MedicarePartD.guide

A non-government resource built from CMS public data

Blue Rx PDP Complete (PDP)

Contract S5593, plan 003, segment 0 · offered by HM HEALTH INSURANCE COMPANY · CMS PDP Region 06 (Pennsylvania).

Plan features

Monthly premium$164.80
Annual deductible$200.00Tier 1 and 2 exempt
Drug benefit type—
$0 premium with full LIS—
Premium with Extra Help (LIS)—
Formulary drugs3,874
Formulary exception tier—
Mail order offered—
Plan reach—
Members in Pennsylvania—
Members nationally—
Member services—
BIN / PCN—

CMS star ratings

Summary rating
3 out of 5 stars for Summary rating
Customer service
—
Member experience
—
Drug pricing & patient safety
—

Formulary tiers — preferred pharmacy, initial coverage phase

TierCost-sharingDrugs on tier
Tier 1$0.00—
Tier 2$5.00—
Tier 325%—
Tier 425%—
Tier 525%—

Cost-sharing by coverage phase

Tier30-day supply90-day supply
PreferredStandardMail OrderPreferredStandardMail Order
Initial deductible phase
Tier 1: Preferred Generic$0.00$4.00n/a$0.00$12.00$0.00
Tier 2: Generic$5.00$10.00n/a$15.00$30.00$12.50
Initial coverage phase
Tier 1: Preferred Generic$0.00$4.00n/a$0.00$12.00$0.00
Tier 2: Generic$5.00$10.00n/a$15.00$30.00$12.50
Tier 3: Preferred Brand25%25%n/a25%25%25%
Tier 4: Non-Preferred Drug25%25%n/a25%25%25%
Tier 5: Specialty Tier25%25%25%n/an/an/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