BlueMedicare Premier RX (PDP)
Plan costs
Premium $123.90 monthly
| Pharmacy Coverage | |
|---|---|
| Prescription Deductible | $0.00 |
| Initial Coverage Limit | $5,030.00 |
| One-Month Supply (Retail Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $0 copay |
| Generic | $5 copay |
| Preferred Brand | $47 copay |
| Non-Preferred Drug | $100 copay |
| Specialty Tier | 33% coinsurance |
| Insulin Products | $35 copay for a one-month supply |
| 100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing | |
| Preferred Generic | $0 copay |
| Generic | $15 copay |
| Preferred Brand | $141 copay |
| Non-Preferred Drug | $300 copay |
| Specialty Tier | Not covered |
| Insulin Products | $70 copay for a two-month supply or $105 for a three-month supply (excluding Tier 5) |
| Plan Documents | |
|---|---|
| Summary of Benefits | 2024 PDP Summary of Benefits [pdf] |
| Plan Documents | Plan Documents |
Preferences
Plan: S5795-002
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.