Blue Medicare Rx Standard (PDP)
Contract S5540, plan 002, segment 0 · offered by BLUE CROSS AND BLUE SHIELD OF NORTH CAROLINA · CMS PDP Region 08 (North Carolina).
Plan features
| Monthly premium | $83.90 |
|---|---|
| Annual deductible | $615.00Tier 1 exempt |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,013 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in North Carolina | at least 6,7417 counties suppressed by CMS (under 11 enrollees) |
| Members nationally | 6,802 |
| Member services | (888)247-4142TTY 711 |
| Pharmacy search | medicare.bluecrossnc.com/prescription-drug-coverage |
| BIN / PCN | 015905 / PDPNCSee 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 S5540 shares this rating.
Formulary tiers — preferred pharmacy, initial coverage phase
| Tier | Cost-sharing | Drugs on tier |
|---|---|---|
| Tier 1 | $5.00 | 203 |
| Tier 2 | $10.00 | 454 |
| Tier 3 | 20% | 643 |
| Tier 4 | 32% | 1,023 |
| Tier 5 | 25% | 690 |
Cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $5.00 | $15.00 | $5.00 | $15.00 | $45.00 | $15.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $5.00 | $15.00 | $5.00 | $15.00 | $45.00 | $15.00 |
| Tier 2: Generic | $10.00 | $20.00 | $10.00 | $30.00 | $60.00 | $30.00 |
| Tier 3: Preferred Brand | 20% | 20% | 20% | 20% | 20% | 20% |
| Tier 4: Non-Preferred Drug | 32% | 32% | 32% | 32% | 32% | 32% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | 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.