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Verified against CMS.gov · on Apr 1, 2026 Plan ID: H0104-016 Cross-check on Medicare.gov →

Blue Advantage Choice (PPO)

Plan Year 2026
$0.00 /month
Monthly Premium
Among the lowest-premium plans in 2026
$325.00 Annual Deductible
928 Drugs Covered
1 States Served

Top Covered Drugs

Most popular medications covered by this plan, ordered by national search frequency. Click any drug to see exact copay, restrictions, and alternatives.

# Drug Name Type Tier 30-Day Copay
1 TESTOSTERONE ENANTHATE Brand Tier 3 $0.00 Details
2 Nefazodone Hydrochloride Brand Tier 4 $0.00 Details
3 Danazol Brand Tier 4 $0.00 Details
4 Rufinamide Brand Tier 4 $0.00 Details
5 Venlafaxine Hydrochloride Brand Tier 2 $0.00 Details
6 NOVOLOG insulin aspart Brand Tier 3 $0.00 Details
7 Omeprazole Brand Tier 1 $0.00 Details
8 Lenalidomide Brand Tier 5 $0.00 Details
9 Venlafaxine Hydrochloride Brand Tier 2 $0.00 Details
10 Haloperidol Brand Tier 3 $0.00 Details
11 KISQALI ribociclib Brand Tier 5 $0.00 Details
12 Xtandi enzalutamide Brand Tier 5 $0.00 Details
13 Trifluoperazine Hydrochloride trifluoperazine hydrochloride Brand Tier 3 $0.00 Details
14 Leucovorin Calcium Brand Tier 3 $0.00 Details
15 RotaTeq Rotavirus Vaccine, Live, Oral, Pentavalent Brand Tier 1 $0.00 Details
16 Perphenazine perphenazine Brand Tier 4 $0.00 Details
17 Dexamethasone Brand Tier 2 $0.00 Details
18 PREVYMIS LETERMOVIR Brand Tier 5 $0.00 Details
19 Loxapine Brand Tier 3 $0.00 Details
20 Levothyroxine Sodium levothyroxine sodium Brand Tier 1 $0.00 Details

Showing 20 of 928 covered drugs.

Compare this plan against others for your medications Enter your drugs and ZIP to see personalized out-of-pocket costs.
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States Served (1)

This plan is available to Medicare beneficiaries in the following states.

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