Blue Cross MedicareRx Basic (PDP)
Contract S5715, plan 015, segment 0 · offered by MEDCO CONTAINMENT LIFE & MEDCO CONTAINMENT NY & HEALTH CARE · CMS PDP Region 23 (Oklahoma).
Plan features
| Monthly premium | $0.00 |
|---|---|
| Annual deductible | $615.00 |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,014 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in Oklahoma | 38,223 |
| Members nationally | 38,593 |
| Member services | (888)285-2249TTY 711 |
| Pharmacy search | getblueok.com/pdp/pharmacies |
| BIN / PCN | 610455 / PDPOKSee 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 | 203 |
| Tier 2 | $5.00 | 454 |
| Tier 3 | 16% | 644 |
| Tier 4 | 40% | 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 coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $5.00 | $10.00 | $5.00 | $15.00 | $30.00 | $15.00 |
| Tier 3: Preferred Brand | 16% | 18% | 16% | 16% | 18% | 16% |
| Tier 4: Non-Preferred Drug | 40% | 42% | 40% | 40% | 42% | 40% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | 0% | 0% | 0% | 0% | 0% | 0% |
| Tier 2: Generic | 0% | 0% | 0% | 0% | 0% | 0% |
| Tier 3: Preferred Brand | 0% | 0% | 0% | 0% | 0% | 0% |
| Tier 4: Non-Preferred Drug | 0% | 0% | 0% | 0% | 0% | 0% |
| Tier 5: Specialty Tier | 0% | 0% | 0% | 0% | 0% | 0% |
Plan facts come from the CMS quarterly prescription drug plan public use files.