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2021 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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2021 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Medicare Plus Blue PPO Assure (PPO) (H9572-003-1)
Benefit Details        
This plan is available in Allegan County, MI

Monthly Premium: $200.00
Rx Deductible: $0
Initial Coverage Limit: $4,130

Click on a letter below to view the
Medicare Plus Blue PPO Assure (PPO) 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
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: Preferred Generic: $1.00 $6.00 $1.00 $0.00 $18.00 $0.00
Tier 2: Generic: $7.00 $12.00 $7.00 $0.00 $36.00 $0.00
Tier 3: Preferred Brand: $37.00 $42.00 $37.00 $111.00 $126.00 $111.00
Tier 4: Non-Preferred Drug: 45% 45% 45% 45% 45% 45%
Tier 5: Specialty Tier: 33% 33% 33% n/a n/a n/a
Tier 6: Select Care Drugs: $0.00 $5.00 $0.00 $0.00 $15.00 $0.00
Coverage Gap (Donut Hole) Phase Cost Sharing
75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap
Tier 6: Select Care Drugs: $0.00(A) $5.00(A) $0.00(A) $0.00(A) $15.00(A) $0.00(A)
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 $3.70 The greater of 5% or $3.70
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $9.20 The greater of 5% or $9.20
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(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 Medicare Plus Blue PPO Assure (PPO) 2021 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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