| Benefit Category |
Original Medicare |
Standard Copay Plan |
Enhanced Copay |
Enhanced Plus Copay |
| Medicare Part B prescription drugs |
You pay 100% for most prescription drugs, unless you enroll in the Medicare Prescription Drug Plan. |
This plan does not cover Medicare Part B prescription drugs. |
This plan does not cover Medicare Part B prescription drugs. |
This plan does not cover Medicare Part B prescription drugs. |
| Formulary |
|
This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsil.com on the web.
|
This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsil.com on the web.
|
This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsil.com on the web.
|
| Indian/ Tribal/ Urban (Indian Health Service) |
|
People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.
|
People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.
|
People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.
|
| Deductible |
|
There is no deductible.
|
There is no deductible.
|
There is no deductible.
|
| Retail in-network preferred pharmacy (30 day supply) |
|
| - |
$5 for a 30-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$40 for a 30-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$59 for a 30-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| - |
$8 for a 30-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$30 for a 30-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$70 for a 30-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| - |
$5 for a 30-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$20 for a 30-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$50 for a 30-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| Retail in-network preferred pharmacy (90 day supply) |
|
| - |
$10 for a 90-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$80 for a 90-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$118 for a 90-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| - |
$16 for a 90-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$60 for a 90-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$140 for a 90-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| - |
$10 for a 90-day supply of generic drugs you get at an in-network preferred pharmacy |
| - |
$40 for a 90-day supply of preferred brand name drugs you get at an in-network preferred pharmacy |
| - |
$100 for a 90-day supply of other brand name drugs you get at an in-network preferred pharmacy
|
|
| Retail in-network non-preferred pharmacy (30 day supply) |
|
| - |
$5 for a 30-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$40 for a 30-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$59 for a 30-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| - |
$8 for a 30-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$30 for a 30-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$70 for a 30-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| - |
$5 for a 30-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$20 for a 30-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$50 for a 30-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| Retail in-network non-preferred pharmacy (90 day supply) |
|
| - |
$15 for a 90-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$120 for a 90-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$177 for a 90-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| - |
$24 for a 90-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$90 for a 90-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$210 for a 90-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| - |
$15 for a 90-day supply of generic drugs you get at an in-network non-preferred pharmacy |
| - |
$60 for a 90-day supply of preferred brand name drugs you get at an in-network non-preferred pharmacy |
| - |
$150 for a 90-day supply of other brand name drugs you get at an in-network non-preferred pharmacy
|
|
| Mail order pharmacy |
|
| - |
$10 for a 90-day supply of mail order generic drugs |
| - |
$80 for a 90-day supply of mail order preferred brand name drugs |
| - |
$118 for a 90-day supply of mail order other brand name drugs
|
|
| - |
$16 for a 90-day supply of mail order generic drugs |
| - |
$60 for a 90-day supply of mail order preferred brand name drugs |
| - |
$140 for a 90-day supply of mail order other brand name drugs
|
|
| - |
$10 for a 90-day supply of mail order generic drugs |
| - |
$40 for a 90-day supply of mail order preferred brand name drugs |
| - |
$100 for a 90-day supply of mail order other brand name drugs
|
|
| Expenses from $2,250 - $5,100 (or $8,200 for Enhanced 1 and $14,400 for Enhanced 2) |
|
After the total yearly drug costs (paid by you and your plan) reach $2,250, you pay 100% per prescription for eligible charges from $2,250 to $5,100.
|
The copay amounts noted above will also apply to eligible expenses from $2,250 to $8,200 (approximately). |
The copay amounts noted above will also apply to eligible expenses from $2,250 to $14,400 (approximately). |
| Expenses beyond $5,100 (or $8,200 for Enhanced 1 and $14,400 for Enhanced 2) |
|
After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
| - |
$2 for generic or preferred brand name drug that is a multi-source drug |
| - |
$5 for other brand name drugs and all other drugs
or |
| - |
5% per prescription
|
|
After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
| - |
$2 for generic or preferred brand name drug that is a multi-source drug |
| - |
$5 for other brand name drugs and all other drugs
or |
| - |
5% per prescription
|
|
After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
| - |
$2 for generic or preferred brand name drug that is a multi-source drug |
| - |
$5 for other brand name drugs and all other drugs
or |
| - |
5% per prescription
|
|
| Quantity limits |
|
Certain prescription drugs will have maximum quantity limits. Contact plan for details.
|
Certain prescription drugs will have maximum quantity limits. Contact plan for details.
|
Certain prescription drugs will have maximum quantity limits. Contact plan for details.
|
| Prior Authorization |
|
Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.
|
Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.
|
Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.
|
| Out-of-network Pharmacies |
|
Covered Part D drugs are available at out-of-network pharmacies in special circumstances including limits while traveling outside of the Plan's service area where there is no network pharmacy.
|
Covered Part D drugs are available at out-of-network pharmacies in special circumstances including limits while traveling outside of the Plan's service area where there is no network pharmacy.
|
Covered Part D drugs are available at out-of-network pharmacies in special circumstances including limits while traveling outside of the Plan's service area where there is no network pharmacy.
|
| Retail out-of-network pharmacy (30 day supply) |
|
| - |
$5 for a 30-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$40 for a 30-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$59 for a 30-day supply of other brand name drugs you get at out-of-network pharmacy
|
|
| - |
$8 for a 30-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$30 for a 30-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$70 for a 30-day supply of other brand name drugs you get at an out-of-network pharmacy
|
|
| - |
$5 for a 30-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$20 for a 30-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$50 for a 30-day supply of other brand name drugs you get at out-of-network pharmacy
|
|
| Retail out-of-network pharmacy (90 day supply) |
|
| - |
$15 for a 90-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$120 for a 90-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$177 for a 90-day supply of other brand name drugs you get at an out-of-network pharmacy |
|
| - |
$24 for a 90-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$90 for a 90-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$210 for a 90-day supply of other brand name drugs you get at an out-of-network pharmacy |
|
| - |
$15 for a 90-day supply of generic drugs you get at an out-of-network pharmacy |
| - |
$60 for a 90-day supply of preferred brand name drugs you get at an out-of-network pharmacy |
| - |
$150 for a 90-day supply of other brand name drugs you get at an out-of-network pharmacy |
|
