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2019 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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2019 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
MeridianCare Extra (HMO SNP) (H5475-004-0)
Benefit Details        
This plan is available in Barry County, MI

Monthly Premium: $32.90
Rx Deductible: $415
Initial Coverage Limit: $3,820

Click on a letter below to view the
MeridianCare Extra (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
Tier 1: Preferred Generic: 100% 100% 100% 100% 100% 100%
Tier 2: Generic: 100% 100% 100% 100% 100% 100%
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: Supplemental Drugs: $0.00(E) $0.00(E) n/a(E) n/a n/a n/a
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: 25% 25% n/a 25% 25% 25%
Tier 2: Generic: 25% 25% n/a 25% 25% 25%
Tier 3: Preferred Brand: 25% 25% n/a 25% 25% 25%
Tier 4: Non-Preferred Brand: 25% 25% n/a 25% 25% 25%
Tier 5: Specialty Tier: 25% 25% n/a 25% 25% 25%
Tier 6: Supplemental Drugs: $0.00 $0.00 n/a n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 63% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 37% 37% 37% 37% 37% 37%
All Formulary Brand-Name Drugs: 25% 25% 25% 25% 25% 25%
Catastrophic Coverage Phase Cost Sharing
Generic & Preferred Multi-Source Drugs: The greater of 5% or $3.40 The greater of 5% or $3.40
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.50 The greater of 5% or $8.50
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 MeridianCare Extra (HMO SNP) 2019 Formulary Browser by choosing a letter below:
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