Initial Coverage:
tooltip_Until yearly drug costs reach $3,310, you'll pay..._2024
Coverage Gap
tooltip_After costs paid by you and the drug plan are greater than $3,310 and your out-of-pocket is less than $4,850, you'll pay..._2024
Catastrophic Coverage
tooltip_After your out-of-pocket costs plus the amount of the drug manufacturer's discounts reach $4,850, you'll pay…_2024
Prescription Drug Coverage
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Prescription Drug Deductible The amount you must pay before our plan begins to pay its share of your covered drugs. |
$0 |
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In-Network Prescription Drug Coverage - Initial Coverage During the Initial Coverage Stage, the plan pays its share of the cost of your drugs and you pay your share of the cost based on the Tier of the drug. You stay in this stage until your total drug costs (both your payments plus any plan payments) reach the Initial Coverage Limit (ICL). Once your reach the ICL, you move into the Coverage Gap Stage. |
Tier 1 - Preferred Generics
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Coverage in the coverage gap In the coverage gap, you may pay more for your drugs than you did in the initial coverage stage. That’s why it’s called a “gap”. You stay in the coverage gap until your total out-of-pocket drug costs reach the Initial Coverage Limit. |
This plan has coverage in the Part D coverage gap. Tier 1 (preferred generic drugs) and Tier 2 (generic drugs) medications are covered in the coverage gap. For these tiers, you continue to pay the same cost-sharing amounts as in the Initial Coverage Stage. You pay no more than $3 for Tier 1 medications at a network retail pharmacy. You pay no more than $10 for Tier 2 medications at a network retail pharmacy. You will pay no more than 25% of the costs for generics in all other tiers. For all brand drugs you pay no more than 25% of the costs. |
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Catastrophic Coverage Once you reach the Catastrophic Stage, you pay a small copay and the plan will pay most of the cost of your drugs for the rest of the year. |
$0 copay |
Out of Network Coverage
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Prescription Drugs Prescription Drugs |
Normally, we cover drugs filled at an out-of-network pharmacy only if you are not able to use one of our network pharmacies (for example, because you are traveling, need emergency or urgent care, or need a drug that it not available at an accessible network pharmacy). Chapter 3 of the Evidence of Coverage provides a full list of situations in which we may cover drugs from an out-of-network pharmacy. (See "Plan Documents" below.) |
Plan Documents
| Summary of Benefits (PDF) |
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| Evidence of Coverage (PDF) |
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| Plan Rating (PDF) |
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| General Transition Notice (PDF) |
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| Low Income Subsidy Premium Summary Table for Those Receiving Extra Help (PDF) |
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| BlueMedicare RX (PDP) Comprehensive Formulary (PDF) |
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| Annual Notice of Change |
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| Enrollment Form |
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Care Coordination Team
A dedicated consultant to assist with coordinating appointments, in or outpatient stays, management of chronic conditions and help with finding the best price on procedures and prescriptions.
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