Prescription Blue Select (PDP) Formulary



Below is the 2023 Formulary, or prescription drug list, from Prescription Blue Select (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 Select (PDP)(S5584-001) 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. 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 Select (PDP)
Plan ID: S5584-001
Formulary
Provider: Bcbs Of Michigan Mutual Insurance Company
Plan Year:2023
Premium:$94.50
Deductible:$505
Initial Coverage Limit:$4660
Coverage Area:Michigan
Similar Plan:S5584-002


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
Deductible
Apply
Cost
Preferred
Cost
Non
Preferred
Cost
Mail
Limit
Amt/Days
Prior Auth
Y/N
Step
Therapy
Paliperidone
4Y37%37%37%90/90NN
Panretin
525%25%25%60/30YN
Paricalcitol
3Y$30$35$30NN
Paromomycin Sulfate
3Y$30$35$30NN
Paroxetine
4Y37%37%37%2700/90NN
Paser
4Y37%37%37%NN
Pediarix
3Y$30$35$30NN
Pedvaxhib
3Y$30$35$30NN
Peg-3350 And Electrolytes
2Y$3$8$3NN
Pegasys
525%25%25%4/28NN
Pemazyre
525%25%25%14/21YN
Penicillamine
525%25%25%NN
Penicillin G Procaine
4Y37%37%37%NN
Penicillin G Sodium
525%25%25%NN
Penicillin V Potassium
2Y$3$8$3NN
Pentacel
3Y$30$35$30NN
Pentamidine Isethionate
4Y37%37%37%NN
Pentoxifylline
2Y$3$8$3NN
Perindopril Erbumine
2Y$3$8$3180/90NN
Periogard Alcohol Free
2Y$3$8$3NN
Permethrin
3Y$30$35$30NN
Perphenazine
3Y$30$35$30NN
Perseris
525%25%25%1/30NY
Phenelzine Sulfate
3Y$30$35$30NN
Phenobarbital
3Y$30$35$30360/90YN
Phenytoin
3Y$30$35$30NN
Pifeltro
525%25%25%NN
Pilocarpine Hydrochloride
3Y$30$35$30NN
Pimozide
3Y$30$35$30NN
Pindolol
3Y$30$35$30NN
Piperacillin And Tazobactam
4Y37%37%37%NN
Piqray
525%25%25%60/30YN
Podofilox
4Y37%37%37%NN
Polyethylene Glycol 3350, Sodium Chloride, Sodium
2Y$3$8$3NN
Polymyxin B Sulfate And Trimethoprim
2Y$3$8$3NN
Potassium Chloride
2Y$3$8$3NN
Potassium Chloride In Dextrose
4Y37%37%37%NN
Potassium Chloride In Dextrose And Sodium Chloride
4Y37%37%37%NN
Potassium Chloride In Sodium Chloride
4Y37%37%37%NN
Potassium Citrate
4Y37%37%37%NN
Prasugrel
3Y$30$35$30NN
Pravastatin Sodium
2Y$3$8$3180/90NN
Praziquantel
3Y$30$35$30NN
Prazosin Hydrochloride
2Y$3$8$3NN
Prednisolone Acetate
3Y$30$35$30NN
Prednisolone Sodium Phosphate
3Y$30$35$30NN
Prednisolone Sodium Phosphate Oral Solution
2Y$3$8$3NN
Prednisone
2Y$3$8$3NN
Prednisone Intensol
2Y$3$8$3NN
Pregabalin
4Y37%37%37%2700/90NN
Premasol - Sulfite-free (amino Acid)
4Y37%37%37%YN
Prevymis
525%25%25%NN
Prezcobix
525%25%25%31/31NN
Prezista
525%25%25%31/31NN
Priftin
4Y37%37%37%NN
Primaquine Phosphate
3Y$30$35$30NN
Primidone
2Y$3$8$3NN
Probenecid
3Y$30$35$30NN
Probenecid And Colchicine
3Y$30$35$30NN
Prochlorperazine Maleate
2Y$3$8$3NN
Procrit
525%25%25%YN
Prograf
4Y37%37%37%YN
Prolastin-c
525%25%25%YN
Prolia
4Y37%37%37%1/180YN
Promacta
525%25%25%62/31YN
Promethazine Hydrochloride
2Y$3$8$3NN
Propafenone Hydrochloride
4Y37%37%37%NN
Propranolol Hydrochloride
4Y37%37%37%NN
Propylthiouracil
3Y$30$35$30NN
Proquad
3Y$30$35$30NN
Protriptyline Hydrochloride
4Y37%37%37%NN
Pulmicort
3Y$30$35$306/90NN
Pulmozyme
525%25%25%YN
Purixan
525%25%25%NN
Pyrazinamide
4Y37%37%37%NN
Pyridostigmine Bromide
4Y37%37%37%NN
Pyrimethamine
525%25%25%NN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for S5584-001

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 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.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.