2012 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue MedicareRx Value (PDP) (S5726-013-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 24 Click on a letter below to view the Blue MedicareRx Value (PDP) 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 | ||||||
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 Drugs: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | $6.00 |
Tier 2: Non-Preferred Generic Drugs: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 3: Preferred Brand Drugs: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Brand Drugs: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Injectable Drugs: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 6: Specialty Tier Drugs: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic Drugs: | $4.00 | $4.00 | n/a | $12.00 | $12.00 | $6.00 |
Tier 2: Non-Preferred Generic Drugs: | $7.00 | $7.00 | n/a | $21.00 | $21.00 | $10.50 |
Tier 3: Preferred Brand Drugs: | $33.00 | $33.00 | n/a | $99.00 | $99.00 | $82.50 |
Tier 4: Non-Preferred Brand Drugs: | $85.00 | $85.00 | n/a | $255.00 | $255.00 | $212.50 |
Tier 5: Injectable Drugs: | 25% | 25% | n/a | 25% | 25% | 25% |
Tier 6: Specialty Tier Drugs: | 25% | 25% | 25% | n/a | n/a | n/a |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 14% Generic and 50% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 86% | 86% | 86% | 86% | 86% | 86% |
All Formulary Brand-Name Drugs: | 50% | 50% | 50% | 50% | 50% | 50% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.60 | The greater of 5% or $2.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.50 | The greater of 5% or $6.50 | ||||
Go to the Blue MedicareRx Value (PDP) 2012 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 |