2015 Platinum Blue Complete Plan with Rx (Cost) Drug Coverage Details



Below is the Formulary, or drug list, for Platinum Blue Complete Plan with Rx (Cost) from Blue Cross And Blue Shield Of Minnesota This formulary is a list of prescription medications that are covered under Blue Cross And Blue Shield Of Minnesota's 2015 Medicare Advantage Plan. The Platinum Blue Complete Plan with Rx (Cost) plan has a $0 drug deductible. The Initial Coverage Limit (ICL) for this plan is $2960. 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 $2960 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 45% 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 2015 if you have spent $4700 in expenditures you enter the Catastrophic Phase. During the Catastrophic Period you will begin to receive significant coverage. Platinum Blue Complete Plan with Rx (Cost) 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:
Platinum Blue Complete Plan with Rx (Cost)
Plan ID:
H2461-010
Provider: Blue Cross And Blue Shield Of Minnesota
Plan Year:2015
Premium:$46.90
Deductible:$0
Initial Coverage Limit:$2960
Coverage Area:Minnesota






Current Table info:


Coverage level : Initial Coverage
Days Supply : 30 Days
Drugs Starting With Letter: B



Change Table Options:


Drugs Starting Letter:
A  B  C  D  E  F  G  H  I  J  K  L  M 
N  O  P  Q  R  S  T  U  V  W  X  Y  Z 

Coverage Level:
Initial Coverage
Coverage Gap, Catastrophic

Drug Days Pricing:
30 Day Supply, 60 Day Supply, 90 Day Supply

(Mouse over for Tips)
(Click the Drug Name to Compare every Plans Price)

