Medicare PPO Blue ValueRx (PPO)

Download 2013 Summary of Benefits

Monthly Plan Premium $66.10*

Call us:
1-800-678-2265
TTY: 1-800-522-1254

Hours of operation:
7 days a week
8 a.m. - 8 p.m.

Or have us call you.

Prescription Drug Coverage

2013 Medicare PPO Blue ValueRx Formulary
Updated 05/2013

Prescription Drug Coverage Summary

	Cost
Annual Deductible	$0 Tiers 1 and 2; $220 Tiers 3, 4, and 5
Initial Coverage	30-day retail	90-day mail order
Tier 1: Preferred Generic Tier 2: Non-Preferred Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Drugs	$6 copay $12 copay $45 copay $90 copay 27% of the cost	$6 copay $24 copay $90 copay $180 copay 27% of the cost
Coverage Gap	For covered generics, you pay 79% of the plan's costs. For covered brand drugs, you pay no more than 47.5% of the plan's costs (excluding dispensing fees)
Catastrophic Coverage	You pay the greater of: $2.65 copay for generics or drugs treated like generic drugs $6.60 copay for brands 5% of the cost

We may periodically make changes to the formulary (covered drug list). If we remove a medication from the formulary, affected members will be notified, in writing, before the change is made.

View Medicare Advantage Network & Formulary

Pharmacy Directory

There are over 1,200 pharmacies in our Massachusetts network and over 61,900 pharmacies in our nationwide network. We contract with pharmacies that equal or exceed regulatory requirements for pharmacy access in your area.

2013 Medicare Advantage Pharmacy Directory

(The pharmacies listed in this network may differ from those in the Blue MedicareRx (PDP) network. Please call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), 8:00 a.m. to 8:00 p.m. ET as follows: from October 1 through February 14, seven days a week, and from February 15 through September 30, Monday through Friday, or visit Blue MedicareRx (PDP) for more information.)

*Your monthly premium will be different if you qualify for Extra Help from Medicare.