BlueMedicare Premier Rx (PDP) S5795-002

Plan costs

Pharmacy coverage
Prescription deductible	$0
Out-of-Pocket	$2,100
One-Month Supply (Retail Pharmacy) with Standard Cost Sharing
Preferred Generic	$0 copay
Generic	$5 copay
Preferred Brand	20% coinsurance
Non-Preferred Drug	34% coinsurance
Specialty Tier	33% coinsurance
Insulin Products	Lesser of a $35 copay or 20% coinsurance on Tier 3 and the lesser of a $35 copay or 25% coinsurance on Tier 4 and Tier 5 for a one-month supply
100-Day Supply (Retail Pharmacy) with Standard Cost Sharing
Preferred Generic	$0 copay
Generic	$15 copay
Preferred Brand	20% coinsurance
Non-Preferred Drug	34% coinsurance
Specialty Tier	Not covered
Insulin Products	Lesser of a $70 copay or 20% coinsurance on Tier 3 and the lesser of a $70 copay or 25% coinsurance on Tier 4 for a two-month supply Lesser of a $105 copay or 20% coinsurance on Tier 3 and the lesser of a $105 copay or 25% coinsurance on Tier 4 for a three-month supply

Plan Documents
Summary of Benefits	BlueMedicare Premier Rx (PDP) 2026 Summary of Benefits
Plan Documents	BlueMedicare Premier Rx (PDP) Plan Documents

Plan: S5795-002

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, 7:00 a.m. to 7:00 p.m.
Your State Medicaid Office.