BlueMedicare Value Rx (PDP) Formulary



Below is the 2022 Formulary, or prescription drug list, from Usable Mutual Insurance Company for BlueMedicare Value Rx (PDP)( S5795-003). A formulary is a list of prescription medications that are covered under Usable Mutual Insurance Company's 2022 Medicare Part-D in Arkansas.

This BlueMedicare Value Rx (PDP) plan has a $400 drug deductible. A deductible is the amount of expenses that must be paid out of pocket before the Initial Coverage period begins. However some drugs do not require that the deductible is met before you receive coverage. You can see if the deductible is required below in the "Does the Deductible Apply" column.

The Initial Coverage Limit (ICL) for this plan is $4430. 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 $4430 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" be clicking the "Coverage Gap" link on the left above the chart.

In 2022 if you have spent $7550 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. BlueMedicare Value Rx (PDP) 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 on the left above the chart.




Plan Name:BlueMedicare Value Rx (PDP)
Plan ID: S5795-003
Formulary
Provider: Usable Mutual Insurance Company
Plan Year:2022
Premium:$50.90
Deductible:$400
Initial Coverage Limit:$4430
Coverage Area:Arkansas


Change Table Options:

Drugs Starting Letter:
Coverage Phase:

⇅ Click the Header to Sort
Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Baclofen
2NNA$10NANN
Balsalazide Disodium
4YNA47%NANN
Balversa
5NA26%NA30/30YN
Balziva
4YNA47%NANN
Baraclude
5NA26%NANN
Bcg Vaccine
3YNA$45NANN
Benazepril Hydrochloride And Hydrochlorothiazide
2NNA$10NANN
Benznidazole
4YNA47%NANN
Benztropine Mesylate
2NNA$10NAYN
Bethanechol Chloride
3YNA$45NANN
Bexarotene
5NA26%NAYN
Bexsero
3YNA$45NANN
Bicillin L-a
4YNA47%NANN
Biktarvy
5NA26%NA30/30NN
Bisoprolol Fumarate
2NNA$10NANN
Blisovi 24 Fe
4YNA47%NANN
Blisovi Fe 1.5/30
4YNA47%NANN
Boostrix
3YNA$45NANN
Bosulif
5NA26%NA30/30YN
Braftovi
5NA26%NA180/30YN
Breo Ellipta
3YNA$45NA60/30NN
Briellyn
4YNA47%NANN
Brilinta
3YNA$45NANN
Brimonidine Tartrate
4YNA47%NANN
Briviact
5NA26%NANN
Budesonide
4YNA47%NA90/30NN
Bumetanide
3YNA$45NANN
Buprenorphine
2NNA$10NA90/30NN
Buprenorphine And Naloxone
2NNA$10NA60/30NN
Buprenorphine Hcl
2NNA$10NA90/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2NNA$10NA90/30NN
Bupropion Hydrochloride
3YNA$45NA30/30NN
Buspirone Hydrochloride
2NNA$10NANN
Butalbital, Aspirin, And Caffeine
3YNA$45NA180/30NN
Bydureon Bcise
3YNA$45NA/28NY

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5795-003

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1.Pre-Deductable: Before you reach the plans deductible of $400. 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 $4430
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $7550 in 2022.
4.Catastrophic: Anything over $7550 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 in order 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 plans 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.

Source:CMS Formulary Data Q1 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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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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