BlueCross Rx Essential (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
$5.00 copay (30-day supply)
$15.00 copay (90-day supply)
Tier 2: Generic
$14.00 copay (30-day supply)
$42.00 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
45% coinsurance (30-day supply)
45% 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
$19.00 copay (30-day supply)
$57.00 copay (90-day supply)
Tier 3: Preferred Brand
$45.00 copay (30-day supply)
$135.00 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
$5.00 copay (30-day supply)
$12.50 copay (90-day supply)
Tier 2: Generic
$14.00 copay (30-day supply)
$22.50 copay (90-day supply)
Tier 3: Preferred Brand
$40.00 copay (30-day supply)
$100.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
45% coinsurance (30-day supply)
45% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Plan Links
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