Medicare Prescription Drug Plans




Blue Cross MedicareRxSM offers three plan designs:

  • Basic
  • Value
  • Plus


Protect yourself from some of the costs that Original Medicare doesn't cover by adding Blue Cross MedicareRx to your coverage.


Blue Cross MedicareRx offers:

  • Fixed copayments and coinsurances
  • Comprehensive drug lists
  • Convenience of nationwide coverage at thousands of pharmacies
  • Mail-order choices
  • Savings on copays when Preferred Pharmacies are used




Select a plan name below to view 2015 plan information.

TX Medicare Tables
Basic Value Plus
2015 Blue Cross MedicareRx Plans
Blue Cross MedicareRx Basic (PDP)
Monthly Premium
$26.20
Annual Prescription Deductible*
$320 (All Tiers)
Copays and Coinsurances
Preferred Pharmacy
Standard
Tier 1 - Preferred Generic Drugs
$1 copay
$6 copay
Tier 2 - Non-Preferred Generic Drugs
$6 copay
$11 copay
Tier 3 - Preferred Brand Drugs
$40 copay
$45 copay
Tier 4 - Non-Preferred Brand Drugs
$90 copay
$95 copay
Tier 5 - Specialty Drugs
25% of the cost
25% of the cost
Gap Coverage
You will pay 45% of the plan's cost for covered Brand Name Drugs and 65% of the plan's cost for Generic Drugs until your yearly out-of-pocket drug costs reach $4,700.
After the Gap Copays
After your yearly out-of-pocket drug costs (including drugs purchased through retail pharmacy and mail-order) reach $4,700, you will pay the greater of:

Tiers 1 & 2 - $2.65 copay or 5% coinsurance for your drug
Tiers 3 & 4 - $6.60 copay or 5% coinsurance for your drug
Tier 5 - 5% coinsurance for your drug
Annual Notice of Change
Evidence of Coverage
Summary of Benefits

2015 Blue Cross MedicareRx Plans
Blue Cross MedicareRx Value (PDP)
Monthly Premium
$55.10
Annual Prescription Deductible*
$275 (Tiers 3 -5)
Copays and Coinsurances
Preferred Pharmacy
Standard
Tier 1 - Preferred Generic Drugs
$0 copay
$5 copay
Tier 2 - Non-Preferred Generic Drugs
$6 copay
$11 copay
Tier 3 - Preferred Brand Drugs
$39 copay
$44 copay
Tier 4 - Non-Preferred Brand Drugs
$85 copay
$95 copay
Tier 5 - Specialty Drugs
25% of the cost
25% of the cost
Gap Coverage
You will pay 45% of the plan's cost for covered Brand Name Drugs and 65% of the plan's cost for Generic Drugs until your yearly out-of-pocket drug costs reach $4,700.
After the Gap Copays
After your yearly out-of-pocket drug costs (including drugs purchased through retail pharmacy and mail-order) reach $4,700, you will pay the greater of:

Tiers 1 & 2 - $2.65 copay or 5% coinsurance for your drug
Tiers 3 & 4 - $6.60 copay or 5% coinsurance for your drug
Tier 5 - 5% coinsurance for your drug
Annual Notice of Change
Evidence of Coverage
Summary of Benefits

2015 Blue Cross MedicareRx Plans
Blue Cross MedicareRx Plus (PDP)
Monthly Premium
$119.50
Annual Prescription Deductible*
$0
Copays and Coinsurances
Preferred Pharmacy
Standard
Tier 1 - Preferred Generic Drugs
$0 copay
$5 copay
Tier 2 - Non-Preferred Generic Drugs
$2 copay
$7 copay
Tier 3 - Preferred Brand Drugs
$33 copay
$40 copay
Tier 4 - Non-Preferred Brand Drugs
$80 copay
$95 copay
Tier 5 - Specialty Drugs
33% of the cost
33% of the cost
Gap Coverage
You will pay $0/$5 for drugs in Tier 1 and $2/$7 for drugs in Tier 2. You will receive coverage for many generics and some brands on Tiers 3, 4 and 5 or pay 45% of the cost of Brand Name drugs and 65% of the cost of Generic drugs.
After the Gap Copays
After your yearly out-of-pocket drug costs (including drugs purchased through retail pharmacy and mail-order) reach $4,700, you will pay the greater of:

Tiers 1 & 2 - $2.65 copay or 5% coinsurance for your drug
Tiers 3 & 4 - $6.60 copay or 5% coinsurance for your drug
Tier 5 - 5% coinsurance for your drug
Annual Notice of Change
Evidence of Coverage
Summary of Benefits



*Amount you pay before the plan begins to pay.


The coverage gap or "donut hole" begins after the total yearly drug costs (includes what the plan and member has paid) reach $2,960.


Copays after your total out-of-pocket costs exceed $4,700.




Thank you for looking at coverage options for Blue Cross MedicareRx
We Can Help!

Call 1-866-273-2777 TTY/TDD 711
for personal help finding a plan.


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To verify your recent enrollment, check the status of a claim or ask questions about your existing coverage, please contact Customer Service at: 1-888-285-2249 TTY/TDD 711

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