BlueJourney PPO Prescription Drug Benefits

 


Prime

Classic

Deductible

$0

$0

Tier 1 Preferred Generics

$0/$8

$0/$10

Tier 2 Generic Drugs

$5/$20

$5/$20

Tier 3 Preferred Brand

$40/$47

$40/$47

Tier 4 Nonpreferred Drugs

$93/$100

$93/$100

Tier 5 Specialty Drugs

33 percent

(30 day supply only)

33 percent

(30 day supply only)

Tier 6 Select Care Drugs
$0/$7 $0/$7

After initial coverage limit reached

25 percent generic;

25 percent brand

25 percent generic;

25 percent brand

Part D Excluded Drugs

Not covered

Not covered

Web Content Viewer - Fixed Context

Updated November 1, 2019

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