Blue Cross MedicareRx Value (PDP)
Contract S5715, plan 005, segment 0 · offered by MEDCO CONTAINMENT LIFE & MEDCO CONTAINMENT NY & HEALTH CARE · CMS PDP Region 22 (Texas).
Plan features
| Monthly premium | $167.40 |
|---|---|
| Annual deductible | $615.00Tier 1 and 2 exempt |
| Drug benefit type | — |
| $0 premium with full LIS | — |
| Premium with Extra Help (LIS) | — |
| Formulary drugs | 3,464 |
| Formulary exception tier | — |
| Plan reach | — |
| Members in Texas | at least 21,89783 counties suppressed by CMS (under 11 enrollees) |
| Members nationally | 22,362 |
| Member services | (888)285-2249TTY 711 |
| Pharmacy search | getbluetx.com/pdp/pharmacies |
| BIN / PCN | 011552 / PDPTXSee 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 | 312 |
| Tier 2 | $1.00 | 625 |
| Tier 3 | 18% | 717 |
| Tier 4 | 32% | 1,047 |
| Tier 5 | 25% | 763 |
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 | $1.00 | $6.00 | $1.00 | $3.00 | $18.00 | $3.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $5.00 | $0.00 | $0.00 | $15.00 | $0.00 |
| Tier 2: Generic | $1.00 | $6.00 | $1.00 | $3.00 | $18.00 | $3.00 |
| Tier 3: Preferred Brand | 18% | 21% | 18% | 18% | 21% | 18% |
| Tier 4: Non-Preferred Drug | 32% | 34% | 32% | 32% | 34% | 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.