BlueJourney HMO Prescription Drug Benefits

 


Essential HMO

Value HMO

Premier HMO

Deductible

$0

$0

$0

Tier 1 Preferred Generics

$4/$10

$4/$9

$3/$8

Tier 2 Generic Drugs

$15/$20

$12/$17

$10/$15

Tier 3 Preferred Brand

$42/$47

$42/$47

$42/$47

Tier 4 Nonpreferred Drugs

$95/$100

$95/$100

$95/$100

Tier 5 Specialty Drugs

33 percent

(30 day supply only)

33 percent

(30 day supply only)

33 percent

(30 day supply only)

After initial coverage limit reached

37 percent generic;

25 percent brand

37 percent generic;

25 percent brand

Tier 1 generics:

Preferred $3;

Nonpreferred $8

Tier 2 generics:

Preferred $10;

Nonpreferred $15

Brand: 25 percent

Part D Excluded Drugs

Not covered

Not covered

Not covered

Updated October 1, 2018

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