2024 Medicare Prescription Drug Formulary (Drug List) Cost-Sharing Details | ||||||
Blue MedicareRx Value Plus (PDP) (S2893-001-0) Benefits & Contact Info all covered insulin pay $35 or less | ||||||
This plan is available in CMS PDP Region 2 which includes: CT MA RI VT Click on a letter below to view the Blue MedicareRx Value Plus (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: | $2.00(E) | $8.00(E) | $2.00(E) | $6.00(E) | $24.00(E) | $2.00(E) |
Tier 2: Generic: | $13.00(E) | $20.00(E) | $13.00(E) | $39.00(E) | $60.00(E) | $26.00(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: | $2.00 | $8.00 | $2.00 | $6.00 | $24.00 | $2.00 |
Tier 2: Generic: | $13.00 | $20.00 | $13.00 | $39.00 | $60.00 | $26.00 |
Tier 3: Preferred Brand: | $42.00 | $47.00 | $42.00 | $126.00 | $141.00 | $84.00 |
Tier 4: Non-Preferred Drug: | 46% | 46% | 46% | 46% | 46% | 46% |
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 | ||||||
All Formulary Drugs: |
$0 cost-sharing. The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP). | |||||
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 MedicareRx Value Plus (PDP) 2024 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 |