Prescription Drug Benefits

Silver, Gold and Platinum plan options all include the same prescription drug benefits and use the same pharmacy network. However, the plans’ list of covered drugs (formulary) are different:

• Silver uses our standard formulary.
• Gold and Platinum use our expanded formulary.

Both formularies include drugs in all classes covered by Medicare Part D. The expanded formulary covers more drugs than the standard formulary.

To see if your drugs are covered and the copays that apply, please see our List of Covered Drugs.

Coverage Phase	You Pay:
Deductible	$0
Initial Coverage Phase (Cost up to $2,700)	For a 30-day supply at a retail pharmacy you pay: $5 for generic(Tier 1) $30 for preferred brand (Tier 2) $55 for non-preferred brand (Tier 3) 33% for Specialty (Tier 4)  For a 90-day supply through mail order service you pay: $12.50 for generic (Tier 1) $75 for preferred brand (Tier 2) $137.50 for non-preferred brand (Tier 3) 33% for Specialty (Tier 4)
Coverage Gap From $2,700 until your out-of-pocket costs reach $4,350 including any copays you paid during your initial coverage phase.	You pay 100% of your prescription drug costs. You receive discounts when you use network pharmacies.
Catastrophic Coverage (Your out-of-pocket costs exceed $4,350)	The greater of: $2.40 for generic (Tier 1) and $6.00 for all other drugs  OR 5% coinsurance

All prescription drugs must be covered by Medicare Part D and the plan’s formulary (d) and must be purchased at a network (d) pharmacy for these cost sharing (d) amounts to apply. For a complete list of benefits, please see the Summary of Benefits. For detailed information on this plan and its major limitations or exclusions, please review the Evidence of Coverage. For full information on BlueAdvantage PFFS, please contact us.

BlueCross BlueShield of Tennessee’s Medicare contract is renewed annually. The availability of coverage beyond the end of this contract year is not guaranteed. Benefits, premiums, copays, coinsurance, formulary and pharmacy directory may change on Jan. 1, 2010.

Definitions of Prescription Drug Benefit Terms

Catastrophic Coverage Threshold: Once your out-of-pocket costs reach $4,300 including any deductibles or copays you paid during your Initial Coverage phase, you enter the Catastrophic Coverage phase. You will pay lower copays for the rest of the calendar year.

Coinsurance: The percentage of your medical or prescription drug expenses that you are required to pay. For example under Original Medicare, you pay 20 percent of the cost of a doctor’s office visit. If the charges are $200, your coinsurance would be $40.

Copay: A flat fee that you are required to pay for a medical service or prescription drug. For example, you might pay $30 for a doctor’s office visit under your plan.

Cost Sharing: A term for how you and your insurance company work together to pay your medical and prescription drug expenses. Coinsurance and copays are examples of cost sharing. You pay a copay and your plan covers the rest of the expense.

Coverage Gap: The middle portion of your prescription drug expenses during which your plan may not cover or may provide limited coverage. You pay 100 percent of your drug expenses during the coverage gap. You may also hear this called the “doughnut hole.”

Creditable Coverage: Prescription drug coverage offered by a plan, other than a Part D plan, that is as good as or better than the minimum benefit standard required by Medicare. If you are currently enrolled in a plan that provides drug coverage, that plan is required to tell you if it meets these standards for creditable coverage.

Formulary: A list of prescription drugs covered by a Part D plan. The formulary may consist of multiple tiers or levels of coinsurance or copays you are required to pay.

Generic Drugs: Prescription drugs that have the same active ingredient formula as brand name drugs. Generic drugs usually cost less than brand name drugs. They are also rated by the Food and Drug Administration (FDA) to be as safe and effective as their brand name counterparts. These drugs are Tier 1 drugs.

Initial Coverage Limit: The first phase of your prescription drug coverage. Your drug costs between $0 and $2,510, including your out-of-pocket costs (such as deductibles and copays or coinsurance) and what your plan pays for your medications.

Network: A list of doctors, hospitals or pharmacies that have contracts with an insurance plan to provide care for the plan’s members. If your plan has a network, you must use a provider or pharmacy in the plan’s network or you may be required to pay more for your care or prescription drugs.

Non-Preferred Brand Drugs: A brand-name drug that is covered by your formulary but may not be as cost-effective as similar preferred brand drugs. These drugs are Tier 3 drugs on our formularies.

Out-of-Pocket Costs: The amount you must pay out of your own pocket of your medical or prescription drug expenses. These costs include things like deductibles, coinsurance or copays.

Preferred Brand Drugs: Brand-name drugs that are medically sound, cost-effective alternatives to higher-priced drugs. These drugs are Tier 2 drugs on our formularies.

Specialty Drugs: Certain highly-specialized drugs that require special handling and administering by the patient or provider. These drugs are Tier 4 drugs.

Step Therapy: Some health or prescription drug plans may require you to try a drug on a lower tier first. If the lower tier drug does not work, you may advance to a higher tier drug.

Tier: A tier is a copay or coinsurance level that applies to drugs on the plan’s formulary. You pay the lowest copay for Tier 1 drugs and the highest coinsurance for Tier 4 drugs.