2024 Medicare Advantage Plan Prescription Drug Cost-Sharing Details
| 2024 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
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Blue Cross Medicare Advantage Health Choice (PPO) (H4801-022-0) Benefits & Contact Info 
 all covered insulin pay $35 or less | ||||||
| This plan is available in Logan County, OK Click on a letter below to view the Blue Cross Medicare Advantage Health 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: | $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 Health Choice (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 | ||||||