Blue Cross MedicareRx Value (PDP)
S5715 - 010 - 0
(3 / 5)
Blue Cross MedicareRx Value (PDP) is a Medicare Prescription Drug Plan by Blue Cross and Blue Shield of IL, NM, OK, TX.
This page features plan details for 2025 Blue Cross MedicareRx Value (PDP) S5715 – 010 – 0.
Locations
Blue Cross MedicareRx Value (PDP) is offered in the following locations.
Plan Overview
Blue Cross MedicareRx Value (PDP) offers the following coverage and cost-sharing.
| Insurer: | Blue Cross and Blue Shield of IL, NM, OK, TX |
| Drugs Covered: | Yes |
Ready to sign up for Blue Cross MedicareRx Value (PDP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Blue Cross MedicareRx Value (PDP) has a monthly premium of $0.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $185.00 | $ | $117.30 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Blue Cross MedicareRx Value (PDP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $590.00 |
| Drug Out-Of-Pocket maximum: | $2,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $117.30 | $67.50 |
Initial Coverage Phase
After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1) Preferred Generic | $1.00 Copay | $10.00 Copay | $1.00 Copay | $10.00 Copay |
| 2) Generic | $8.00 Copay | $20.00 Copay | $8.00 Copay | $20.00 Copay |
| 3) Preferred Brand | $45.00 Copay | $47.00 Copay | $45.00 Copay | $47.00 Copay |
| 4) Non-Preferred Drug | 47.00% Coinsurance | 50.00% Coinsurance | 47.00% Coinsurance | 50.00% Coinsurance |
| 5) Specialty Tier | 25.00% Coinsurance | 25.00% Coinsurance | 25.00% Coinsurance | 25.00% Coinsurance |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1) Preferred Generic | $2.00 Copay | $20.00 Copay | $2.00 Copay | $20.00 Copay |
| 2) Generic | $16.00 Copay | $40.00 Copay | $16.00 Copay | $40.00 Copay |
| 3) Preferred Brand | $90.00 Copay | $94.00 Copay | $90.00 Copay | $94.00 Copay |
| 4) Non-Preferred Drug | 47.00% Coinsurance | 50.00% Coinsurance | 47.00% Coinsurance | 50.00% Coinsurance |
| 5) Specialty Tier |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1) Preferred Generic | $3.00 Copay | $30.00 Copay | $3.00 Copay | $30.00 Copay |
| 2) Generic | $24.00 Copay | $60.00 Copay | $24.00 Copay | $60.00 Copay |
| 3) Preferred Brand | $135.00 Copay | $141.00 Copay | $135.00 Copay | $141.00 Copay |
| 4) Non-Preferred Drug | 47.00% Coinsurance | 50.00% Coinsurance | 47.00% Coinsurance | 50.00% Coinsurance |
| 5) Specialty Tier |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Ready to sign up for Blue Cross MedicareRx Value (PDP) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST