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Prescription Drugs

Options	Separate Deductibles	Prescription Drug Card Program
	*Individual (per calendar year)	Copayment Amounts			Calendar Year Maximum Benefits
		Generic	Preferred	Non-preferred
Plan I	$500	$10	$50	$65	$2,500
Plan II	$500	$10	$50	$65	$2,500
Plan III
Plan IV	$500	$10	$50	$65	$2,500

* Separate deductible of $500 not applicable to Generic drugs, but will be applicable to Preferred and Non-preferred drugs.

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.
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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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