $8.50.
Although it rarely happens that you would be responsible for the entire
$5,100 for a purchase in the coverage gap, it can occur, for example
on an expensive generic drug with a $0 copay in the initial coverage phase. |
--- If you purchase during the Catastrophic Coverage Phase --- |
Catastrophic Coverage Phase Cost-Sharing for Generic & Preferred Multi-Source Drugs: |
| The greater of 5% or $3.40 |
The greater of 5% or $3.40 |
Your Estimated Cost in Catastrophic Coverage Phase (Generic): |
| $1,126.29 | $1,126.29 | $1,126.29 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $3.40. Calculating 5% of $22,525.80 = $1,126.29. Since $1,126.29 is more than $3.40, you would pay $1,126.29 for this drug at a preferred pharmacy, if it is a generic or preferred multi-source drug. |
Catastrophic Coverage Phase Cost-Sharing for Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): |
| The greater of 5% or $8.50 |
The greater of 5% or $8.50 |
Your Estimated Cost in Catastrophic Coverage (Brand-Name or Non-Preferred Multi-Source Drugs): |
| $1,126.29 | $1,126.29 | $1,126.29 |
n/a | n/a | n/a |
Explanation for 30-Day Preferred Pharmacy purchase: |
| In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price or the minimum cost-share of $8.50. Calculating 5% of $22,525.80 = $1,126.29. Since $1,126.29 is more than $8.50, you would pay $1,126.29 for this drug at any pharmacy, if it is not a generic or preferred multi-source drug. |
Express Scripts Medicare - Value (PDP) Average Negotiated Retail Drug Price History |
| 30-Day Supply | 90 Day Supply |
September, 2019: | $22,525.80 | $68,237.90 |
June, 2019: | $22,590.80 | $68,367.40 |
March, 2019: | $22,690.70 | $68,981.00 |
January, 2019: | $22,797.20 | $70,038.00 |
September, 2018: | $22,823.00 | $70,166.10 |
June, 2018: | $22,876.00 | $70,282.10 |
March, 2018: | n/a | n/a |
January, 2018: | n/a | n/a |
September, 2017: | n/a | n/a |
June, 2017: | n/a | n/a |
March, 2017: | n/a | n/a |
January, 2017: | n/a | n/a |
September, 2016: | | |
June, 2016: | | |
April, 2016: | | |
January, 2016: | | |
September, 2015: | | |
June, 2015: | | |
April, 2015: | | |
January, 2015: | | |
September, 2014: | | |
June, 2014: | | |
March, 2014: | | |
January, 2014: | | |
October, 2013: | | |
January, 2013: | | -- |
April, 2012: | | -- |
September, 2010: | | -- |
Notes: *The plan’s Average Retail Drug Price is based on three things: (1) the medication, (2) the specific Medicare Part D plan, and (3) the pharmacies in the plan’s service area. In this case, the average of the SYMDEKO 100/150 MG-150 MG TABS prices that the Express Scripts Medicare - Value (PDP) has negotiated with each of the retail pharmacies in the plan’s service area ( CMS PDP Region 12, includes: AL TN).
In other words, when you use the Express Scripts Medicare - Value (PDP) to purchase SYMDEKO 100/150 MG-150 MG TABS, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription.
**The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
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