2019 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Cross Medicare Advantage Choice (PPO) (H5959-014-2) Benefit Details | ||||||
This plan is available in Becker County, MN Monthly Premium: $99.10 Rx Deductible: $415 Initial Coverage Limit: $3,820 Click on a letter below to view the Blue Cross Medicare Advantage Choice (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 |
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Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $5.00(E) | $12.00(E) | $5.00(E) | $10.00(E) | $24.00(E) | $0.00(E) |
Tier 2: Generic: | 100% | 100% | 100% | 100% | 100% | 100% |
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% |
Tier 6: Select Care Drugs: | $0.00(E) | $5.00(E) | $5.00(E) | $0.00(E) | $10.00(E) | $0.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $5.00 | $12.00 | $5.00 | $10.00 | $24.00 | $0.00 |
Tier 2: Generic: | $10.00 | $17.00 | $10.00 | $20.00 | $34.00 | $20.00 |
Tier 3: Preferred Brand: | 20% | 25% | 20% | 20% | 25% | 20% |
Tier 4: Non-Preferred Drug: | 45% | 50% | 45% | 45% | 50% | 45% |
Tier 5: Specialty Tier: | 25% | 25% | 25% | 25% | 25% | 25% |
Tier 6: Select Care Drugs: | $0.00 | $5.00 | $5.00 | $0.00 | $10.00 | $0.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 63% Generic and 75% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 37% | 37% | 37% | 37% | 37% | 37% |
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 $3.40 | The greater of 5% or $3.40 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.50 | The greater of 5% or $8.50 | ||||
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 Blue Cross Medicare Advantage Choice (PPO) 2019 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 |