2023 Medicare Prescription Drug Plan Details | |||||
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Medicare Plan Name: | Blue Rx Standard (PDP) by BlueCross BlueShield: Empire, Excellus, WNY & NEN | ||||
State: | New York | ||||
Plan ID: | S3375 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-833-409-1209 TTY users 711 | ||||
— 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 Blue Rx Standard (PDP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $82.60 (see Plan Premium Details below) | ||||
Annual Deductible: | $460 (Tier 1 and 2 excluded from the Deductible.) | ||||
$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): | $4,660 | ||||
Drug Benefit Type ❔ | Basic Alternative Standard (BA) | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 2,975 drugs | Browse the Blue Rx Standard (PDP) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $1.00 | $46.00 | 40% | 25% |
• Number of Drugs per Tier: | 64 | 398 | 1092 | 935 | 486 |
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 020115 PCN: IS See BIN/PCNs for all plans | ||||
Plan Type (Reach): | Regional Plan | ||||
Number of Members enrolled in this plan in New York: | 467 members (CMS Region 03) | ||||
Number of Members enrolled in this plan nationally: | 467 members | ||||
Plan’s Summary Star Rating: | 2 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 1 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 2 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part D Basic Premium | Part D Supplemental Premium | ||
$82.60 | $82.60 | $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: | $43.70 | $53.40 | $63.10 | $72.90 |