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Blue Medicare Rx Standard (PDP) - S5540-002-000
$103.40
Monthly Premium
Blue Medicare Rx Standard (PDP) is a Medicare Part D Prescription Drug Plan offered by Blue Cross and Blue Shield of North Carolina
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$103.40
Monthly Premium
North Carolina 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 North Carolina Medicare prescription drug plans like the one below and find a plan that offers the benefits you want at an affordable price.
Blue Medicare Rx Standard (PDP) - S5540-002-000 Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $103.40 |
| 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 Medicare Rx Standard (PDP) is a prescription drug plan which offers the following coverage:
Deductible Coverage Level
| Tiers | Tier 1 Preferred Generic Drug |
|---|---|
| Preferred retail | $5.00 |
| Standard retail | $15.00 |
| Preferred mail order | $5.00 |
| Standard mail order | $15.00 |
| Tiers | Tier 1 Preferred Generic Drug |
|---|---|
| Preferred retail | $10.00 |
| Standard retail | $30.00 |
| Preferred mail order | $10.00 |
| Standard mail order | $30.00 |
| Tiers | Tier 1 Preferred Generic Drug |
|---|---|
| Preferred retail | $15.00 |
| Standard retail | $45.00 |
| Preferred mail order | $15.00 |
| Standard mail order | $45.00 |
Initial Coverage Level
| 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 | $5.00 | $10.00 | 19% | 50% | 25% |
| Standard retail | $15.00 | $20.00 | 19% | 50% | 25% |
| Preferred mail order | $5.00 | $10.00 | 19% | 50% | 25% |
| Standard mail order | $15.00 | $20.00 | 19% | 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 | $10.00 | $20.00 | 19% | 50% | N/A |
| Standard retail | $30.00 | $40.00 | 19% | 50% | N/A |
| Preferred mail order | $10.00 | $20.00 | 19% | 50% | N/A |
| Standard mail order | $30.00 | $40.00 | 19% | 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 | $15.00 | $30.00 | 19% | 50% | N/A |
| Standard retail | $45.00 | $60.00 | 19% | 50% | N/A |
| Preferred mail order | $15.00 | $30.00 | 19% | 50% | N/A |
| Standard mail order | $45.00 | $60.00 | 19% | 50% | N/A |
Plan Documents
| Links to plan documents |
North Carolina Counties Served
- Alamance
- Alexander
- Alleghany
- Anson
- Ashe
- Avery
- Beaufort
- Bertie
- Bladen
- Brunswick
- Buncombe
- Burke
- Cabarrus
- Caldwell
- Camden
- Carteret
- Caswell
- Catawba
- Chatham
- Cherokee
- Chowan
- Clay
- Cleveland
- Columbus
- Craven
- Cumberland
- Currituck
- Dare
- Davidson
- Davie
- Duplin
- Durham
- Edgecombe
- Forsyth
- Franklin
- Gaston
- Gates
- Graham
- Granville
- Greene
- Guilford
- Halifax
- Harnett
- Haywood
- Henderson
- Hertford
- Hoke
- Hyde
- Iredell
- Jackson
- Johnston
- Jones
- Lee
- Lenoir
- Lincoln
- Macon
- Madison
- Martin
- Mcdowell
- Mecklenburg
- Mitchell
- Montgomery
- Moore
- Nash
- New Hanover
- Northampton
- Onslow
- Orange
- Pamlico
- Pasquotank
- Pender
- Perquimans
- Person
- Pitt
- Polk
- Randolph
- Richmond
- Robeson
- Rockingham
- Rowan
- Rutherford
- Sampson
- Scotland
- Stanly
- Stokes
- Surry
- Swain
- Transylvania
- Tyrrell
- Union
- Vance
- Wake
- Warren
- Washington
- Watauga
- Wayne
- Wilkes
- Wilson
- Yadkin
- Yancey