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2015 Medicare Prescription Drug Plan Benefit Details for the Blue Cross MedicareRx Value (PDP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2015 Medicare Prescription Drug Plan Details
Medicare Plan Name:Blue Cross MedicareRx Value (PDP)
   by HISC - Blue Cross Blue Shield of Oklahoma
State:Oklahoma
Plan ID:S5715 - 010 - 0     Click to see other plans
Member Services:(888) 285-2249 TTY users (888) 285-2252
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Blue Cross MedicareRx Value (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$54.80 (see Plan Premium Details below)
Annual Deductible:$275 (Some Tiers exempt, details coming soon.)
$0 Premium if LIS Benefits?No, this plan does NOT qualify for the $0 Premium. (See premiums for partial LIS subsidy below.)
Annual Initial Coverage Limit (ICL):$2,960
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,199 drugsBrowse the Blue Cross MedicareRx Value (PDP) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$6.00$37.00$85.0025%
• Number of Drugs per
  Tier:		801720341575483
Plan Offers Mail Order?Yes
Plan Type (Reach):Regional Plan
Number of Members enrolled in this plan in Oklahoma:25,710 members     (CMS Region 23)
Number of Members enrolled in this plan nationally:218,213 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part D Basic
Premium		Part D Supplemental
Premium
$54.80$46.70$8.10
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$24.80$32.30$39.80$47.30




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