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2023 Medicare Prescription Drug Plan Cost-Sharing Details
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
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2023 Medicare Advantage Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Medicare BlueEssential (PPO) (H3335-053-0)
Benefit Details        
all covered insulin pay $35 or less
This plan is available in Broome County, NY

Click on a letter below to view the
Medicare BlueEssential (PPO) 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
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $0.00(E) $5.00(E) $0.00(E) $0.00(E) $10.00(E) $0.00(E)
Tier 2: Generic: $10.00(E) $15.00(E) $10.00(E) $20.00(E) $30.00(E) $20.00(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 $5.00 $0.00 $0.00 $10.00 $0.00
Tier 2: Generic: $10.00 $15.00 $10.00 $20.00 $30.00 $20.00
Tier 3: Preferred Brand: $42.00 $47.00 $42.00 $84.00 $94.00 $84.00
Tier 4: Non-Preferred Drug: $95.00 $100.00 $95.00 $190.00 $200.00 $190.00
Tier 5: Specialty Tier: 30% 30% 30% 30% 30% 30%
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 $4.15 The greater of 5% or $4.15
Other Drugs (Brand-Name or Non-Preferred Multi-Source Drugs): The greater of 5% or $10.35 The greater of 5% or $10.35
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 Medicare BlueEssential (PPO) 2023 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 
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