2018 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
BlueMedicare Choice (Regional PPO) (R3332-001-0) Benefit Details | ||||||
This plan is available in Statewide County, FL Monthly Premium: $41.00 Rx Deductible: $260 Initial Coverage Limit: $3,750 Click on a letter below to view the BlueMedicare Choice (Regional 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* | |
Initial Deductible Phase Cost Sharing | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $3.00 | $13.00 | n/a | $9.00 | $39.00 | n/a |
Tier 2: Generic: | $10.00 | $20.00 | n/a | $30.00 | $60.00 | n/a |
Tier 3: Preferred Brand: | $47.00 | $47.00 | n/a | $141.00 | $141.00 | n/a |
Tier 4: Non-Preferred Brand: | $100.00 | $100.00 | n/a | $300.00 | $300.00 | n/a |
Tier 5: Specialty Tier: | 28% | 28% | n/a | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $0.00 | $0.00 | n/a | $0.00 | $0.00 | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 56% Generic and 65% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: Preferred Generic: | $3.00(A) | $13.00(A) | n/a | $9.00(A) | $39.00(A) | n/a |
Tier 6: Select Care Drugs: | $0.00(A) | $0.00(A) | n/a | $0.00(A) | $0.00(A) | n/a |
All Formulary Generic Drugs: | 44% | 44% | 44% | 44% | 44% | 44% |
All Formulary Brand-Name Drugs: | 35% | 35% | 35% | 35% | 35% | 35% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.35 | The greater of 5% or $3.35 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.35 | The greater of 5% or $8.35 | ||||
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 BlueMedicare Choice (Regional PPO) 2018 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 |