Drug Name Drug Strength Units in Package Tier Level Amount Limit Days Limit Prior Authorization Y/N Step Therapy Y/N Cost Prefered Max Cost Pref Cost Non Pref Max Cost Non Pref Cost Amt Mail Max Cost Mail
Bacitracin 500[USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
4
N N N N 45%None45%None45%None
Bacitracin Zinc And Polymyxin B Sulfate 500; 10000[USP'U]/g; [USP'U]/g 1 Tube In 1 Carton > 3.5 G In 1 Tube
2
N N N N $14None$14None$14None
Baclofen 20mg 500 Tablet In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Baclofen 10mg 500 Tablet In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Balsalazide Disodium 750mg 280 Capsule In 1 Bottle
2
N N N N $14None$14None$14None
Balziva 6 Pouch In 1 Carton > 1 Blister Pack In 1 Pouch > 1 Kit In 1 Blister Pack
2
N N N N $14None$14None$14None
Banzel 200mg 120 Tablet, Film Coated In 1 Bottle
4
N N N N 45%None45%None45%None
Banzel 400mg 120 Tablet, Film Coated In 1 Bottle
4
N N N N 45%None45%None45%None
Banzel 40mg/mL 1 Bottle In 1 Carton > 460 Ml In 1 Bottle
4
N N N N 45%None45%None45%None
Baraclude .5mg 1 Bottle In 1 Carton > 30 Tablet, Film Coated In 1 Bottle
4
N N N N 45%None45%None45%None
Baraclude 1mg 1 Bottle In 1 Carton > 30 Tablet, Film Coated In 1 Bottle
4
N N N N 45%None45%None45%None
Baraclude .05mg/mL 1 Bottle In 1 Carton > 210 Ml In 1 Bottle
4
N N N N 45%None45%None45%None
Bcg Vaccine 50mg 1 Vial In 1 Carton
4
N N N N 45%None45%None45%None
Benazepril Hydrochloride 5mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Benazepril Hydrochloride 10mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Benazepril Hydrochloride 20mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Benazepril Hydrochloride 40mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Benazepril Hydrochloride And Hydrochlorothiazide 5; 6.25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Benazepril Hydrochloride And Hydrochlorothiazide 10; 12.5mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Benazepril Hydrochloride And Hydrochlorothiazide 20; 12.5mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Benazepril Hydrochloride And Hydrochlorothiazide 20; 25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Benicar 5mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
60 30 N N $40None$40None$40None
Benicar 20mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N $40None$40None$40None
Benicar 40mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N $40None$40None$40None
Benicar Hct 12.5; 20mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N $40None$40None$40None
Benicar Hct 12.5; 40mg/1; mg 30 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N $40None$40None$40None
Benicar Hct 25; 40mg/1; mg 90 Tablet, Film Coated In 1 Bottle, Plastic
3
30 30 N N $40None$40None$40None
Benztropine Mesylate .5mg 100 Tablet In 1 Bottle, Plastic
4
N N Y N 45%None45%None45%None
Benztropine Mesylate 1mg 100 Tablet In 1 Bottle, Plastic
4
N N Y N 45%None45%None45%None
Benztropine Mesylate 2mg 100 Tablet In 1 Bottle
4
N N Y N 45%None45%None45%None
Besivance 6mg/mL 1 Bottle, Dropper In 1 Carton > 5 Ml In 1 Bottle, Dropper
4
N N N N 45%None45%None45%None
Betamethasone Dipropionate .5mg/mL 1 Bottle In 1 Carton > 60 Ml In 1 Bottle
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .5mg/mL 60 Ml In 1 Bottle
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .5mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .5mg/g 50 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .64mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Dipropionate .5mg/g 1 Tube In 1 Carton > 50 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Valerate 1.2mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Valerate 1mg/g 1 Tube In 1 Carton > 45 G In 1 Tube
2
N N N N $14None$14None$14None
Betamethasone Valerate 1mg/mL 1 Bottle, Plastic In 1 Carton > 60 Ml In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Betaseron 14 Tray In 1 Box > 1 Kit In 1 Tray * 1 Ml In 1 Vial, Single-use * 1.2 Ml In 1 Syringe
