2013 Medicare HMO Blue ValueRx/PlusRx Formulary - Blue Cross ...

Your Medicare Prescription Drug CostsMedicare HMO Blue ValueRxMedicare HMO Blue PlusRxDrug CoverageYou pay:Annual DeductibleInitial Coverage$0 for Tiers 1 and 2$220 for Tiers 3, 4 and 5$0 for Tiers 1 and 2$150 for Tiers 3, 4 & 5You pay the following until total yearly drug costs reach $2,970 for:30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacy30-day supplyat a networkretail pharmacy90-day supplyat networkretail pharmacy 190-day supplythrough networkmail-order pharmacyTier 1: Preferred Generic drugs $6 $18 $6 $6 $18 $6Tier 2: Non-Preferred Generic drugs $12 $36 $24 $12 $36 $24Tier 3: Preferred Brand drugs $45 $135 $90 $45 $135 $90Tier 4: Non-Preferred Brand drugs $90 $270 $180 $90 $270 $180Tier 5: Specialty Tier drugs 27% 27% 27% 30% 30% 30%Coverage GapAfter your total yearly drug costs reach $2,970 and untilyour yearly out-of-pocket drug costs reach $4,750 you pay no more than:79% of the cost of generic drugs and 47.5% of the negotiated price(excluding dispensing and vaccine administration fees) for brand name drugs.Catastrophic CoverageAfter your yearly out-of-pocket drug costs reach $4,750 you pay the greater of:Generic (including brand drugstreated as generic)$2.65 or 5%All other drugs 2 $6.60 or 5%1. Available at retail pharmacies that have agreed to allow members to fill 90-daysupplies of their prescriptions.2. All covered drugs are on the formulary/drug list.6