Blue Cross MedicareRx Basic (PDP)
Health Insurance Company: Blue Cross and Blue Shield of IL, NM, OK, TX
Medicare Prescription Drug Part D Plan Details
- Rx
General Plan Details
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$1.00 copay (30-day supply)
$3.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$15.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 3: Preferred Brand
19% coinsurance (30-day supply)
19% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$15.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 3: Preferred Brand
19% coinsurance (30-day supply)
19% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Preferred Mail Order Cost
Tier 1: Preferred Generic
$1.00 copay (30-day supply)
$3.00 copay (90-day supply)
Tier 2: Generic
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
48% coinsurance (30-day supply)
48% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
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