4
15 30 Y N 45%None45%None45%None
Betaxolol 5mg/mL 1 Vial In 1 Carton > 10 Ml In 1 Vial
2
N N N N $14None$14None$14None
Betaxolol 10mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N $14None$14None$14None
Betaxolol 20mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N $14None$14None$14None
Bethanechol Chloride 25mg 100 Tablet In 1 Bottle
2
N N N N $14None$14None$14None
Bethanechol Chloride 50mg 100 Tablet In 1 Bottle
2
N N N N $14None$14None$14None
Bethanechol Chloride 5mg 100 Tablet In 1 Bottle
2
N N N N $14None$14None$14None
Bethanechol Chloride 10mg 100 Tablet In 1 Bottle
2
N N N N $14None$14None$14None
Betoptic S 2.8mg/mL 10 Ml In 1 Bottle, Plastic
4
N N N N 45%None45%None45%None
Bicalutamide 50mg 30 Tablet, Film Coated In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Bicillin L-a 600000[iU]/mL 10 Syringe In 1 Package
4
N N N N 45%None45%None45%None
Bicillin L-a 1200000[iU]/2mL 10 Syringe In 1 Package
4
N N N N 45%None45%None45%None
Bicillin L-a 2400000[iU]/4mL 10 Syringe In 1 Package
4
N N N N 45%None45%None45%None
Bicnu 1 Kit In 1 Carton * 30 Ml In 1 Vial, Single-dose * 3 Ml In 1 Vial
4
N N N N 45%None45%None45%None
Biltricide 600mg 6 Tablet, Film Coated In 1 Bottle
4
N N N N 45%None45%None45%None
Bisoprolol Fumarate 5mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N $14None$14None$14None
Bisoprolol Fumarate 10mg 100 Tablet, Film Coated In 1 Bottle
2
N N N N $14None$14None$14None
Bisoprolol Fumarate And Hydrochlorothiazide 2.5; 6.25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Bisoprolol Fumarate And Hydrochlorothiazide 5; 6.25mg/1; mg 100 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Bisoprolol Fumarate And Hydrochlorothiazide 10; 6.25mg/1; mg 500 Tablet, Film Coated In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Bleomycin 30[USP'U] 1 Vial, Single-use In 1 Carton > 1 Injection, Powder, Lyophilized, For Solution In 1 Vial, Single-use
2
N N Y N $14None$14None$14None
Boostrix 8; 2.5; 8; 5; 2.5ug/.5mL; ug/.5mL; ug/.5mL; [iU]/.5mL; [iU]/.5mL 10 Vial In 1 Carton
4
N N N N 45%None45%None45%None
Boostrix 8; 2.5; 8; 5; 2.5ug/.5mL; ug/.5mL; ug/.5mL; [iU]/.5mL; [iU]/.5mL 10 Syringe In 1 Carton
4
N N N N 45%None45%None45%None
Bosulif 100mg 120 Tablet, Film Coated In 1 Bottle
4
120 30 Y N 45%None45%None45%None
Bosulif 500mg 30 Tablet, Film Coated In 1 Bottle
4
30 30 Y N 45%None45%None45%None
Breo Ellipta 100; 25ug/1; ug 1 Tray In 1 Carton > 1 Inhaler In 1 Tray > 30 Powder In 1 Inhaler
3
60 30 N N $40None$40None$40None
Briellyn 3 Blister Pack In 1 Carton > 1 Kit In 1 Blister Pack
2
N N N N $14None$14None$14None
Brilinta 90mg 60 Tablet In 1 Bottle
3
N N N N $40None$40None$40None
Brimonidine Tartrate 2mg/mL 1 Bottle, Dropper In 1 Carton > 10 Ml In 1 Bottle, Dropper
2
N N N N $14None$14None$14None
Brimonidine Tartrate 1.5mg/mL 10 Ml In 1 Bottle
2
N N N N $14None$14None$14None
Brintellix 5mg 30 Tablet, Film Coated In 1 Bottle
4
30 30 N N 45%None45%None45%None
Brintellix 10mg 30 Tablet, Film Coated In 1 Bottle
4
30 30 N N 45%None45%None45%None
Brintellix 20mg 30 Tablet, Film Coated In 1 Bottle
4
30 30 N N 45%None45%None45%None
Bromocriptine Mesylate 5mg 30 Capsule In 1 Bottle, Unit-dose
2
N N N N $14None$14None$14None
Bromocriptine Mesylate 2.5mg 100 Tablet In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Budesonide 3mg 100 Capsule In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Bumetanide .5mg 100 Tablet In 1 Bottle
1
N N N N $4None$4None$4None
Bumetanide 2mg 100 Tablet In 1 Bottle
1
N N N N $4None$4None$4None
Bumetanide .25mg/mL 10 Vial In 1 Box > 4 Ml In 1 Vial
2
N N N N $14None$14None$14None
Bumetanide 1mg 100 Blister Pack In 1 Box, Unit-dose
1
N N N N $4None$4None$4None
Buprenorphine Hcl 2mg 30 Tablet In 1 Bottle
2
N N Y N $14None$14None$14None
Buprenorphine Hcl 8mg 30 Tablet In 1 Bottle
2
