2023 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
BlueMedicare Premier Rx (PDP) (S5904-001-0) Benefit Details ![]() ![]() ![]() all covered insulin pay $35 or less | ||||||
This plan is available in CMS PDP Region 11 Click on a letter below to view the BlueMedicare Premier Rx (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 |
|||||
Preferred Pharmacy | Standard Pharmacy | Mail- Order* | Preferred Pharmacy | Standard Pharmacy | Mail- Order* | |
Initial Deductible Phase Cost Sharing | ||||||
Tier 1: Preferred Generic: | $3.00(E) | $3.00(E) | $3.00(E) | $9.00(E) | $9.00(E) | $9.00(E) |
Tier 2: Generic: | $14.00(E) | $14.00(E) | $14.00(E) | $42.00(E) | $42.00(E) | $42.00(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: | $3.00 | $3.00 | $3.00 | $9.00 | $9.00 | $9.00 |
Tier 2: Generic: | $14.00 | $14.00 | $14.00 | $42.00 | $42.00 | $42.00 |
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: | 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 BlueMedicare Premier Rx (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 |