BlueCross Rx Value (PDP)
Contract S5953, plan 001, segment 0 · offered by BLUECROSS AND BLUESHIELD OF SOUTH CAROLINA · CMS PDP Region 09 (South Carolina).
Plan features
| Monthly premium | $139.70 |
|---|---|
| Annual deductible | $615.00Tier 1 and 6 exempt |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,151 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in South Carolina | 13,722 |
| Members nationally | 13,772 |
| Member services | (888)645-6025TTY 711 |
| Pharmacy search | www.scbluesmedadvantage.com |
| BIN / PCN | 021692 / CTRXMEDDSee BIN/PCNs for all plans |
CMS star ratings
- Part D summary rating
- 3.5 out of 5 stars for Part D summary rating
Published per contract, which is how CMS scores them — every plan under contract S5953 shares this rating.
Formulary tiers — preferred pharmacy, initial coverage phase
| Tier | Cost-sharing | Drugs on tier |
|---|---|---|
| Tier 1 | $12.00 | 131 |
| Tier 2 | $17.00 | 544 |
| Tier 3 | 17% | 809 |
| Tier 4 | 50% | 756 |
| Tier 5 | 25% | 758 |
| Tier 6 | $5.00 | 153 |
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 | $12.00 | $15.00 | $12.00 | $36.00 | $45.00 | $30.00 |
| Tier 6: Select Care Drugs | $5.00 | $8.00 | $5.00 | $15.00 | $24.00 | $12.50 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $12.00 | $15.00 | $12.00 | $36.00 | $45.00 | $30.00 |
| Tier 2: Generic | $17.00 | $20.00 | $17.00 | $51.00 | $60.00 | $42.50 |
| Tier 3: Preferred Brand | 17% | 19% | 17% | 17% | 19% | 17% |
| Tier 4: Non-Preferred Drug | 50% | 50% | 50% | 50% | 50% | 50% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $5.00 | $8.00 | $5.00 | $15.00 | $24.00 | $12.50 |
| 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 |
| Tier 6: Select Care Drugs | $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.