Blue Cross Medicare Advantage Classic (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from Blue Cross Medicare Advantage Classic (PPO) by Ghs 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 Texas 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 Blue Cross Medicare Advantage Classic (PPO)(H4801-004) plan has a $200 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. Ghs 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:Blue Cross Medicare Advantage Classic (PPO)
Plan ID: H4801-004
Provider: Ghs Insurance Company
Plan Year:2023
Premium:$0.00
Deductible:$200
Initial Coverage Limit:$4660
Coverage Area:Texas
Similar Plan:H4801-005


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
Bacitracin Zinc And Polymyxin B Sulfate
2N$5$20$5NN
Baclofen
2N$5$20$5NN
Balsalazide Disodium
4Y$85$100$85NN
Balversa
529%29%29%30/30YN
Balziva
4Y$85$100$85NN
Baraclude
529%29%29%NN
Bcg Vaccine
3Y$44$47$44NN
Benazepril Hydrochloride And Hydrochlorothiazide
2N$5$20$5NN
Benznidazole
4Y$85$100$85NN
Benztropine Mesylate
2N$5$20$5YN
Betamethasone Dipropionate
3Y$44$47$44120/30NN
Betamethasone Valerate
3Y$44$47$44120/30NN
Betaxolol Hydrochloride
2N$5$20$5NN
Bethanechol Chloride
3Y$44$47$44NN
Bexarotene
529%29%29%YN
Bexsero
3Y$44$47$44NN
Bicillin L-a
4Y$85$100$85NN
Biktarvy
529%29%29%30/30NN
Bisoprolol Fumarate
2N$5$20$5NN
Bisoprolol Fumarate And Hydrochlorothiazide
2N$5$20$5NN
Blisovi 24 Fe
4Y$85$100$85NN
Blisovi Fe 1.5/30
4Y$85$100$85NN
Boostrix
3Y$44$47$44NN
Bosulif
529%29%29%30/30YN
Braftovi
529%29%29%180/30YN
Breo Ellipta
3Y$44$47$4460/30NN
Briellyn
4Y$85$100$85NN
Brilinta
4Y$85$100$85NN
Brimonidine Tartrate
4Y$85$100$85NN
Briviact
529%29%29%NN
Budesonide
529%29%29%30/30YN
Bumetanide
2N$5$20$5NN
Buprenorphine
3Y$44$47$4490/30NN
Buprenorphine And Naloxone
4Y$85$100$8560/30NN
Buprenorphine Hcl
3Y$44$47$4490/30NN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2N$5$20$590/30NN
Bupropion Hydrochloride
3Y$44$47$4430/30NN
Buspirone Hydrochloride
2N$5$20$5NN
Bydureon Bcise
3Y$44$47$44/28NY
Byetta
4Y$85$100$85/30NY

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H4801-004

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $200. 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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