Blue Cross MedicareRx Value (PDP)
Contract S5715, plan 020, segment 0 · offered by MEDCO CONTAINMENT LIFE & MEDCO CONTAINMENT NY & HEALTH CARE · CMS PDP Region 26 (New Mexico).
Plan features
| Monthly premium | $111.30 |
|---|---|
| Annual deductible | $615.00Tier 1 and 2 exempt |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,251 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in New Mexico | at least 2,8805 counties suppressed by CMS (under 11 enrollees) |
| Members nationally | 2,923 |
| Member services | (888)285-2249TTY 711 |
| Pharmacy search | getbluenm.com/pdp/pharmacies |
| BIN / PCN | 011552 / PDPNMSee BIN/PCNs for all plans |
CMS star ratings
- Part D summary rating
- 2 out of 5 stars for Part D summary rating
Published per contract, which is how CMS scores them — every plan under contract S5715 shares this rating.
Formulary tiers — preferred pharmacy, initial coverage phase
| Tier | Cost-sharing | Drugs on tier |
|---|---|---|
| Tier 1 | $0.00 | 243 |
| Tier 2 | $4.00 | 613 |
| Tier 3 | 14% | 430 |
| Tier 4 | 33% | 1,245 |
| Tier 5 | 25% | 720 |
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 | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $4.00 | $10.00 | $4.00 | $12.00 | $30.00 | $12.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $4.00 | $10.00 | $4.00 | $12.00 | $30.00 | $12.00 |
| Tier 3: Preferred Brand | 14% | 16% | 14% | 14% | 16% | 14% |
| Tier 4: Non-Preferred Drug | 33% | 35% | 33% | 33% | 35% | 33% |
| 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.