Blue MedicareRx Premier (PDP)
Health Insurance Company: Blue MedicareRx
Medicare Prescription Drug Part D Plan Details
- Rx
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
$7.00 copay (30-day supply)
$21.00 copay (90-day supply)
Tier 3: Preferred Brand
$30.00 copay (30-day supply)
$90.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$6.00 copay (30-day supply)
$18.00 copay (90-day supply)
Tier 2: Generic
$12.00 copay (30-day supply)
$36.00 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
44% coinsurance (30-day supply)
44% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$1.00 copay (30-day supply)
$1.00 copay (90-day supply)
Tier 2: Generic
$7.00 copay (30-day supply)
$14.00 copay (90-day supply)
Tier 3: Preferred Brand
$30.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 4: Non-Preferred Drug
35% coinsurance (30-day supply)
35% coinsurance (90-day supply)
Tier 5: Specialty Tier
33% coinsurance (30-day supply)
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