2023 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue Rx Standard (PDP) (S3375-001-0) Benefit Details all covered insulin pay $35 or less | ||||||
This plan is available in CMS PDP Region 3 Click on a letter below to view the Blue Rx Standard (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 | ||||||
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) | $1.00(E) | $0.00(E) | $0.00(E) | $3.00(E) | $0.00(E) |
Tier 2: Generic: | $1.00(E) | $2.00(E) | $1.00(E) | $3.00(E) | $6.00(E) | $3.00(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 | $1.00 | $0.00 | $0.00 | $3.00 | $0.00 |
Tier 2: Generic: | $1.00 | $2.00 | $1.00 | $3.00 | $6.00 | $3.00 |
Tier 3: Preferred Brand: | $46.00 | $46.00 | $46.00 | $138.00 | $138.00 | $138.00 |
Tier 4: Non-Preferred Drug: | 40% | 40% | 40% | 40% | 40% | 40% |
Tier 5: Specialty Tier: | 25% | 25% | 25% | 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 $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 Blue Rx Standard (PDP) 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 |