Blue Cross MedicareRxSM Plans 2014




Blue Cross MedicareRx offers three plan designs, Basic, 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 Cross MedicareRx.
Learn more about eligibility.

You must continue to pay your Medicare Part B premium.



Blue Cross MedicareRx (PDP)SM Plans 2014

  Basic Value Plus
Monthly Premium $23.10 $42.40 $103.00
Deductible $310 All Tiers $200 Tiers 3-5 $0

Copays and Coinsurance

Tier 1 - Preferred Generic Drugs
Preferred Non
Preferred Network
$1 $6
Preferred Non
Preferred Network
$0 $5
Preferred Non
Preferred
Network
$0 $5
Tier 2 - Non-Preferred Generic Drugs
$2 $8
$2 $7
$2 $7
Tier 3 - Preferred Brand Drugs
$39 $45
$39 $44
$33 $40
Tier 4 - Non-Preferred Brand Drugs
$85 $95
$85 $95
$80 $95
Tier 5 - Specialty Drugs
25% 25%
25% 25%
33% 33%
Gap Coverage You will receive a discount on drugs and generally pay no more than 47.5% of the cost on brand name drugs and 72% of the cost for generic drugs until your yearly out-of-pocket drug costs reach $4,550 You will receive a discount on drugs and generally pay no more than 47.5% of the cost on brand name drugs and 72% of the cost for generic drugs until your yearly out-of-pocket drug costs reach $4,550 You will continue to pay initial cost sharing on all formulary generics in Tiers 1, 2 and 5. You will also continue to pay initial cost sharing on some brands in Tiers 3, 4 and 5. On the remaining brand name drugs you will generally pay no more than 47.5% of the costs of the drugs.
After the Gap

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:

Tier 1 : Preferred Generic Drugs $2.55 copay or 5% coinsurance for your drug

Tier 2 : Non-Preferred Generic Drugs $2.55 copay or 5% coinsurance for drug

Tier 3 : Preferred Brand Drugs $6.35 copay or 5% coinsurance for your drug.

Tier 4 : Non-Preferred Brand Drugs $6.35 copay or 5% coinsurance for drug

Tier 5 : Specialty Drugs 5% coinsurance for drug

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:

Tier 1 : Preferred Generic Drugs $2.55 copay or 5% coinsurance for your drug

Tier 2 : Non-Preferred Generic Drugs $2.55 copay or 5% coinsurance for drug

Tier 3 : Preferred Brand Drugs $6.35 copay or 5% coinsurance for your drug.

Tier 4 : Non-Preferred Brand Drugs $6.35 copay or 5% coinsurance for drug

Tier 5 : Specialty Drugs 5% coinsurance for drug

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of:

Tier 1 : Preferred Generic Drugs $2.55 copay or 5% coinsurance for your drug

Tier 2 : Non-Preferred Generic Drugs $2.55 copay or 5% coinsurance for drug

Tier 3 : Preferred Brand Drugs $6.35 copay or 5% coinsurance for your drug.

Tier 4 : Non-Preferred Brand Drugs $6.35 copay or 5% coinsurance for drug

Tier 5 : Specialty Drugs 5% coinsurance for drug

Evidence of Coverage

English
Y0096_BEN_TX_
EOCBASIC2014
Accepted 08232013


Español
Y0096_BEN_TMP_
PDPEOCCVR13SPA
Approved 08222013

English
Y0096_BEN_TX_
ANOCEOCVALUE2014
Accepted 08232013


Español
Y0096_BEN_TMP_
PDPEOCCVR13SPA
Approved 08222013

English
Y0096_BEN_TX_
ANOCEOCPLS2014
Accepted 08232013


Español
Y0096_BEN_TMP_
PDPEOCCVR13SPA
Approved 08222013

Summary of Benefits

English
Y0096_BEN_TX_PDPSB14 Accepted 10012013

Español
Y0096_BEN_TX_PDPSB14SPA





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

Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

Limitations, co-payments, and restrictions may apply. Find more information here .

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