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BlueMedicare Value RX (PDP)

Plan costs

Premium $50.90 monthly

Pharmacy Coverage
Prescription Deductible$400.00
Pharmacy Deductible Drug Tier Exclusions$0 Deductible on Tier(s) 1, 2; $400 Deductible on Tier(s) 3, 4, 5
Initial Coverage Limit$4,430.00
One-Month Supply (Retail Pharmacy) with Standard Cost Sharing
Preferred Generic$4.00
Preferred Brand$45.00
Non-Preferred Drug47%
Specialty Tier26%
100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing
Preferred Generic$12.00
Preferred Brand$135.00
Non-Preferred Drug47%
Specialty TierNot covered
Plan Documents
Summary of Benefits2022 HMO Summary of Benefits[pdf]
Plan DocumentsPlan Documents


Plan: S5795-003-000

Limitations, copayments, and restrictions may apply. See above or contact the plan for more details.

*Enrollee must continue to pay the Medicare Part B premium.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. 24 hours a day, 7 days a week.
  • The Social Security Office at 800-772-1213. TTY users should call 1-800-325-0778. Monday through Friday, 7 a.m. to 7 p.m.
  • Your State Medicaid Office.