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2025 Medicare Prescription Drug Plan Benefit Details for the Prescription Blue Premium (PDP) - S5584-002
2025 Medicare Prescription Drug Plan Details
Medicare Plan Name:Prescription Blue Premium (PDP)
   by Blue Cross Blue Shield of Michigan
State:Michigan
Plan ID:S5584 - 002 - 0     Click to see other plans
Member Services:(800)565-1770 TTY users 711
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 Prescription Blue Premium (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$138.90 (see Plan Premium Details below)
Annual Deductible:$0 (Tier excluded from the Deductible.)
$0 Premium if LIS Benefits?No, this plan does NOT qualify for the $0 Premium. (See premium for LIS subsidy beneficiaries below.)
Drug Benefit Type ❔Enhanced Alternative (EA)
Total Number of Formulary Drugs:3,000 drugsBrowse the Prescription Blue Premium (PDP) Formulary
Formulary Exception Tier:Tier 4 If your formulary exception request is approved, your drug will be placed on this tier.
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 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$1.00$5.00$40.0045%33%
• Number of Drugs per
  Tier:		115555862774694
Plan's Pharmacy Search:http://www.bcbsm.com/pharmaciesmedicare
Plan Offers Mail Order?Yes
Plan Type (Reach):Regional Plan
Number of Members enrolled in this plan in Michigan:22,144 members     (CMS Region 13)
Number of Members enrolled in this plan nationally:22,144 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
• Customer Service Rating: 5 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 Basic
Premium		Part D Supplemental
Premium
$138.90$76.70$62.20
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ $112.30




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