2016 Medicare Prescription Drug Plan Details | |||||
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Medicare Plan Name: | MedicareBlue Rx Premier (PDP) by Wellmark Blue Cross and Blue Shield of Iowa | ||||
State: | Nebraska | ||||
Plan ID: | S5743 - 004 - 0 Click to see other plans | ||||
Member Services: | 1-888-832-0075 TTY users 1-800-693-3819 | ||||
— 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 |
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Email a copy of the MedicareBlue Rx Premier (PDP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $111.20 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 (Tier excluded from the Deductible.) | ||||
$0 Premium if Full LIS Benefits? | No, this plan does NOT qualify for the $0 Premium. (See premiums for partial LIS subsidy below.) | ||||
Annual Initial Coverage Limit (ICL): | $3,310 | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,171 drugs | Browse the MedicareBlue Rx Premier (PDP) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $2.00 | 20% | 45% | 33% |
• Number of Drugs per Tier: | 454 | 1463 | 309 | 388 | 557 |
Plan Offers Mail Order? | Yes | ||||
Plan Type (Reach): | Regional Plan | ||||
Number of Members enrolled in this plan in Nebraska: | 1,407 members | ||||
Number of Members enrolled in this plan in your CMS Region: | 15,172 members (CMS Region 25) | ||||
Number of Members enrolled in this plan nationally: | 15,172 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 2 out of 5 Stars. | ||||
• Member Experience Rating: | 4 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 Base Premium | Part D Supplemental Premium | ||
$111.20 | $41.80 | $69.40 | |||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $80.30 | $88.00 | $95.70 | $103.50 |