2015 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Cross Senior Secure Plan I (HMO) (H0564-068-0) Benefit Details | ||||||
This plan is available in LOS ANGELES County, CA Monthly Premium: $0.00 Rx Deductible: $50 Initial Coverage Limit: $2,960 Click on a letter below to view the Blue Cross Senior Secure Plan I (HMO) 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) | $10.00(E) | $5.00(E) | $15.00(E) | $30.00(E) | $10.00(E) |
Tier 2: Non-Preferred Generic: | $28.00(E) | $33.00(E) | $28.00(E) | $84.00(E) | $99.00(E) | $56.00(E) |
Tier 3: Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: Non-Preferred Brand: | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: Specialty Tier: | 33%(E) | 33%(E) | 33%(E) | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) | $0.00(E) |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $5.00 | $10.00 | $5.00 | $15.00 | $30.00 | $10.00 |
Tier 2: Non-Preferred Generic: | $28.00 | $33.00 | $28.00 | $84.00 | $99.00 | $56.00 |
Tier 3: Preferred Brand: | $40.00 | $45.00 | $40.00 | $120.00 | $135.00 | $120.00 |
Tier 4: Non-Preferred Brand: | $90.00 | $95.00 | $90.00 | $270.00 | $285.00 | $270.00 |
Tier 5: Specialty Tier: | 33% | 33% | 33% | n/a | n/a | n/a |
Tier 6: Select Care Drugs: | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 35% Generic and 55% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 65% | 65% | 65% | 65% | 65% | 65% |
All Formulary Brand-Name Drugs: | 45% | 45% | 45% | 45% | 45% | 45% |
Catastrophic Coverage Phase Cost Sharing | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $2.65 | The greater of 5% or $2.65 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $6.60 | The greater of 5% or $6.60 | ||||
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 Senior Secure Plan I (HMO) 2015 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 |