2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
BlueAdvantage Ruby (PPO) (H7917-014-0) Benefit Details ![]() ![]() ![]() | ||||||
This plan is available in DeKalb County, TN Monthly Premium: $91.00 Rx Deductible: $0 Initial Coverage Limit: $4,020 Click on a letter below to view the BlueAdvantage Ruby (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* | |
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: : | $1.00 | $6.00 | $1.00 | $1.00 | $15.00 | $1.00 |
Tier 2: : | $5.00 | $10.00 | $5.00 | $5.00 | $25.00 | $5.00 |
Tier 3: : | $28.00 | $33.00 | $28.00 | $70.00 | $95.00 | $70.00 |
Tier 4: : | $65.00 | $70.00 | $65.00 | $165.00 | $185.00 | $165.00 |
Tier 5: : | 33% | 33% | 33% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing 75% Generic and 75% Brand Donut Hole Discount applies to all drugs even those with coverage in the gap | ||||||
Tier 1: : | $1.00(A) | $6.00(A) | $1.00(A) | $1.00(A) | $15.00(A) | $1.00(A) |
All Formulary Generic Drugs: | 25% | 25% | 25% | 25% | 25% | 25% |
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 $3.60 | The greater of 5% or $3.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.95 | The greater of 5% or $8.95 | ||||
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 BlueAdvantage Ruby (PPO) 2020 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 |