BlueJourney HMO Prescription Drug Benefits

Deductible

$0

$0

$0

Tier 1 Preferred Generics

$0/$7

$0/$7

$0/$7

Tier 2 Generic Drugs

$5/$15

$5/$15

$0/$8

Tier 3 Preferred Brand

$40/$47

$40/$47

$40/$47

Tier 4 Nonpreferred Drugs

$93/$100

$93/$100

$93/$100

Tier 5 Specialty Drugs

33 percent

(30 day supply only)

33 percent

(30 day supply only)

33 percent

(30 day supply only)

$0/$7

$0/$7

$0/$7

After initial coverage limit reached

25 percent generic;

25 percent brand

25 percent generic;

25 percent brand

Tier 1 generics: Preferred $0; Nonpreferred $7

Tier 2 generics: Preferred $0; Nonpreferred $8

Tier 6 Select Care: Preferred $0; Nonpreferred $7

Brand: 25 percent

Part D Excluded Drugs

Not covered

Not covered

Not covered