BlueJourney PPO Prescription Drug Benefits

 

Prime PPO 
Preferred/Standard

Classic PPO 
Preferred/Standard

Select PPO 
Preferred/Standard

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 Insulin Saver Program

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 brands

Not covered

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Updated October 1, 2020

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