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
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
$3.00 copay (30-day supply)
$9.00 copay (90-day supply)
Tier 3: Preferred Brand
$35.00 copay (30-day supply)
$105.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$9.00 copay (30-day supply)
$27.00 copay (90-day supply)
Tier 2: Generic
$13.00 copay (30-day supply)
$39.00 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$9.00 copay (30-day supply)
$27.00 copay (90-day supply)
Tier 2: Generic
$13.00 copay (30-day supply)
$39.00 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$120.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% 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
$3.00 copay (30-day supply)
$9.00 copay (90-day supply)
Tier 3: Preferred Brand
$35.00 copay (30-day supply)
$105.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
50% coinsurance (30-day supply)
50% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Plan Links
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