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2025 Medicare Prescription Drug Plan Cost-Sharing Details
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2025 Medicare Prescription Drug
Formulary (Drug List) Cost-Sharing Details
Blue Cross MedicareRx Value (PDP) (S5715-003-0)
Benefits & Contact Info        
all covered insulin pay $35 or less
This plan is available in CMS PDP Region 26
Click on a letter below to view the
Blue Cross MedicareRx Value (PDP) Formulary
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
This Plan Uses Lower Cost-Sharing for Preferred Pharmacies
  30-Day Supply
Cost-Sharing		 90-Day Supply
Cost-Sharing
Preferred Pharmacy Standard Pharmacy Mail- Order* Preferred Pharmacy Standard Pharmacy Mail- Order*
Initial Deductible Phase Cost Sharing
Tier 1: Preferred Generic: $1.00(E) $10.00(E) $1.00(E) $3.00(E) $30.00(E) $3.00(E)
Tier 2: Generic: $8.00(E) $20.00(E) $8.00(E) $24.00(E) $60.00(E) $24.00(E)
Tier 3: Preferred Brand: 100% 100% 100% 100% 100% 100%
Tier 4: Non-Preferred Drug: 100% 100% 100% 100% 100% 100%
Tier 5: Specialty Tier: 100% 100% 100% 100% 100% 100%
Initial Coverage Phase Cost-Sharing
Tier 1: Preferred Generic: $1.00 $10.00 $1.00 $3.00 $30.00 $3.00
Tier 2: Generic: $8.00 $20.00 $8.00 $24.00 $60.00 $24.00
Tier 3: Preferred Brand: $42.00 $44.00 $42.00 $126.00 $132.00 $126.00
Tier 4: Non-Preferred Drug: 44% 50% 44% 44% 50% 44%
Tier 5: Specialty Tier: 25% 25% 25% n/a n/a n/a
Catastrophic Coverage Phase Cost Sharing
All Formulary Drugs:


 $0 cost-sharing.
The Inflation Reduction Act (IRA) of 2022 eliminates beneficiary cost-sharing once your TrOOP reaches the established maximum cap on out-of-pocket spending for Part D formulary drugs (RxMOOP).
Notes:
*The mail-order cost-sharing is the plan’s "preferred" mail-order cost-sharing.
(E) Drugs on this tier are excluded from the Initial Deductible and do not count toward meeting the deductible.
Go to the Blue Cross MedicareRx Value (PDP) 2025 Formulary Browser by choosing a letter below:
A  B  C  D  E  F  G  H  I  J  K  L  M  N  O  P  Q  R  S  T  U  V  W  X  Y  Z  0-9 
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