Platinum Blue Complete Plan with Rx (Cost) Formulary



Below is the 2023 Formulary, or prescription drug list, from Platinum Blue Complete Plan with Rx (Cost) by Bcbsm, Inc. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a Minnesota Medicare Part-C 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 Platinum Blue Complete Plan with Rx (Cost)(H2461-010) plan has a $505 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 $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. Bcbsm, Inc 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:Platinum Blue Complete Plan with Rx
Plan ID: H2461-010
Provider: Bcbsm, Inc
Plan Year:2023
Premium:$66.10
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Minnesota
Similar Plan:H2461-008


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
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Drug
Name⇅
Tier
Level
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
4YNA40%NA30/30YN
Palynziq
5NA25%NAYN
Panretin
5NA25%NAYN
Paricalcitol
3YNA20%NANN
Paromomycin Sulfate
4YNA40%NANN
Paroxetine
4YNA40%NA900/30NN
Paroxetine Hydrochloride
3YNA20%NA60/30NN
Paser
4YNA40%NANN
Pediarix
3YNA20%NANN
Pedvaxhib
3YNA20%NANN
Peg-3350 And Electrolytes
1NNA$0NANN
Peg-3350, Electrolytes, And Ascorbate
1NNA$0NANN
Pegasys
5NA25%NAYN
Pemazyre
5NA25%NA14/21YN
Penicillamine
5NA25%NANN
Penicillin G Potassium
4YNA40%NANN
Penicillin G Sodium
4YNA40%NANN
Penicillin V Potassium
1NNA$0NANN
Pentacel
3YNA20%NANN
Pentamidine Isethionate
3YNA20%NAYN
Pentasa
4YNA40%NA240/30NN
Pentoxifylline
2NNA$9NANN
Perindopril Erbumine
1NNA$0NANN
Periogard Alcohol Free
1NNA$0NANN
Permethrin
2NNA$9NANN
Perphenazine
2NNA$9NAYN
Perseris
5NA25%NA1/28NN
Phenelzine Sulfate
2NNA$9NANN
Phenobarbital
2NNA$9NANN
Phenoxybenzamine Hydrochloride
5NA25%NANN
Phenytoin
2NNA$9NANN
Phoslyra
3YNA20%NANN
Pifeltro
5NA25%NA30/30NN
Pilocarpine Hydrochloride
2NNA$9NANN
Pimecrolimus
4YNA40%NAYN
Pimozide
4YNA40%NANN
Pindolol
2NNA$9NANN
Pioglitazone And Glimepiride
3YNA20%NA30/30NN
Piperacillin And Tazobactam
4YNA40%NANN
Piqray
5NA25%NA60/30YN
Pirmella 1/35
3YNA20%NANN
Piroxicam
2NNA$9NA30/30NN
Plegridy
5NA25%NA1/28YN
Podofilox
2NNA$9NANN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
1NNA$0NANN
Polymyxin B Sulfate And Trimethoprim
1NNA$0NANN
Portia
3YNA20%NANN
Potassium Chloride
2NNA$9NANN
Potassium Chloride In Dextrose
4YNA40%NANN
Potassium Chloride In Dextrose And Sodium Chloride
4YNA40%NANN
Potassium Chloride In Lactated Ringers And Dextros
4YNA40%NANN
Potassium Chloride In Sodium Chloride
4YNA40%NANN
Potassium Citrate
3YNA20%NANN
Pradaxa
4YNA40%NA60/30NN
Prasugrel
2NNA$9NANN
Pravastatin Sodium
1NNA$0NA45/30NN
Praziquantel
4YNA40%NANN
Prazosin Hydrochloride
2NNA$9NANN
Prednisolone Acetate
3YNA20%NANN
Prednisolone Sodium Phosphate
3YNA20%NANN
Prednisolone Sodium Phosphate Oral Solution
3YNA20%NANN
Prednisone
2NNA$9NANN
Pregabalin
3YNA20%NA900/30NN
Premarin
3YNA20%NANN
Premphase
3YNA20%NANN
Prempro
3YNA20%NANN
Prevymis
5NA25%NA30/30NN
Prezcobix
5NA25%NA30/30NN
Prezista
5NA25%NA30/30NN
Priftin
4YNA40%NANN
Primaquine Phosphate
4YNA40%NANN
Primidone
2NNA$9NANN
Probenecid
2NNA$9NANN
Probenecid And Colchicine
2NNA$9NANN
Prochlorperazine Maleate
2NNA$9NANN
Procrit
5NA25%NAYN
Procto-med Hc
1NNA$0NA454/30NN
Proctosol-hc
1NNA$0NA454/30NN
Proctozone-hc
1NNA$0NA454/30NN
Progesterone
2NNA$9NANN
Prograf
4YNA40%NAYN
Prolastin-c
5NA25%NAYN
Prolensa
3YNA20%NANN
Prolia
4YNA40%NAYN
Promacta
5NA25%NAYN
Promethazine Hydrochloride
2NNA$9NAYN
Propafenone Hydrochloride
4YNA40%NANN
Propranolol Hydrochloride
2NNA$9NANN
Propylthiouracil
2NNA$9NANN
Proquad
3YNA20%NANN
Protriptyline Hydrochloride
4YNA40%NANN
Pulmozyme
5NA25%NAYN
Purixan
5NA25%NANN
Pylera
5NA25%NANN
Pyrazinamide
3YNA20%NANN
Pyridostigmine Bromide
4YNA40%NANN
Pyrimethamine
5NA25%NAYN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

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 $505. 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 2023 is $505. 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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