2014 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Cross Medicare Advantage Basic (HMO) (H3822-001-0) Benefit Details | ||||||
This plan is available in COOK County, IL Monthly Premium: $0.00 Rx Deductible: $0 Initial Coverage Limit: $2,850 Click on a letter below to view the Blue Cross Medicare Advantage Basic (HMO) 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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
This plan does not have an Initial Deductible: | n/a | n/a | n/a | n/a | n/a | n/a |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $0.00 | $5.00 | n/a | $0.00 | $15.00 | $12.50 |
Tier 2: Non-Preferred Generic: | $2.00 | $7.00 | n/a | $5.00 | $21.00 | $17.50 |
Tier 3: Preferred Brand: | $39.00 | $44.00 | n/a | $97.50 | $132.00 | $110.00 |
Tier 4: Non-Preferred Brand: | $85.00 | $95.00 | n/a | $212.50 | $285.00 | $237.50 |
Tier 5: Specialty Tier: | 33% | 33% | n/a | 33% | 33% | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 28% Generic and 52.5% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 79% | 79% | 79% | 79% | 79% | 79% |
All Formulary Brand-Name Drugs: | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% | 47.5% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.55 | The greater of 5% or $2.55 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.35 | The greater of 5% or $6.35 | ||||
Go to the Blue Cross Medicare Advantage Basic (HMO) 2014 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 |