2015 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Asuris Medicare Script Basic (PDP) (S5609-001-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in CMS PDP Region 30 which includes: OR WA Monthly Premium: $97.50 Rx Deductible: $195 Initial Coverage Limit: $2,960 Qualifies for LIS: No Click on a letter below to view the Asuris Medicare Script Basic (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 | ||||||
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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $7.00 | $7.00 | $7.00 | $14.00 | $14.00 | $14.00 |
Tier 2: Non-Preferred Generic: | $15.00 | $15.00 | $15.00 | $30.00 | $30.00 | $30.00 |
Tier 3: Preferred Brand: | $45.00 | $45.00 | $45.00 | $112.50 | $112.50 | $112.50 |
Tier 4: Non-Preferred Brand: | $95.00 | $95.00 | $95.00 | $237.50 | $237.50 | $237.50 |
Tier 5: Specialty Tier: | 27% | 27% | 27% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 35% Generic and 55% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 65% | 65% | 65% | 65% | 65% | 65% |
All Formulary Brand-Name Drugs: | 45% | 45% | 45% | 45% | 45% | 45% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
Go to the Asuris Medicare Script Basic (PDP) 2015 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 |