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2021 Medicare Prescription Drug Plan Benefit Details for the Express Scripts Medicare - Value (PDP)
2021 Medicare Prescription Drug Plan Details
Medicare Plan Name:Express Scripts Medicare - Value (PDP)
   by Express Scripts Medicare
State:Wisconsin
Plan ID:S5660 - 118 - 0     Click to see other plans
Member Services:1-800-758-4574 TTY users 1-800-716-3231
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Email a copy of the Express Scripts Medicare - Value (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$31.60 (see Plan Premium Details below)
Annual Deductible:$445 (Tier 1 and 2 excluded from the Deductible.)
$0 Premium if Full LIS Benefits?Yes, this plan does qualify for the $0 Premium. (See premiums for partial LIS subsidy below.)
Annual Initial Coverage Limit (ICL):$4,130
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,033 drugsBrowse the Express Scripts Medicare - Value (PDP) Formulary
This plan has 6 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:		$1.00$3.00$30.0050%25%
• Number of Drugs per
  Tier:		656536591079482
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 610014   PCN: MEDDPRIME   See BIN/PCNs for all plans
Plan Type (Reach):National Plan
Number of Members enrolled in this plan in Wisconsin:6,223 members     (CMS Region 16)
Number of Members enrolled in this plan nationally:355,282 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part D Base
Premium		Part D Supplemental
Premium
$31.60$31.60$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$7.90$15.80$23.70


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