2019 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
BlueRx Essential (PDP) (S1030-006-0) Benefit Details | ||||||
This plan is available in CMS PDP Region 12 which includes: AL TN Monthly Premium: $34.40 Rx Deductible: $415 Initial Coverage Limit: $3,820 Qualifies for LIS: No Click on a letter below to view the BlueRx Essential (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 | ||||||
All Formulary Drug Tiers: | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: Preferred Generic: | $1.00 | $1.00 | $1.00 | $3.00 | $3.00 | $2.00 |
Tier 2: Generic: | $4.00 | $4.00 | $4.00 | $12.00 | $12.00 | $8.00 |
Tier 3: Preferred Brand: | $47.00 | $47.00 | $47.00 | $141.00 | $141.00 | $94.00 |
Tier 4: Non-Preferred Drug: | 50% | 50% | 50% | 50% | 50% | 50% |
Tier 5: Specialty Tier: | 25% | 25% | 25% | 25% | 25% | 25% |
Coverage Gap (Donut Hole) Phase Cost Sharing Plan offers no Gap Coverage -- 63% Generic and 75% Brand Donut Hole Discount applies | ||||||
All Formulary Generic Drugs: | 37% | 37% | 37% | 37% | 37% | 37% |
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 $3.40 | The greater of 5% or $3.40 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.50 | The greater of 5% or $8.50 | ||||
Go to the BlueRx Essential (PDP) 2019 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 |