Capital Blue Cross Premier (HMO)
$25.30 /month
Monthly Premium
Among the lowest-premium plans in 2026
$100.00
Annual Deductible
1,003
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 | Gilotrif afatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 2 | Haloperidol | Brand | Tier 2 | $0.00 | Details |
| 3 | Amoxicillin and Clavulanate Potassium | Brand | Tier 2 | $0.00 | Details |
| 4 | Phenobarbital | Brand | Tier 2 | $0.00 | Details |
| 5 | RETEVMO selpercatinib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 6 | Fetzima LEVOMILNACIPRAN HYDROCHLORIDE | Brand | Tier 4 | $100.00 | Details |
| 7 | KISQALI ribociclib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 8 | Cilostazol | Brand | Tier 2 | $0.00 | Details |
| 9 | Lupron Depot leuprolide acetate | Brand | Tier 5 | 0.3% coinsurance | Details |
| 10 | Probenecid | Brand | Tier 3 | $47.00 | Details |
| 11 | Priftin rifapentine | Brand | Tier 4 | $100.00 | Details |
| 12 | Ipratropium Bromide | Brand | Tier 2 | $0.00 | Details |
| 13 | Cyclosporine Modified Modified Cyclosporine | Brand | Tier 4 | $100.00 | Details |
| 14 | Tiagabine Hydrochloride | Brand | Tier 4 | $100.00 | Details |
| 15 | Valsartan valsartan | Brand | Tier 1 | $0.00 | Details |
| 16 | Ampicillin and Sulbactam | Brand | Tier 4 | $100.00 | Details |
| 17 | Xalkori CRIZOTINIB | Brand | Tier 5 | 0.3% coinsurance | Details |
| 18 | Ibrance palbociclib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 19 | Trelegy Ellipta fluticasone furoate, umeclidinium bromide and vilanterol trifenatate | Brand | Tier 3 | $47.00 | Details |
| 20 | INLYTA axitinib | Brand | Tier 5 | 0.3% coinsurance | Details |
Showing 20 of 1,003 covered drugs.
States Served (1)
This plan is available to Medicare beneficiaries in the following states.
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