Blue Shield Rx Plus (PDP)
Health Insurance Company: Blue Shield of California
Medicare Prescription Drug Part D Plan Details
- Rx
General Plan Details
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$3.00 copay (30-day supply)
$7.50 copay (90-day supply)
Tier 2: Generic
$14.00 copay (30-day supply)
$35.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (30-day supply)
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
47% coinsurance (30-day supply)
47% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$9.00 copay (30-day supply)
$27.00 copay (90-day supply)
Tier 2: Generic
$20.00 copay (30-day supply)
$60.00 copay (90-day supply)
Tier 3: Preferred Brand
20% coinsurance (30-day supply)
20% 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
$7.50 copay (90-day supply)
Tier 2: Generic
$35.00 copay (90-day supply)
Tier 3: Preferred Brand
18% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
47% coinsurance (90-day supply)
Tier 5: Specialty Tier
25% coinsurance (30-day supply)
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