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Plain Page Title DnD
BlueJourney PPO Prescription Drug Benefits
Plain Page with Image DnD
|
Prime PPO |
Classic PPO |
Select PPO |
---|---|---|---|
Deductible |
$0 |
$0 |
$0 |
Tier 1 Preferred Generics |
$0/$8 |
$0/$10 |
$8/$15 |
Tier 2 Generic Drugs |
$5/$20 |
$5/$20 |
$12/$20 |
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% (30 day supply only) |
33% (30 day supply only) |
33% (30 day supply only) |
Tier 6 Select Care Drugs | $0/$7 | $0/$7 | $0/$7 |
After initial coverage limit reached |
25% generic, 25% brand |
||
Part D Excluded Drugs |
Not covered |
||
Part D Senior Saver Model |
During the initial and coverage gap stage, your out-of-pocket costs for select insulins will be a $5 copay for 30-day supply of our preferred insulin brands1. |
Not covered |
1Select insulin cost-sharing does not apply to members who qualify for low income subsidy.
Web Content Viewer - Fixed Context
Updated October 1, 2020
Y0016_WBST21_M