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2020 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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2020 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Senior Advantage Medicare Medicaid Plan (HMO D-SNP) (H1170-008-0)
Benefit Details        
This plan is available in Cherokee County, GA

Monthly Premium: $24.80
Rx Deductible: $0
Initial Coverage Limit: $4,020

Click on a letter below to view the
Senior Advantage Medicare Medicaid Plan (HMO D-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*
This plan does not have an Initial Deductible:n/an/an/an/an/an/a
Initial Coverage Phase Cost-Sharing
Tier 1: : $12.00 $12.00 $12.00 $36.00 $36.00 $24.00
Tier 2: : $18.00 $18.00 $18.00 $54.00 $54.00 $36.00
Tier 3: : $47.00 $47.00 $47.00 $141.00 $141.00 $94.00
Tier 4: : $100.00 $100.00 $100.00 $300.00 $300.00 $200.00
Tier 5: : 33% 33% 33% 33% 33% 33%
Tier 6: : $0.00 $0.00 n/a n/a n/a n/a
Coverage Gap (Donut Hole) Phase Cost Sharing
Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies
All Formulary Generic Drugs: 25% 25% 25% 25% 25% 25%
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 $3.60 The greater of 5% or $3.60
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $8.95 The greater of 5% or $8.95
Go to the Senior Advantage Medicare Medicaid Plan (HMO D-SNP) 2020 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 
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  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
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