BlueMedicare Value Rx (PDP)
Contract S5795, plan 003, segment 0 · offered by USABLE MUTUAL INSURANCE COMPANY · CMS PDP Region 19 (Arkansas).
Plan features
| Monthly premium | $52.50 |
|---|---|
| Annual deductible | $615.00 |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,220 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in Arkansas | 13,936 |
| Members nationally | 13,987 |
| Member services | (844)280-5833TTY 711 |
| Pharmacy search | www.arkansasbluecross.com/medicare |
| BIN / PCN | 004336 / MEDDADVSee BIN/PCNs for all plans |
CMS star ratings
- Part D summary rating
- 3 out of 5 stars for Part D summary rating
Published per contract, which is how CMS scores them — every plan under contract S5795 shares this rating.
Formulary tiers — preferred pharmacy, initial coverage phase
| Tier | Cost-sharing | Drugs on tier |
|---|---|---|
| Tier 1 | $0.00 | 187 |
| Tier 2 | $5.00 | 479 |
| Tier 3 | 19% | 1,051 |
| Tier 4 | 34% | 791 |
| Tier 5 | 25% | 712 |
Cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | n/a |
| Tier 2: Generic | $5.00 | $5.00 | n/a | $15.00 | $15.00 | n/a |
| Tier 3: Preferred Brand | 19% | 19% | n/a | 19% | 19% | n/a |
| Tier 4: Non-Preferred Drug | 34% | 34% | n/a | 34% | 34% | n/a |
| Tier 5: Specialty Tier | 25% | 25% | n/a | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Plan facts come from the CMS quarterly prescription drug plan public use files.