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Benefits
Benefits |
Option I |
Option II |
You Pay: |
You Pay: |
|
Deductible |
$220 |
$0 |
Monthly Premium* |
$28.50 |
$61.10 |
Amount you pay for a 30-day supply at a retail pharmacy** |
||
Preferred Generics (Tier 1) |
$3 |
$2 |
Non-Preferred Generics (Tier 2) |
$5 |
$4 |
Preferred Brand (Tier 3) |
$35 |
$35 |
Non-Preferred Brand (Tier 4) |
$60 |
$60 |
Specialty (Tier 5) |
25% |
33% |
Amount you pay for a 90-day supply at a mail order pharmacy** |
||
Preferred Generics |
$9 |
$5 |
Non-Preferred Generics (Tier 2) |
$15 |
$10 |
Preferred Brand (Tier 3) |
$105 |
$87.50 |
Non-Preferred Brand (Tier 4) |
$180 |
$150 |
Specialty (Tier 5) |
25% |
33% |
Gap Coverage (Total annual drug costs reach $2,830) |
No coverage in the gap. You pay 100%; You will receive discounts when you use network pharmacies. |
Tier 1 drugs (Preferred Generics) are covered |
Catastrophic Coverage (Begins when your annual out-of-pocket costs exceed $4,550) |
You pay the greater of $2.50 for generics, $6.30 for all other drugs, or 5% coinsurance. |
|
Formulary (Drug list) |
||
Summary of Benefits |
||
Evidence of Coverage |
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Specialty (Tier 5) |
25% |
33% |
*You must continue to pay your Medicare Part B Premium, if it is not otherwise paid for under Medicaid or by another third party.
** You pay this amount until you and the plan pay a total of $2,830 for covered prescription drug expenses (including drug costs, copayments, coinsurance, and deductibles).
Please note: After your total yearly drug costs reach $2,830 you pay 100% of your drug costs until your yearly out-of-pocket drug costs reach $4,550.
For full information on BlueCross BlueShield of Tennessee benefits, call our Customer Service Department at 1-866-210-1522, 8 am to 9 pm, Eastern Time, 7 days a week. TTY users should call, 1-877-664-6422. From March 1 to September 30, you may be required to leave a voice mail on weekends and holidays. Calls will be returned within one business day.
A Medicare approved Part D sponsor.
S1030_W10_R2 CMS Approved 01042010
S1030_W10_R2 CMS Approved 01042010
© 2008 BlueCross BlueShield of Tennessee, Inc., an Independent Licensee of the BlueCross BlueShield Association. ® Registered marks of BlueCross BlueShield Association. BlueRx is a regional Medicare prescription drug plan provided by BlueCross and BlueShield of Alabama and BlueCross BlueShield of Tennessee, Independent Licensees of the BlueCross and BlueShield Association. Please see our Privacy Policy, guidelines for E-mail Correspondence, and other Legal Information for this site.
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