Capital Blue Cross Prime (PPO)
$77.30 /month
Monthly Premium
$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 | Gentamicin Sulfate | Brand | Tier 2 | $0.00 | Details |
| 2 | Haloperidol | Brand | Tier 2 | $0.00 | Details |
| 3 | Ciprofloxacin in Dextrose ciprofloxacin | Brand | Tier 4 | $100.00 | Details |
| 4 | Thioridazine Hydrochloride thioridazine hydrochloride | Brand | Tier 3 | $47.00 | Details |
| 5 | Digoxin | Brand | Tier 2 | $0.00 | Details |
| 6 | Prograf Tacrolimus | Brand | Tier 4 | $100.00 | Details |
| 7 | Chlorpromazine Hydrochloride | Brand | Tier 4 | $100.00 | Details |
| 8 | Atomoxetine | Brand | Tier 4 | $100.00 | Details |
| 9 | Dextrose and Sodium Chloride | Brand | Tier 4 | $100.00 | Details |
| 10 | Levothyroxine Sodium levothyroxine sodium | Brand | Tier 1 | $0.00 | Details |
| 11 | Jardiance Empagliflozin | Brand | Tier 3 | $47.00 | Details |
| 12 | Talzenna talazoparib | Brand | Tier 5 | 0.3% coinsurance | Details |
| 13 | Dupixent Dupilumab | Brand | Tier 5 | 0.3% coinsurance | Details |
| 14 | Bupropion Hydrochloride SR SR bupropion hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 15 | Aptivus tipranavir | Brand | Tier 5 | 0.3% coinsurance | Details |
| 16 | ETHOSUXIMIDE | Brand | Tier 4 | $100.00 | Details |
| 17 | Cefuroxime | Brand | Tier 4 | $100.00 | Details |
| 18 | Nortriptyline Hydrochloride | Brand | Tier 2 | $0.00 | Details |
| 19 | Carbidopa and levodopa | Brand | Tier 2 | $0.00 | Details |
| 20 | Metoprolol Tartrate metoprolol tartrate | Brand | Tier 1 | $0.00 | 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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