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Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Tier 1 (407)
Tier 2 (1277)
Tier 3 (451)
Tier 4 (270)
Tier 5 (604)
Tier 6 (434)
Requires Prior Authorization:
Yes No Show either
Uses Step Therapy:
Yes No Show either
Has Quantity Limits:
Yes No Show either
Cick on the first letter of your drug name to browse the formulary:

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2012 Medicare Part D Plan Formulary Information
Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Benefit Details           
The Blue Cross MedicareRx Plus (PDP) (S5596-034-0)
Formulary Drugs Starting with the Letter J

in CMS PDP Region 32 which includes: CA
Drugs Starting with Letter J

Drug Name
Drug Tier Information Cost-Sharing Drug
Usage
Mgmt
Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
JAKAFI 10 MG TABLET   6 Specialty Tier Drugs 33%N/AP
JAKAFI 15 MG TABLET   6 Specialty Tier Drugs 33%N/AP
JAKAFI 20 MG TABLET   6 Specialty Tier Drugs 33%N/AP
JAKAFI 25 MG TABLET   6 Specialty Tier Drugs 33%N/AP
JAKAFI 5 MG TABLET   6 Specialty Tier Drugs 33%N/AP
JALYN CAPSULES   3 Preferred Brand Drugs $45.00$112.50None
JANTOVEN 1MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN 2.5MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN 3MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN 4MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
JANTOVEN 6MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN 7.5MG TABLET   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN WARFARIN SODIUM 10MG TABLET (500 CT)   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN WARFARIN SODIUM 5MG TABLET (100 CT)   1 Preferred Generic Drugs $2.00$3.00None
JANTOVEN WARFARIN SODIUM TABLET 2MG (1000 CT)   1 Preferred Generic Drugs $2.00$3.00None
JANUMET 50-1000MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
JANUMET 50MG-500MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:60
/30Days
JANUVIA 25MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
JANUVIA 50MG TABLET   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
JANUVIA TABLET 100MG (30 CT)   3 Preferred Brand Drugs $45.00$112.50Q:30
/30Days
JE-VAX VACCINE 50NMG   3 Preferred Brand Drugs $45.00$112.50None
Drug Name Tier
Nbr.
Tier
Description
30-Day
Preferred
Pharm
90-Day
Mail
Order
Drug
Usage
Mgmt
Jinteli 5; 1ug/1; mg/1 90 TABLET in 1 BOTTLE   4 Non-Preferred Brand Drugs $90.00$225.00None
JOLIVETTE 0.35MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
JUNEL 1-0.02MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
JUNEL 1.5-0.03MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
JUNEL FE 1-0.02MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None
JUNEL FE 1.5-0.03MG TABLET   2 Non-Preferred Generic Drugs $7.00$10.50None

Chart Legend:

Below are a few notes to help you understand the above 2012 Medicare Part D Blue Cross MedicareRx Plus (PDP) Plan Formulary.
  • Plan Name: This is the official Medicare Part D prescription drug plan name from the Centers for Medicare and Medicaid Services (CMS). The same Medicare Part D plan name generally has a different Plan ID in each state (or CMS Region).

  • Monthly Premium: This is the amount you must pay each month for this prescription drug plan. This monthly premium must be paid even if you are in the initial deductible phase or the coverage gap (donut hole) phase.

  • Deductible: If your Part D plan has an initial deductible, you are 100% responsible for your drug costs until your expenses exceed this value and you begin your Initial Coverage Phase. Many Medicare Part D plans use the standard $320 deductible as provided by CMS in their Standard plan design. Some Part D plan providers offer an initial deductible lower than the Standard deductible. Many prescription drug plans do not have a deductible (also called first dollar coverage or a $0 deductible), however the monthly premium for a plan with a $0 deductible may be slightly higher.

  • Qualifies for LIS: The Extra Help or Low Income Subsidy (LIS) Program.
    • Yes - This plan qualifies for the $0 Premium for those persons with a full LIS or Extra Help benefit. Persons on the LIS program who select a qualifying plan will also pay a $0 deductible, pay lower cost-sharing payments and have coverage through the Coverage Gap or Doughnut Hole.

    • No - This plan does not qualify for the $0 Premium for persons with the full LIS benefit.

  • Plan ID: This is the Medicare Part D prescription drug plan's unique ID.
  • Drug Tier Information - Drug Tiers are the logical grouping of prescription drugs on a Part D plan formulary. These fields represent the Tier (or drug list group) - for this particular medication - on this particular plan’s Formulary or Drug List.
    • Tier Number - This is the actual numerical tier level from the formulary. Most Part D plans have four (4) tiers 1=Preferred Generics, 2=Preferred Brands, 3=Non-preferred Brands and Generics, 4=Specialty Drugs.
    • Drug Description - This is the Medicare Part D plan’s description of this particular drug tier.
  • Cost Sharing - Copay / Coinsurance - These figures apply to the initial coverage phase of your plan. This is the phase after the initial deductible has been met and before you reach the Coverage Gap (Donut Hole). Plans often cover drugs in "tiers". Tiers are specific to the list of drugs covered by the plan. Plans may have several tiers, and the copay for a drug depends on the drug’s tier. The drug Tier is shown to the left of this column. These cost sharing figures DO NOT necessarily apply to the Coverage Gap. The plan may have a separate copay/coinsurance for the same drug while in the Coverage Gap. There are two figures shown under this "Cost Sharing" category:
    • Preferred Network Pharmacy - (Preferred Pharm) - This is the cost-share amount you would pay during the intial coverage phase for a 30-Day supply (until your total retail prescription drug costs reach $2930) at a "Preferred" network pharmacy. In most cases, the "Preferred" network and network pharmacy pricing are the same. However, for example on the 2012 Humana Walmart-Preferred Rx Plan the cost-sharing is much higher at a network pharmacy over a "Preferred" network pharmacy. "Preferred" network pharmacies for this plan include only Walmart, Sam’s Club and RightSource.
    • Mail Order - This is the cost-share amount you would pay during the initial coverage phase for a 90-Day supply if you purchased your medication through your plan’s preferred mail order partner(s).
  • Drug Utilization Management or Coverage Rules - (Drug Usage Mgmt) - This shows the plan requires drug utilization management controls for this particular medication.
    • None - This drug does not fall under any drug utilization management controls.
    • P - Prior Authorization -This drug is subject to prior authorization.
    • S - Step Therapy -This drug is subject to step therapy.
    • Q - Quantity Limits -This drug is subject to quantity limits. The actual quantity limit is shown as Q:Amount/Days. For Example: Q:6/28Days means the quantity limit is a quantity of 6 pills per 28 days. Q:90/365Days would mean that the plan limits this drug to 90 pills for the entire year.




(Chart Source: Centers for Medicare and Medicaid files: CMS Data September 2012 )

Please note: The above plan information comes from CMS. We make every attempt to keep our information up-to-date with plan/premium changes. However, the Medicare Part D plan data changes over time and we cannot guarantee the accuracy of this information. You should always verify cost and coverage information with your Part D plan provider.