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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 Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Humana Walmart Value Rx Plan (PDP) (S5884-190-0)
Benefit Details        
This plan is available in CMS PDP Region 11
Monthly Premium: $17.20
Rx Deductible: $445
Initial Coverage Limit: $4,130 Qualifies for LIS: No

Click on a letter below to view the
Humana Walmart Value Rx Plan (PDP) 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*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $1.00(E) $10.00(E) $1.00(E) $3.00(E) $30.00(E) $3.00(E)
Tier 2: Generic: $4.00(E) $20.00(E) $4.00(E) $12.00(E) $60.00(E) $12.00(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $1.00 $10.00 $1.00 $3.00 $30.00 $3.00
Tier 2: Generic: $4.00 $20.00 $4.00 $12.00 $60.00 $12.00
Tier 3: Preferred Brand: 16% 22% 16% 16% 22% 16%
Tier 4: Non-Preferred Drug: 34% 50% 34% 34% 50% 34%
Tier 5: Specialty Tier: 25% 25% 25% 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 $3.70 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.
(E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible.
Go to the Humana Walmart Value Rx Plan (PDP) 2021 Formulary Browser by choosing a letter below:
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