2022 Blue Rx Standard (PDP) By BlueCross BlueShield: Empire, Excellus, WNY and

Blue Rx Standard (PDP) is a Basic Alternative 2022 Medicare (Part-D) Prescription Plan by BlueCross BlueShield: Empire, Excellus, WNY and. Stand-alone plans offer additional prescription drug coverage only and are an option if you are on Original Medicare insurance or you have a Medicare health plan that does not include Part D coverage. The Blue Rx Standard (PDP) plan has a monthly drug premium of $60.20 and a $325.00 drug deductible.

S3375-001 Part-D Summary of Bennefits

Plan Name:Blue Rx Standard (PDP)
Provider:BlueCross BlueShield: Empire, Excellus, WNY and
Plan ID:S3375-001
Plan Year:2022
State: New York

Benefit Type:Basic
Monthly Drug Premium:$60.20
Drug Deductible:$325.00
Tiers with No Deductible:0
Gap Coverage:No
National Plan:No
Similar Plan:S3375-002
New 2023 Plan:S3375-001

Deductible and Premium for Blue Rx Standard (PDP)

The Blue Rx Standard (PDP) plan has a monthly drug premium of $60.20 and a $325.00 drug deductible. This BlueCross BlueShield: Empire, Excellus, WNY and plan offers a $60.20 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by BlueCross BlueShield: Empire, Excellus, WNY and above and beyond the standard PDP benefits. This can include additional help in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $60.20. The Part D Total Premium is the combined total of the supplemental and basic premiums for some plans this amount can be lower due to negative premiums.

Part D Basic Premium:$60.20
Benchmark:not below the regional benchmark
Part D Supplemental Premium$0.00
Benefit Type: Basic Alternative
Total Part D Premium:$60.20

BlueCross BlueShield: Empire, Excellus, WNY and Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Blue Rx Standard (PDP) medicare insurance plan offers a $17.80 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $28.40 for 75% low income subsidy $39.00 for 50% and $49.60 for 25%.

$0 Premium with Full LIS:No
Full LIS Premium:$17.80
75% LIS Premium:$28.40
50% LIS Premium:$39.00
25% LIS Premium:$49.60

S3375-001 Gap Coverage

In 2022 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will still receive a 75% discount on covered brand-name drugs and a discount on generic drugs. Once you reach the coverage gap you will pay 25% of the plans cost for covered brand-name prescription drugs and 25% on generic drugs unless your plan offers additional coverage. This BlueCross BlueShield: Empire, Excellus, WNY and plan does not offer additional coverage through the gap. If you are looking for additional health coverage you can see the New York MA Plans here.

S3375-001 Formulary or Drug Prices

Blue Rx Standard (PDP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Blue Rx Standard (PDP) S3375-001 Formulary here.

Drug Tier Copay
Tier 1 $1 $4
Tier 2 $4 $6
Tier 3 $41 $41
Tier 4 33% 33%
Tier 5 27% 27%
*Initial Coverage Phase and 30 day supply

Source: CMS.
Plans as of September 1, 2021.
Notes: Data are subject to change. All contracts for 2020 have been not finalized. For 2020, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Includes 2020 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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