Skip to Content (Press Enter)
Info

BlueMedicare Value RX (PDP)

Plan costs

Premium $40.30 monthly

Pharmacy Coverage
Prescription Deductible$495 on Tier 3, Tier 4, and Tier 5
Pharmacy Deductible Drug Tier ExclusionsTier 1 and Tier 2
Initial Coverage Limit$5,030.00
One-Month Supply (Retail Pharmacy) with Standard Cost Sharing
Preferred Generic$6 copay
Generic$10 copay
Preferred Brand$45 copay
Non-Preferred Drug45% coinsurance
Specialty Tier25% coinsurance
Insulin Products$35 copay for a one-month supply
100-Day Supply (Mail-Order Pharmacy) with Standard Cost Sharing
Preferred Generic$18 copay
Generic$30 copay
Preferred Brand$135 copay
Non-Preferred Drug45% coinsurance
Specialty TierNot covered
Insulin Products$70 copay for a two-month supply or $105 for a three-month supply (exluding Tier 5)
Plan Documents
Summary of Benefits2024 PDP Summary of Benefits  [pdf]
Plan DocumentsPlan Documents

 

Preferences

Plan: S5795-003

Limitations, copayments, and restrictions may apply. See above or contact the plan for more details.

*Enrollee must continue to pay the Medicare Part B premium.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. 24 hours a day, 7 days a week.
  • The Social Security Office at 800-772-1213. TTY users should call 1-800-325-0778. Monday through Friday, 7 a.m. to 7 p.m.
  • Your State Medicaid Office.