Prescription Blue Premium (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Prescription Blue Premium (PDP) by Bcbs Of Michigan Mutual Insurance Company. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a 2023 Medicare Part-D in Michigan plan that covers your prescriptions. It also helps you compare costs among Medicare Part D and Medicare Advantage plans available to you. You’ll want to make sure the medicines you are currently taking are covered under any plans you are considering enrolling in.

This Prescription Blue Premium (PDP)(S5584-002) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $4660. The Initial Coverage Period is the period after the Deductible has been met but before the Coverage Gap phase. Once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will enter the coverage gap. (AKA "donut hole") Once you reach the coverage gap you will be required to pay 25% of the plan's cost for covered brand-name prescription drugs unless your plan offers additional coverage. You can see if this plan offers coverage in the "donut hole" by clicking the "Coverage Gap" link above the chart.

In 2023 if you have spent $7400 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Bcbs Of Michigan Mutual Insurance Company will begin paying approximately 95% of your covered medication expenses. You can see if this plan covers your drugs in the Catastrophic Phase by clicking the "Catastrophic" link above the chart.



Plan Overview

Plan Name:Prescription Blue Premium (PDP)
Plan ID: S5584-002
Formulary
Provider: Bcbs Of Michigan Mutual Insurance Company
Plan Year:2023
Premium:$112.00
Deductible:$0
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:S5584-001


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

*Tip Click the Drug name to Compare Coverage and Retail Cost for Every Plan In Your Area
⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
2$5$10$590/90NN
Panretin
533%33%33%60/30YN
Paricalcitol
2$5$10$5NN
Paromomycin Sulfate
2$5$10$5NN
Paroxetine
445%45%45%2700/90NN
Paroxetine Hydrochloride
2$5$10$5180/90NN
Paser
445%45%45%NN
Pediarix
3$40$45$40NN
Pedvaxhib
3$40$45$40NN
Peg-3350 And Electrolytes
2$5$10$5NN
Pegasys
533%33%33%4/28NN
Pemazyre
533%33%33%14/21YN
Penicillamine
533%33%33%NN
Penicillin G Procaine
445%45%45%NN
Penicillin G Sodium
533%33%33%NN
Penicillin V Potassium
1$1$6$1NN
Pentacel
3$40$45$40NN
Pentamidine Isethionate
445%45%45%NN
Pentasa
445%45%45%NN
Pentoxifylline
2$5$10$5NN
Perindopril Erbumine
1$1$6$1180/90NN
Periogard Alcohol Free
2$5$10$5NN
Permethrin
2$5$10$5NN
Perphenazine
2$5$10$5NN
Perseris
533%33%33%1/30NY
Phenelzine Sulfate
2$5$10$5NN
Phenobarbital
3$40$45$40360/90YN
Phenytoin
2$5$10$5NN
Pifeltro
533%33%33%NN
Pilocarpine Hydrochloride
2$5$10$5NN
Pimozide
2$5$10$5NN
Pindolol
1$1$6$1NN
Pioglitazone And Glimepiride
1$1$6$190/90NN
Piperacillin And Tazobactam
445%45%45%NN
Piqray
533%33%33%60/30YN
Piroxicam
2$5$10$5NN
Plenamine
445%45%45%YN
Podofilox
445%45%45%NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2$5$10$5NN
Polymyxin B Sulfate And Trimethoprim
2$5$10$5NN
Potassium Chloride
2$5$10$5NN
Potassium Chloride In Dextrose
445%45%45%NN
Potassium Chloride In Dextrose And Sodium Chloride
445%45%45%NN
Potassium Chloride In Lactated Ringers And Dextros
445%45%45%NN
Potassium Chloride In Sodium Chloride
445%45%45%NN
Potassium Citrate
2$5$10$5NN
Pramipexole Dihydrochloride
445%45%45%NN
Prasugrel
3$40$45$40NN
Pravastatin Sodium
1$1$6$1180/90NN
Praziquantel
2$5$10$5NN
Prazosin Hydrochloride
2$5$10$5NN
Pred Mild
445%45%45%NN
Pred-g
445%45%45%NN
Prednisolone Acetate
2$5$10$5NN
Prednisolone Sodium Phosphate
2$5$10$5NN
Prednisolone Sodium Phosphate Oral Solution
2$5$10$5NN
Prednisone
2$5$10$5NN
Prednisone Intensol
2$5$10$5NN
Pregabalin
445%45%45%2700/90NN
Premasol - Sulfite-free (amino Acid)
445%45%45%YN
Pretomanid
445%45%45%90/90YN
Prevymis
533%33%33%NN
Prezcobix
533%33%33%31/31NN
Prezista
533%33%33%31/31NN
Priftin
445%45%45%NN
Primaquine Phosphate
3$40$45$40NN
Primidone
2$5$10$5NN
Probenecid
2$5$10$5NN
Probenecid And Colchicine
2$5$10$5NN
Prochlorperazine Maleate
2$5$10$5NN
Procrit
533%33%33%YN
Procto-med Hc
2$5$10$590/90NN
Proctosol-hc
2$5$10$590/90NN
Proctozone-hc
2$5$10$590/90NN
Progesterone
2$5$10$5NN
Prograf
3$40$45$40YN
Prolastin-c
533%33%33%YN
Prolia
445%45%45%1/180YN
Promacta
533%33%33%62/31YN
Promethazine Hydrochloride
2$5$10$5NN
Propafenone Hydrochloride
445%45%45%NN
Propranolol Hydrochloride
1$1$6$1NN
Propylthiouracil
2$5$10$5NN
Proquad
3$40$45$40NN
Protriptyline Hydrochloride
2$5$10$5NN
Pulmicort
3$40$45$406/90NN
Pulmozyme
533%33%33%YN
Purixan
533%33%33%NN
Pyrazinamide
2$5$10$5NN
Pyridostigmine Bromide
2$5$10$5NN
Pyrimethamine
533%33%33%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5584-002

