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Medicare PPO Blue PlusRx (PPO)

Download 2013 Summary of Benefits

Prescription Drug Coverage Summary

 

Cost

Annual Deductible

$0

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
30% of the cost

$6 copay
$24 copay
$90 copay
$180 copay
30% 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.

(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.

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: