Anthem MediBlue Rx Plus (PDP)
Health Insurance Company: Anthem / Anthem or Blue KC in Missouri
Medicare Prescription Drug Part D Plan Details
- Rx
General Plan Details
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$4.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$4.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 2: Generic
$8.00 copay (30-day supply)
$24.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$4.00 copay (30-day supply)
$12.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
31% coinsurance (30-day supply)
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