BlueCross Rx Plus (PDP)
Health Insurance Company: Blue Cross Blue Shield of South Carolina
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
$3.00 copay (30-day supply)
$9.00 copay (90-day supply)
Tier 3: Preferred Brand
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
40% coinsurance (30-day supply)
40% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 2: Generic
$8.00 copay (30-day supply)
$24.00 copay (90-day supply)
Tier 3: Preferred Brand
$27.00 copay (30-day supply)
$81.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
45% coinsurance (30-day supply)
45% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% 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
$3.00 copay (30-day supply)
$7.50 copay (90-day supply)
Tier 3: Preferred Brand
$20.00 copay (30-day supply)
$50.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
40% coinsurance (30-day supply)
40% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Plan Links
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