BlueJourney PPO Prescription Drug Benefits

 


Prime

Classic

Deductible

$0

$0

Tier 1 Preferred Generics

$3/$8

$3/$10

Tier 2 Generic Drugs

$15/$20

$15/$20

Tier 3 Preferred Brand

$42/$47

$42/$47

Tier 4 Nonpreferred Drugs

$95/$100

$95/$100

Tier 5 Specialty Drugs

33 percent

(30 day supply only)

33 percent

(30 day supply only)

After initial coverage limit reached

44 percent generic;

35 percent brand

44 percent generic;

35 percent brand

Part D Excluded Drugs

Not covered

Not covered

Updated October 1, 2018

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