Blue MedicareRxSM Plans 2013


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Blue MedicareRx offers two plan designs, Value and Plus. Below is an overview of each plan. To compare the plans to determine which best meets your needs, use the Plan Selector Tool .

Before picking a plan, be sure you are eligible for Blue MedicareRx.
Learn more about eligibility.

You must continue to pay your Medicare Part B premium.



Value Plan Plus Plan
Monthly Premium $39.00 $95.90
Deductible

$325 (Tiers 3,4 and 5 only)

 $0
Copays and Coinsurances
Tier 1 – Preferred Generic $3.00 $3.00
Tier 2 – Non-Preferred Generics $11.00 $10.00
Tier 3 – Preferred Brand $44.00 $38.00
Tier 4 – Non-Preferred Brand $95.00 $86.00
Tier 5 – Specialty 25% 33%
Gap Coverage After your yearly total drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 79% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs
reach $4,750. 		$3.00 for Preferred Generic Drugs $10.00 for Non-Preferred Generic Drugs You will receive a discount on Brand Name Drugs.
After the Gap
After your yearly out-of-pocket drug costs reach $4,750, you pay the greater of:
Tier 1 – Preferred Generic $2.65 copay or 5% coinsurance
for your drug 		$2.65 copay or 5% coinsurance
for your drug
Tier 2 – Non-Preferred Generics $2.65 copay or 5% coinsurance
for your drug 		$2.65 copay or 5% coinsurance
for your drug
Tier 3 – Preferred Brand $6.60 copay or 5% coinsurance
for your drug 		$6.60 copay or 5% coinsurance
for your drug
Tier 4 – Non-Preferred Brand $6.60 copay or 5% coinsurance
for your drug 		$6.60 copay or 5% coinsurance
for your drug
Tier 5 – Specialty 5% coinsurance for your drug 5% coinsurance for your drug
Evidence of Coverage Evidence of Coverage: Value Plan
S5715_BEN_IL_ANOCEOCVALUE2013LP

Evidence of Coverage: Value Plan en Español
S5715_BEN_IL_ANOCEOCVALUE2013SPA		 Evidence of Coverage: Plus Plan
S5715_BEN_IL_ANOCEOCPLS2013LP

Evidence of Coverage: Plus Plan en Español
S5715_BEN_IL_ANOCEOCPLS2013SPA
Summary of Benefits Summary of Benefits
S5715_IL_BEN_BNFTSMRY13b Approved 10152012

Summary of Benefits en Español
S5715_IL_BEN_BNFTSMRY13bSPA Accepted 10152012

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.

Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year.

Limitations, copayments, and restrictions may apply.

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form  or contact the Office of the Medicare Ombudsman .