N N Y N $14None$14None$14None
Buprenorphine Hydrochloride And Naloxone Hydrochlo 2; .5mg/1; mg 30 Tablet In 1 Bottle
2
N N Y N $14None$14None$14None
Buprenorphine Hydrochloride And Naloxone Hydrochlo 8; 2mg/1; mg 30 Tablet In 1 Bottle
2
N N Y N $14None$14None$14None
Buproban 150mg 100 Tablet, Extended Release In 1 Bottle, Plastic
2
N N N N $14None$14None$14None
Bupropion Hydrochloride 200mg 60 Tablet, Film Coated, Extended Release In 1 Bottle
2
60 30 N N $14None$14None$14None
Bupropion Hydrochloride 150mg 100 Tablet, Extended Release In 1 Bottle
2
60 30 N N $14None$14None$14None
Bupropion Hydrochloride 100mg 60 Tablet, Film Coated, Extended Release In 1 Bottle, Plastic
2
60 30 N N $14None$14None$14None
Bupropion Hydrochloride 75mg 1000 Tablet, Film Coated In 1 Bottle
2
60 30 N N $14None$14None$14None
Bupropion Hydrochloride 100mg 100 Tablet, Film Coated In 1 Bottle
2
120 30 N N $14None$14None$14None
Bupropion Hydrochloride 150mg 500 Tablet, Film Coated, Extended Release In 1 Bottle
2
30 30 N N $14None$14None$14None
Bupropion Hydrochloride 300mg 30 Tablet, Film Coated, Extended Release In 1 Bottle
2
30 30 N N $14None$14None$14None
Buspirone Hcl 5mg 100 Tablet In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Buspirone Hcl 15mg 180 Tablet In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Buspirone Hydrochloride 10mg 100 Tablet In 1 Bottle
1
N N N N $4None$4None$4None
Buspirone Hydrochloride 30mg 60 Tablet In 1 Bottle, Plastic
1
N N N N $4None$4None$4None
Buspirone Hydrochloride 7.5mg 500 Tablet In 1 Bottle
1
N N N N $4None$4None$4None
Busulfex 6mg/mL 8 Vial In 1 Package
4
N N N N 45%None45%None45%None
Butalbital, Acetaminophen And Caffeine With Codein 325; 50; 40; 30mg/1; mg/1; mg/1; mg 100 Capsule In 1 Bottle, Plastic
4
180 30 Y N 45%None45%None45%None
Butalbital, Acetaminophen, Caffeine, And Codeine P 300; 50; 40; 30mg/1; mg/1; mg/1; mg 100 Capsule In 1 Bottle, Plastic
4
180 30 Y N 45%None45%None45%None
Butorphanol Tartrate 10mg/mL 1 Bottle, Spray In 1 Container > 15 Ml In 1 Bottle, Spray
2
N N N N $14None$14None$14None
Butorphanol Tartrate 1mg/mL 10 Vial, Single-dose In 1 Carton > 1 Ml In 1 Vial, Single-dose
2
N N N N $14None$14None$14None
Butorphanol Tartrate 2mg/mL 10 Vial, Single-dose In 1 Carton > 1 Ml In 1 Vial, Single-dose
2
N N N N $14None$14None$14None
Butrans 5ug/h 4 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
3
4 28 N N $40None$40None$40None
Butrans 10ug/h 4 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
3
4 28 N N $40None$40None$40None
Butrans 20ug/h 4 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
3
4 28 N N $40None$40None$40None
Butrans 15ug/h 4 Pouch In 1 Carton > 1 Patch In 1 Pouch > 168 H In 1 Patch
3
4 28 N N $40None$40None$40None
Bydureon 4 Tray In 1 Carton
3
4 28 N N $40None$40None$40None
Bystolic 2.5mg 100 Tablet In 1 Bottle
4
N N N N 45%None45%None45%None
Bystolic 5mg 30 Tablet In 1 Bottle
4
N N N N 45%None45%None45%None
Bystolic 10mg 100 Tablet In 1 Box, Unit-dose
4
N N N N 45%None45%None45%None
Bystolic 20mg 90 Tablet In 1 Bottle
4
N N N N 45%None45%None45%None



Medicare Help's

Additional Notes:



Coverage Levels for H2461-010

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 $2960
3.Coverage Gap: (AKA Donut Hole) After you reach the plans ICL but before the Catastrophic of $4700 in 2015.
4.Catastrophic: Anything over $4700 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 2015 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 Prefered: Your Cost for the Drug at the Providers In Network Prefered Pharmacy. As a Percent of the total drug cost or a flat rate.
Cost Non Pref: Your Cost for the Prescription Drug at a Non-Prefered 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 Oct. 2014
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.

Call For A licensed Sales Agent

1-855-492-4169

  • Mon-Fri 8:30am-8:00pm


Or Enroll Online Here

Call to Enroll!