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Prescription Drugs

Options	Prescription Drug Card Program
	Copayment Amounts			Calendar Year Maximum Benefits
	Generic	Preferred	Non Preferred
Plan I	$10	$30	$45	$3,000
Plan II
Plan III	$10	$30	$45	$3,000
Plan IV
Plan V	$10	$30	$45	$3,000
Plan VI
Plan VII	$10	$30	$45	$3,000
Plan VIII

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
© Copyright 2012. Health Care Service Corporation. All Rights Reserved.

Important Information about Blue MedicareRx^SM

^SM Service Mark of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

^® Registered Service Marks of the Blue Cross and Blue Shield Association, an Association of Independent Blue Cross and Blue Shield Plans.

Blue Cross and Blue Shield of Texas refers to HCSC Insurance Services Company, which is a wholly owned subsidiary of Health Care Service Corporation, a Mutual Legal Reserve Company. These companies are independent licensees of the Blue Cross and Blue Shield Association and offer or provide services for stand-alone prescription drug plans with a Medicare contract under contract number S5715 with the Centers for Medicare and Medicaid Services.

A stand-alone prescription drug plan with a Medicare contract.

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