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $0. Some plans offer select Pre-deductible drug Coverage
2. Initial Coverage: (ICL) After you reach the plans deductible but before the Initial Coverage limit of $4660
3. Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7400 in 2023.
4. Catastrophic: Anything over $7400 you will receive a significant increase in coverage.

Definitions:

Premium: A monthly flat fee that varies by plan.
Deductible: The amount you must pay each year for your prescriptions before your plan begins to pay its share of your covered drugs. The max in 2022 is $320. Some plans have a $0 Deductible.
Tier Level: Medicare drug plans place drugs into different "tiers" on their formularies. Drugs in each tier have a different cost. A drug in a lower tier will generally cost you less.
Quantity Limit Amount/Days: Certain drugs have a Quantity Limit. That means the plan will only cover the drug up to a designated quantity or amount. If your prescribing doctor feels it is necessary to exceed the set limit, he or she must get prior approval before the higher quantity will be covered.
Prior Authorization: Certain Drugs require you or your doctor to get prior authorization to be covered. Usually just an additional form. If you dont get approval, the plan may not cover the drug.
Does the Deduct Apply: Some drugs do not require that the deductible is met before you receive coverage.
Step Therapy: Means you must first try one drug to treat your medical condition before the plan will cover another drug for the same condition. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
Cost Preferred: Your Cost for the Drug at the Providers In-Network Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non-Preferred: Your Cost for the Prescription Drug at a Non-Preferred Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Mail: Your Cost for Prescription Drugs through a Mail Order Pharmacy. As a Percent of the total drug cost or a flat rate.


What if a drug I need is not listed?

Please check the formulary for different brand and generic names. If you still cannot locate your drugs, your plan may not offer coverage. Talk to your doctor first about changing your prescription to a drug on your plan's formulary. If this is not an option, you can request an exception to have the plan review its coverage decision based on your individual circumstances.

Last updated on
Source:CMS Formulary Data Q4 2022
Source:NDC Directory by FDA.gov

**We make every attempt to keep our information accurate. But please check with the plan providers to verify all information.

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