List of creditable plans

Medicare Part D creditable Coverage DeterminationsCreditable/Non- creditable Testing Results for Independence Blue Cross Commercial Pharmacy plans List of creditable plansStandard Drug Program options$1 / $3$5 / $10$8 / $15$15 / $25$2 / $6$5 / $15$9 / $15$15 / $30$2 / $10$5 / $20$10 / $15$20 / $30$3 / $5$5 / $25$10 / $20$10 / $35$3 / $10$6 / $10$10 / $25$15 / $35$4 / $8$7 / $15$10 / $30$20 / $35$4 / $10$8 / $14$15 / $20$20 / $40 Select Drug Program options $0 / $25 / $50 $5 / $20 / $35$10 / $20 / $35$15 / $20 / $35$5 / $10 / $25$5 / $20 / $50$10 / $20 / $40$15 / $25 / $35$5 / $10 / $35$5 / $25 / $50$10 / $20 / $50$15 / $25 / $50$5 / $10 / $50$5 / $30 / $50$10 / $25 / $40$15 / $35 / $50$5 / $15 / $25$5 / $40 / $60$10 / $30 / $50$20 / $40 / $60$5 / $15 / $30$7 / $35 / $50$10 / $40 / $60$5 / $15 / $35$10 / $15 / $25$10 / $40 / $70$5 / $15 / $50$10 / $20 / $30$10 / $45 / $75$250/$5/$40/$60$250/$20/$40/$60$250/$ 10/$45/$75$500/$15/$40/$75 Deductible/Coinsurance Drug Program optionsCoinsuranceDeductible20%$10020%$1 5020%$20020%$25030%$15030%$200 The determinations in these exhibits were based on standard benefit designs only.

Medicare Part D Creditable Coverage Determinations Creditable/Non-Creditable Testing Results for Independence Blue Cross Commercial Pharmacy Plans

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