www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
`Q1GROUP LLC
`www.Q1Medicare.com
`
`2015 Medicare Part D Plan’s Negotiated Retail Drug Price
` Below you will find the average negotiated retail prescription drug price for your chosen Medicare Part D or
` Medicare Advantage plan, along with, tier cost-sharing details, your estimated cost for purchases during each
` coverage phase, tier cost-sharing details and your costs with explanations, and plan’s retail drug price history.
`
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` below:
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`2015 Medicare Part D Prescription Drug Price Information
`Alliance Medicare PPO (PPO) (H2322-008-0)
`
`Monthly Plan Premium: $48.70 Deductible: $0 ICL: $2,960
`KERYDIN 5% TOPICAL SOLUTION
`Plan’s average negotiated retail drug price
` for a 30-Day
`supply in MONROE, MI: CMS MA Region
` 11, includes: MI
`
`$509.54* 30-Day Supply
`$1,477.81* 90-Day Supply
`
`Formulary (Drug List) Drug Tier:
`
`Tier #4: Non-Preferred Brand
`
`Gap Coverage:
`
`No Gap Coverage
`
`Drug Usage Management Restrictions:
`
`Prior Authorization
`
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
`
`Formulary (Drug List) Tier Cost-Sharing Details
`
`CFAD Exhibit 1032
`
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`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
`90-Day Supply Cost-Sharing
`30-Day Supply Cost-Sharing
`Prfrd. Pharm. Non- Prfrd. Mail- Order Prfrd. Pharm. Non- Prfrd. Mail- Order
`
`
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`33%
`
`33%
`
`33%
`
`33%
`
`33%
`
`33%
`
`45%
`
`45%
`
`45%
`
`45%
`
`45%
`
`45%
`
`This plan
` does not
` have an
`Initial
` Deductible:
`
`Initial
` Coverage
` Phase
`Cost-
`Sharing:
`Coverage
` Gap Phase
` Cost-
`Sharing
`Including
` Donut Hole
` Discount
`(Brand
` 55%):
`Catastrophic
` Coverage
` Phase
`Cost-
`Sharing for
` Other
` Drugs
`(Brand-
`Name or
` Non-
`Preferred
`Multi-Source
` Drugs):
`Your Estimated Cost for Purchases During Each Coverage Phase (brands)
`30-Day Supply Cost-Sharing
`90-Day Supply Cost-Sharing
`Prfrd. Pharm. Non- Prfrd. Mail- Order Prfrd. Pharm. Non- Prfrd. Mail- Order
`
`The greater of 5% or $6.60
`
`The greater of 5% or $6.60
`
`
`
`Est. Cost
` Initial
` Coverage
` Phase:
`
`$168.15
`
`$168.15
`
`$168.15
`
`$487.68
`
`$487.68
`
`$487.68
`
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
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`$229.29
`
`$229.29
`
`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
`Your Est.
` Cost in
` Coverage
` Gap Using
`the Brand-
`Name Drug
` Discount
` (55%):
`Your
` Estimated
` Cost in
` Catastrophic
`
`Coverage
` (Brand-
`Name or
`Non-
`Preferred
` Multi-
`Source
` Drugs):
`
`$25.48
`
`$25.48
`
`$229.29
`
`$665.01
`
`$665.01
`
`$665.01
`
`$25.48
`
`$73.89
`
`$73.89
`
`$73.89
`
`
`
`Tier Cost-Sharing Details and Your Costs with Explanations
`30-Day Supply Cost-Sharing
`90-Day Supply Cost-Sharing
`Prfrd. Pharm. Non- Prfrd. Mail- Order Prfrd. Pharm. Non- Prfrd. Mail- Order
`--- If you purchase during the Initial Deductible Phase ---
`
`This plan
` does not
` have an
`Initial
` Deductible:
`
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`--- If you purchase during the Initial Coverage Phase ---
`
`33%
`
`33%
`
`33%
`
`Initial
` Coverage
` Phase
`Cost-
`Sharing:
`Est. Cost
` Initial
` Coverage
` Phase:
`Explanation
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
`
`33%
`
`33%
`
`33%
`
`$168.15
`
`$168.15
`
`$168.15
`
`$487.68
`
`$487.68
`
`$487.68
`
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`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
` for 30-Day
` Preferred
`Pharmacy
` purchase:
`
`The cost-sharing for purchases made during the initial coverage phase (ICP) would be
` $168.15 or ($509.54 x 33%).
