2020 Medicare Advantage Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
BlueCHiP for Medicare Standard with Drugs (HMO) (H4152-013-0) Benefit Details | ||||||
This plan is available in Bristol County, RI Monthly Premium: $65.00 Rx Deductible: $100 Initial Coverage Limit: $4,020 Click on a letter below to view the BlueCHiP for Medicare Standard with Drugs (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: : | $1.00(E) | $9.00(E) | n/a(E) | $3.00(E) | $27.00(E) | $0.00(E) |
Tier 2: : | $8.00(E) | $16.00(E) | n/a(E) | $24.00(E) | $48.00(E) | $0.00(E) |
Tier 3: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 4: : | 100% | 100% | 100% | 100% | 100% | 100% |
Tier 5: : | 100% | 100% | 100% | 100% | 100% | 100% |
Initial Coverage Phase Cost-Sharing | ||||||
Tier 1: : | $1.00 | $9.00 | n/a | $3.00 | $27.00 | $0.00 |
Tier 2: : | $8.00 | $16.00 | n/a | $24.00 | $48.00 | $0.00 |
Tier 3: : | $47.00 | $47.00 | n/a | $141.00 | $141.00 | $117.50 |
Tier 4: : | $100.00 | $100.00 | n/a | $300.00 | $300.00 | $250.00 |
Tier 5: : | 31% | 31% | 31% | 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 | ||||||
Generic & Preferred Multi-Source Drugs: | The greater of 5% or $3.60 | The greater of 5% or $3.60 | ||||
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): | The greater of 5% or $8.95 | The greater of 5% or $8.95 | ||||
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 BlueCHiP for Medicare Standard with Drugs (HMO) 2020 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 |