2024 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Cross Medicare Advantage Dental Premier (PPO) (H4801-016-0) Benefits & Contact Info ![]() ![]() ![]() all covered insulin pay $35 or less | ||||||
This plan is available in Harris County, TX Click on a letter below to view the Blue Cross Medicare Advantage Dental Premier (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: | $0.00(E) | $15.00(E) | $0.00(E) | $0.00(E) | $45.00(E) | $0.00(E) |
Tier 2: Generic: | $8.00(E) | $20.00(E) | $8.00(E) | $24.00(E) | $60.00(E) | $24.00(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Drug: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $0.00 | $15.00 | $0.00 | $0.00 | $45.00 | $0.00 |
Tier 2: Generic: | $8.00 | $20.00 | $8.00 | $24.00 | $60.00 | $24.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $141.00 |
Tier 4: Non-Preferred Drug: | $100.00 | $100.00 | $100.00 | $300.00 | $300.00 | $300.00 |
Tier 5: : | 25% | 25% | 25% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 75% Generic and 75% Brand Donut Hole Discount applies | ||||||
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 | ||||||
All Formulary Drugs: |
$0 cost-sharing. The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||
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 Dental Premier (PPO) 2024 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 |