2024 Medicare Advantage Prescription Drug Price Information | ||||||
Blue Cross Medicare Advantage Complete (PPO) (H4801-011-0) Benefits & Contact Info ![]() ![]() ![]() ![]() Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | ||||||
Click on a letter below to view the Blue Cross Medicare Advantage Complete (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 | ||||||
SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE ![]() | ||||||
Plan’s average negotiated retail drug price in in Potter, TX: CMS MA Region 17, includes: TX | $10.00* 30-Day Supply $29.99* 90-Day Supply | |||||
Formulary (Drug List) drug tier: | Tier #2: Generic | |||||
Does this plan offer any Gap coverage? | No Gap Coverage | |||||
Does this drug have Gap coverage? | No, this drug IS NOT covered in the gap, but all drugs receive the donut hole discount. | |||||
Drug Usage Management Restrictions: | None | |||||
Formulary (Drug List) Tier Cost-Sharing Details | ||||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | ||||||
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** | |
This plan does not have an Initial Deductible: | ||||||
n/a | n/a | n/a | n/a | n/a | n/a | |
Initial Coverage Phase Cost-Sharing: | ||||||
$8.00 | $20.00 | $8.00 | $24.00 | $60.00 | $24.00 | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Generics 75%): | ||||||
25% | 25% | 25% | 25% | 25% | 25% | |
Coverage Gap Phase Cost-Sharing Incl. Donut Hole Discount (Brand 75%): | ||||||
25% | 25% | 25% | 25% | 25% | 25% | |
Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
$0 | $0 | $0 | $0 | $0 | $0 | |
Your Estimated Cost for Purchases During Each Coverage Phase | ||||||
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** | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$8.00 | $10.00 | $8.00 | $24.00 | $29.99 | $24.00 | |
Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
$2.50 | $2.50 | $2.50 | $7.50 | $7.50 | $7.50 | |
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
$2.50 | $2.50 | $2.50 | $7.50 | $7.50 | $7.50 | |
Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
$0 | $0 | $0 | $0 | $0 | $0 | |
Tier Cost-Sharing Details and Your Costs with Explanations | ||||||
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** | |
--- If you purchase during the Initial Deductible Phase --- | ||||||
This plan does not have an Initial Deductible: | ||||||
n/a | n/a | n/a | n/a | n/a | n/a | |
--- If you purchase during the Initial Coverage Phase --- | ||||||
Initial Coverage Phase Cost-Sharing: | ||||||
$8.00 | $20.00 | $8.00 | $24.00 | $60.00 | $24.00 | |
Your Estimated Cost Initial Coverage Phase: | ||||||
$8.00 | $10.00 | $8.00 | $24.00 | $29.99 | $24.00 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
The cost-sharing for purchases made during the initial coverage phase (ICP) would be a flat fee of $8.00. | ||||||
--- If you purchase during the Coverage Gap Phase (Donut Hole) --- | ||||||
Your Estimated Cost in Gap if Drug is Generic (75% discount): | ||||||
$2.50 | $2.50 | $2.50 | $7.50 | $7.50 | $7.50 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your cost is the negotiated retail price of $10.00 x 25%. | ||||||
Your Estimated Cost in Gap if Drug is Brand-Name (75% discount): | ||||||
$2.50 | $2.50 | $2.50 | $7.50 | $7.50 | $7.50 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Your costs is the negotiated retail price of $10.00 x 25%. | ||||||
--- If you purchase during the Catastrophic Coverage Phase --- | ||||||
Catastrophic Coverage Phase Cost-Sharing (all Formulary Drugs): | ||||||
$0 | $0 | $0 | $0 | $0 | $0 | |
Your Estimated Cost in Catastrophic Coverage (all Formulary Drugs): | ||||||
$0 | $0 | $0 | $0 | $0 | $0 | |
Explanation for 30-Day Preferred Pharmacy purchase: | ||||||
Beginning with plan year 2024, the Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches $8,000 -- the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | ||||||
Blue Cross Medicare Advantage Complete (PPO) Average Negotiated Retail Drug Price History | ||||||
30-Day Supply | 90 Day Supply | |||||
March, 2024: | $10.00 | $29.99 | ||||
January, 2024: | $9.82 | $29.45 | ||||
September, 2023: | $11.27 | $33.80 | ||||
June, 2023: | $13.20 | $39.60 | ||||
March, 2023: | $13.20 | $39.60 | ||||
January, 2023: | $13.20 | $39.60 | ||||
September, 2022: | $14.40 | $43.20 | ||||
June, 2022: | $12.00 | $36.00 | ||||
March, 2022: | $13.20 | $39.60 | ||||
January, 2022: | $12.00 | $36.00 | ||||
September, 2021: | n/a | n/a | ||||
June, 2021: | n/a | n/a | ||||
March, 2021: | n/a | n/a | ||||
January, 2021: | n/a | n/a | ||||
September, 2020: | n/a | n/a | ||||
June, 2020: | n/a | n/a | ||||
March, 2020: | n/a | n/a | ||||
January, 2020: | n/a | n/a | ||||
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October, 2013: | ||||||
January, 2013: | -- | |||||
April, 2012: | -- | |||||
September, 2010: | -- | |||||
Notes:
*The Medicare drug plan’s average negotiated retail drug price is based on several variables: the medication, the quantity of your prescription, the specific Medicare Part D plan, and the pharmacies in the plan’s service area. In this case, the average of the SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE prices that the Blue Cross Medicare Advantage Complete (PPO) has negotiated with each of the retail pharmacies in the plan’s service area (in Potter, TX: CMS MA Region 17, includes: TX). In other words, when you use the Blue Cross Medicare Advantage Complete (PPO) to purchase SELENIUM SULFIDE 2.5mg/100mL 118 mL in 1 BOTTLE, you may pay slightly more or slightly less than the figures shown in the table above depending on the pharmacy where you fill your prescription and the quantity of your prescription. The example average retail prices used above are based on a quantity of 120 for the 30-day supply and a quantity of 360 for the 90-day supply. **The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing. |
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