| BlueMedicareRx Plans |
Value |
Plus |
Premier |
| You pay a Monthly Premium of |
$28.70 |
$43.40 |
$68.80 |
| Annual Deductible |
$275 |
$0 |
$0 |
| You pay a flat-dollar amount (copayment) or a percentage of the cost (coinsurance) for covered generic, brand or other prescription drugs, until the annual cost of prescription drug expenses reaches $2510. This includes any deductible, copayments or coinsurance. This is your Initial Coverage |
30-day Retail Pharmacy
Generic: $5
Brand: $24
Non-preferred Brand: $65
Injectable Drugs: 25%
|
30-day Retail Pharmacy
Generic: $8
Brand: $30
Non-preferred Brand: $60
Injectable Drugs: 33%
|
30-day Retail Pharmacy
Generic: $2
Brand: $30
Non-preferred Brand: $60
Injectable Drugs: 33%
|
90-day Retail Pharmacy
Generic: $15
Brand: $72
Non-preferred Brand: $195
Injectible Drugs: 25%
|
90-day Retail Pharmacy
Generic: $24
Brand: $90
Non-preferred Brand: $180
Injectible Drugs: 33%
|
90-day Retail Pharmacy
Generic: $6
Brand: $90
Non-preferred Brand: $180
Injectable Drugs: 33%
|
90-day Pref. Mail Order
Generic: $7.50
Brand: $60
Non-preferred Brand: $162.50
Injectable Drugs: 25%
|
90-day Pref. Mail Order
Generic: $12
Brand: $75
Non-preferred Brand: $150
Injectable Drugs: 33% |
90-day Pref. Mail Order
Generic: $3
Brand: $75
Non-preferred Brand: $150
Injectable Drugs: 33%
|
| You pay the cost for covered prescription drug expenses between $2510 in drug costs and $4050 in annual out-of-pocket costs. This is called the Coverage Gap |
|
|
30-day Retail Pharmacy
Generic: $2
|
90-day Retail Pharmacy
Generic: $6 |
90-day Pref. Mail Order
Generic: $3 |
After you have paid $4050 in annual out-of-pocket costs,
you pay a flat-dollar as indicated or 5%, whichever is greater. This is called Catastrophic Coverage. |
Generic: $2.25 or 5%, whichever is greater
All Others: $5.60 or 5%, whichever is greater
|
