Blue Cross MedicareRx Value (PDP) - S5715-005-000

3 out of 5 stars* for plan year 2025

$117.40

Monthly Premium

Blue Cross MedicareRx Value (PDP) is a Medicare Part D Prescription Drug Plan offered by Health Care Service Corporation

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$117.40

Monthly Premium

Plan ID: S5715-005-000

Texas Medicare beneficiaries may want to consider reviewing their Medicare prescription drug coverage options, such as a standalone Part D prescription drug plan (PDP) or a Medicare Advantage (Medicare Part C) plan that includes drug coverage.

A Part D plan can be used alongside your Original Medicare (Part A and Part B) coverage. A Medicare Advantage plan that includes drug coverage combines your Part A, Part B and Part D benefits into a single plan

Learn more about Texas Medicare prescription drug plans like the one below and find a plan that offers the benefits you want at an affordable price.

Blue Cross MedicareRx Value (PDP) - S5715-005-000 Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$117.40
Annual deductible	$590.00
Preferred pharmacies?	Yes
Accepts Mail Order?	Yes
Star Rating	3 out of 5 stars

Prescription Drug Costs and Coverage

The Blue Cross MedicareRx Value (PDP) is a prescription drug plan which offers the following coverage:

Deductible Coverage Level

30 day supply
60 day supply
90 day supply

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug
Preferred retail	$1.00	$8.00
Standard retail	$10.00	$20.00
Preferred mail order	$1.00	$8.00
Standard mail order	$10.00	$20.00

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug
Preferred retail	$2.00	$16.00
Standard retail	$20.00	$40.00
Preferred mail order	$2.00	$16.00
Standard mail order	$20.00	$40.00

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug
Preferred retail	$3.00	$24.00
Standard retail	$30.00	$60.00
Preferred mail order	$3.00	$24.00
Standard mail order	$30.00	$60.00

Initial Coverage Level

30 day supply
60 day supply
90 day supply

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug	Tier 3 Preferred Brand Drug	Tier 4 Non-Preferred Drug	Tier 5 Specialty Tier Drug
Preferred retail	$1.00	$8.00	$33.00	45%	25%
Standard retail	$10.00	$20.00	$35.00	50%	25%
Preferred mail order	$1.00	$8.00	$33.00	45%	25%
Standard mail order	$10.00	$20.00	$35.00	50%	25%

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug	Tier 3 Preferred Brand Drug	Tier 4 Non-Preferred Drug	Tier 5 Specialty Tier Drug
Preferred retail	$2.00	$16.00	$66.00	45%	N/A
Standard retail	$20.00	$40.00	$70.00	50%	N/A
Preferred mail order	$2.00	$16.00	$66.00	45%	N/A
Standard mail order	$20.00	$40.00	$70.00	50%	N/A

Tiers	Tier 1 Preferred Generic Drug	Tier 2 Generic Drug	Tier 3 Preferred Brand Drug	Tier 4 Non-Preferred Drug	Tier 5 Specialty Tier Drug
Preferred retail	$3.00	$24.00	$99.00	45%	N/A
Standard retail	$30.00	$60.00	$105.00	50%	N/A
Preferred mail order	$3.00	$24.00	$99.00	45%	N/A
Standard mail order	$30.00	$60.00	$105.00	50%	N/A

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