`
`--- If you purchase during the Coverage Gap Phase (Donut Hole) ---
`
`Your Est.
` Cost in
` Coverage
` Gap Using
`the Brand-
`Name Drug
` Discount
` (55%):
`Explanation
` for 30-Day
` Preferred
`Pharmacy
` purchase:
`
`$229.29
`
`$229.29
`
`$229.29
`
`$665.01
`
`$665.01
`
`$665.01
`
`Your costs is the negoiated retail price of $509.54 x 45%.
`
`--- If you purchase during the Catastrophic Coverage Phase ---
`
`The greater of 5% or $6.60
`
`The greater of 5% or $6.60
`
`Catastrophic
` Coverage
` Phase
`Cost-
`Sharing for
` Other
` Drugs
`(Brand-
`Name or
` Non-
`Preferred
`Multi-Source
` Drugs):
`Your
` Estimated
` Cost in
` Catastrophic
`
`Coverage
` (Brand-
`Name or
`Non-
`Preferred
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
`
`$25.48
`
`$25.48
`
`$25.48
`
`$73.89
`
`$73.89
`
`$73.89
`
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`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
` Multi-
`Source
` Drugs):
`Explanation
` for 30-Day
` Preferred
`Pharmacy
` purchase:
`
`In the catastrophic coverage phase, you will pay the greater of 5% of the retail drug price
` or the minimum cost-share of $6.60. Calculating 5% of $509.54 = $25.48. Since $25.48 is
` more than $6.60, you would pay $25.48 for this drug at any pharmacy, because it is not a
` generic or preferred multi-source drug.
`
`Alliance Medicare PPO (PPO) Average Negotiated Retail Drug Price History
`30-Day Supply
`90 Day Supply
`$509.54
`$1,477.81
`N/A
`N/A
`
`June, 2015:
`April, 2015:
`January,
` 2015:
`September,
` 2014:
`June, 2014:
`March,
` 2014:
`January,
` 2014:
`October,
` 2013:
`January,
` 2013:
`April, 2012:
`September,
` 2010:
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`N/A
`
`*The plan’s Average Retail Drug Price is based on three things: (1) the medication, (2) the specific
`Medicare Part D plan, and (3) the pharmacies in the plan’s service area. In this case, the average of the
`KERYDIN 5% TOPICAL SOLUTION prices that the Alliance Medicare PPO (PPO) has negotiated with
`each of the retail pharmacies in the plan’s service area (in MONROE, MI: CMS MA Region 11, includes:
`MI). In other words, when you use the Alliance Medicare PPO (PPO) to purchase KERYDIN 5%
`TOPICAL SOLUTION, you may pay slightly more or slightly less than the figures shown in the table
`above depending on the pharmacy where you fill your prescription.
`
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
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`
`Return to this plan’s 2015 Formulary Browser by choosing a letter below:
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` 2015
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`Chart
` Legend:
`What does all this
` mean? Below are a
` few notes to help you
` understand the above
` 2015 Medicare Part D
` Alliance Medicare
` PPO (PPO) Plan
` Formulary.
`
`Plan Name: This is the official Medicare Part D prescription drug plan
` name from the Centers for Medicare and Medicaid Services (CMS). The
` same Medicare Part D plan name generally has a different Plan ID in each
` state (or CMS Region).
`
`Monthly Premium: This is the amount you must pay each month for this
` prescription drug plan. This monthly premium must be paid even if you are
` in the initial deductible phase or the coverage gap (donut hole) phase.
`
`Deductible: If your Part D plan has an initial deductible, you are 100%
` responsible for your drug costs until your expenses exceed this value and
` you begin your Initial Coverage Phase. Many Medicare Part D plans use
` the the standard $320 deductible as provided by CMS in their Standard
` plan design. Some Part D plan providers offer an initial deductible lower
` than the Standard deductible. Many prescription drug plans do not have a
` deductible (also called first dollar coverage or a $0 deductible), however
` the monthly premium for a plan with a $0 deductible may be slightly
` higher.
`
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
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`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
`
`Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
`Yes - This plan qualifies for the $0 Premium for those persons with a
` full LIS or Extra Help benefit. Persons on the LIS program who
` select a qualifying plan will also pay a $0 deductible, pay lower
` cost-sharing payments and have coverage through the Coverage
` Gap or Doughnut Hole.
`
`No - This plan does not qualify for the $0 Premium for persons wit
` the full LIS benefit.
`
`Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
`
`Drug Tier Information - Drug Tiers are the logical grouping of prescription
` drugs on a Part D plan formulary. These fields represent the Tier (or drug
` list group) - for this particular medication - on this particular plan’s
` Formulary or Drug List.
`Tier Number - This is the actual numerical tier level from the
` formulary. Most Part D plans have four (4) tiers 1=Preferred
` Generics, 2=Preferred Brands, 3=Non-preferred Brands and
` Generics, 4=Specialty Drugs.
`Drug Description - This is the Medicare Part D plan’s description of
` this particular drug tier.
`Cost Sharing - Copay / Coinsurance - These figures apply to the initial
` coverage phase of your plan. This is the phase after the initial deductible
` has been met and before you reach the Coverage Gap (Donut Hole).
` Plans often cover drugs in "tiers". Tiers are specific to the list of drugs
` covered by the plan. Plans may have several tiers, and the copay for a
` drug depends on which tier the drug is in. The drug Tier is shown to the
` left of this column. These cost sharing figures DO NOT necessarily apply
` to the Coverage Gap. The plan may have a separate copay/coinsurance
` for the same drug while in the Coverage Gap. There are two figures
` shown under this "Cost Sharing" category:
`Preferred Network Pharmacy - (Preferred Pharm) - This is the
` cost-share amount you would pay during the intial coverage
` phase for a 30-Day supply (until your total retail prescription drug
` costs reach $2960) at a "Preferred" network pharmacy. In most
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
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`www.Q1Medicare.com 2015 Medicare Part D Plan's Negotiated Retail Drug Price
` cases, the "Preferred" network and network pharmacy pricing are
` the same. However, for example on the 2015 Humana Walmart-
`Preferred Rx Plan the cost-sharing is much higher at a network
` pharmacy over a "Preferred" network pharmacy. "Preferred"
` network pharmacies for this plan include only Walmart, Sam’s Club
` and RightSource.
`Mail Order - This is the cost-share amount you would pay during the
` initial coverage phase for a 90-Day supply if you purchased your
` medication through your plan’s preferred mail order partner(s).
`Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) -
` This shows the plan requires drug utilization management controls for this
` particular medication.
`None - This drug does not fall under any drug utilization
` management controls.
`P - Prior Authorization -This drug is subject to prior authorization.
`S - Step Therapy -This drug is subject to step therapy.
`Q - Quantity Limits -This drug is subject to quantity limits. The
` actual quantity limit is shown as Q:Amount/Days. For Example:
` Q:6/28Days means the quantity limit is a quantity of 6 pills per 28
` days. Q:90/365Days would mean that the plan limits this drug to 90
` pills for the entire year.
`
` (Chart Source: Centers for Medicare and Medicaid files: CMS Data July 2015 )
`
` Please note: The above plan information comes from CMS. We make every
` attempt to keep our information up-to-date with plan/premium changes.
` However, the Medicare Part D plan data changes over time and we cannot
` guarantee the accuracy of this information. You should always verify cost and
` coverage information with your Part D plan provider.
`
`http://www.q1medicare.com/...&ndc=55724011121&formulary=00015191&contractId=H2322&planId=008&segmentId=0&zipCountyCode=26115&cplanType=M&cletter=K&cmode=state[08/06/2015 2:09:40 PM]
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