BlueCross Total Value (PPO) Formulary



Below is the 2023 Formulary, or prescription drug list, from BlueCross Total Value (PPO) by Bluecross And Blueshield Of South Carolina. A formulary is a continually updated list of available medications and prescription drug cost information. Examining a plans formulary can help you find a South Carolina 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 BlueCross Total Value (PPO)(H8003-006) plan has a $25 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. Bluecross And Blueshield Of South Carolina 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:BlueCross Total Value
Plan ID: H8003-006
Provider: Bluecross And Blueshield Of South Carolina
Plan Year:2023
Premium:$0.00
Deductible:$25
Initial Coverage Limit:$4660
Coverage Area:South Carolina
Similar Plan:H8003-001


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
Bacitracin Zinc And Polymyxin B Sulfate
2N$10$15NANN
Baclofen
3Y$42$47NANN
Bafiertam
532%32%NA120/30YN
Balsalazide Disodium
4Y$100$100NANN
Balversa
532%32%NAYN
Balziva
3Y$42$47NANN
Baqsimi
3Y$42$47NANN
Baraclude
532%32%NA600/30NN
Baxdela
532%32%NANN
Bcg Vaccine
3Y$42$47NANN
Benazepril Hydrochloride And Hydrochlorothiazide
6N$0$5NANN
Benznidazole
4Y$100$100NANN
Benztropine Mesylate
2N$10$15NANN
Bepotastine Besilate
4Y$100$100NANN
Besremi
532%32%NAYN
Betamethasone Dipropionate
3Y$42$47NANN
Betamethasone Valerate
3Y$42$47NANN
Betaxolol Hydrochloride
3Y$42$47NANN
Bethanechol Chloride
2N$10$15NANN
Bexarotene
532%32%NAYN
Bexsero
3Y$42$47NANN
Bicillin L-a
4Y$100$100NANN
Biktarvy
532%32%NA30/30NN
Bisoprolol Fumarate
2N$10$15NANN
Bisoprolol Fumarate And Hydrochlorothiazide
2N$10$15NANN
Bivigam
532%32%NAYN
Blisovi Fe 1.5/30
3Y$42$47NANN
Boostrix
3Y$42$47NANN
Bosulif
532%32%NAYN
Braftovi
532%32%NAYN
Breo Ellipta
3Y$42$47NA60/30NN
Breztri
3Y$42$47NA23/28NN
Briellyn
3Y$42$47NANN
Brilinta
3Y$42$47NANN
Brimonidine Tartrate
2N$10$15NANN
Brinzolamide
4Y$100$100NANN
Briviact
532%32%NAYN
Budesonide
532%32%NANN
Bumetanide
2N$10$15NANN
Buprenorphine
4Y$100$100NA4/28NN
Buprenorphine And Naloxone
3Y$42$47NA60/30NN
Buprenorphine Hcl
2N$10$15NANN
Buprenorphine Hydrochloride And Naloxone Hydrochlo
2N$10$15NA90/30NN
Bupropion Hydrochloride
2N$10$15NA30/30NN
Buspirone Hydrochloride
4Y$100$100NANN

* Drug Prices and Coverage is for a 30 Day Supply



Additional Notes by Medicare Help:

Coverage Levels for H8003-006

Most plans have 4 levels of coverage. The exception is the $0 Deductible Plans.
1. Pre-Deductable: Before you reach the plans deductible of $25. 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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