Medicare HMO Blue ValueRx (HMO)

Download 2013 Summary of Benefits

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

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.)

Prior Authorization, Step Therapy, and Quality Care Dosing Requirements

We have additional requirements for coverage or limits on our coverage for certain prescription drugs. This ensures that our members use these drugs in a safe way.

2013 Medicare Advantage Prior Authorization Criteria
Updated 06/2013
2013 Medicare Advantage Step Therapy Criteria
Updated 06/2013
2013 Medicare Advantage Quality Care Dosing Guidelines
Updated 06/2013

If a drug you are taking requires prior authorization or step therapy from the Plan, please download and complete the 2013 Request for Medicare Prescription Drug Coverage Determination Form below, and ask your doctor to fax it to us at 1-617-246-8506.

Other prescription-related information you may need:

Plan Drug Transition Policy