BlueCross Rx Value (PDP)
Health Insurance Company: Blue Cross Blue Shield of South Carolina
Medicare Prescription Drug Part D Plan Details
- Rx
General Plan Details
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$12.00 copay (30-day supply)
$36.00 copay (90-day supply)
Tier 2: Generic
$17.00 copay (30-day supply)
$51.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (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
$15.00 copay (30-day supply)
$45.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (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
$12.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 2: Generic
$17.00 copay (30-day supply)
$42.50 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (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)
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