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2025 Medicare Prescription Drug Plan Benefit Details for the Blue Cross MedicareRx Value (PDP) - S5715-003
2025 Medicare Prescription Drug Plan Details
Medicare Plan Name:Blue Cross MedicareRx Value (PDP)
   by Blue Cross and Blue Shield of IL, NM, OK, TX
State:New Mexico
Plan ID:S5715 - 003 - 0     Click to see other plans
Member Services:(888)285-2249 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 Blue Cross MedicareRx Value (PDP) benefit details
— Medicare Plan Features —
Monthly Premium:$99.20 (see Plan Premium Details below)
Annual Deductible:$590 (Tier 1 and 2 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:3,486 drugsBrowse the Blue Cross MedicareRx Value (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$8.00$42.0044%25%
• Number of Drugs per
  Tier:		321639913847766
Plan's Pharmacy Search:http://getbluenm.com/pdp/pharmacies
Plan Offers Mail Order?Yes
Plan Type (Reach):Regional Plan
Number of Members enrolled in this plan in New Mexico:1,755 members     (CMS Region 26)
Number of Members enrolled in this plan nationally:106,234 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 3 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
$99.20$80.40$18.80
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ $83.40




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