BlueMedicare Value RX (PDP)
Plan costs
Premium $53.10 monthly
| Pharmacy Coverage | |
|---|---|
| Prescription Deductible | $495 on Tier 3, Tier 4, and Tier 5 |
| Pharmacy Deductible Drug Tier Exclusions | Tier 1 and Tier 2 |
| Initial Coverage Limit | $4,660.00 |
| One-Month Supply (Retail Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $6 copay |
| Generic | $10 copay |
| Preferred Brand | $45 copay |
| Non-Preferred Drug | 45% coinsurance |
| Specialty Tier | 25% coinsurance |
| 100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $18 copay |
| Generic | $30 copay |
| Preferred Brand | $135 copay |
| Non-Preferred Drug | 45% coinsurance |
| Specialty Tier | Not covered |
| Plan Documents | |
|---|---|
| Summary of Benefits | 2023 Summary of Benefits [pdf] |
| Plan Documents | Plan Documents |
Preferences
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.