2020 Medicare Prescription Drug Plan Cost-Sharing Details

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2020 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
BlueMedicare Premier Rx (PDP) (S5904-001-0)
Benefit Details        
This plan is available in CMS PDP Region 11
Monthly Premium: $72.20
Rx Deductible: $355
Initial Coverage Limit: $4,020 Qualifies for LIS: No


Click on a letter below to view the
BlueMedicare Premier Rx (PDP) Formulary
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  30-Day Supply
Cost-Sharing
90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $0.00(E) $0.00(E) $0.00(E) $0.00(E) $0.00(E) $0.00(E)
Tier 2: Generic: $9.00(E) $9.00(E) $9.00(E) $27.00(E) $27.00(E) $27.00(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Tier 2: Generic: $9.00 $9.00 $9.00 $27.00 $27.00 $27.00
Tier 3: Preferred Brand: $47.00 $47.00 $47.00 $141.00 $141.00 $141.00
Tier 4: Non-Preferred Drug: 50% 50% 50% 50% 50% 50%
Tier 5: Specialty Tier: 26% 26% 26% 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 BlueMedicare Premier Rx (PDP) 2020 Formulary Browser by choosing a letter below:
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