Blue Cross MedicareRx Choice (PDP)
Health Insurance Company: Blue Cross and Blue Shield of IL, NM, OK, TX
Medicare Prescription Drug Part D Plan Details
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
$7.00 copay (30-day supply)
$21.00 copay (90-day supply)
Tier 3: Preferred Brand
$46.00 copay (30-day supply)
$138.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$15.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$15.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
$47.00 copay (30-day supply)
$141.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$7.00 copay (30-day supply)
$21.00 copay (90-day supply)
Tier 3: Preferred Brand
$46.00 copay (30-day supply)
$138.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
38% coinsurance (30-day supply)
38% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Plan Links
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