BlueCross Rx Value (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
$8.00 copay (30-day supply)
$24.00 copay (90-day supply)
Tier 2: Generic
$18.00 copay (30-day supply)
$54.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$126.00 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
$12.00 copay (30-day supply)
$36.00 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
46% coinsurance (30-day supply)
46% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$8.00 copay (30-day supply)
$20.00 copay (90-day supply)
Tier 2: Generic
$18.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 3: Preferred Brand
$42.00 copay (30-day supply)
$105.00 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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