Plan Detail

It's easy to choose with six Blue MedicareRx benefit plans: Standard Copay Plan, Standard Coinsurance Plan, Enhanced Copay Plan, Enhanced Coinsurance Plan, Enhanced Plus Copay Plan, Enhanced Plus Coinsurance Plan.  Featuring ZERO deductible options and LOW copayment choices within the entire state of New Mexico. 

Blue Cross and Blue Shield of New Mexico offers employer groups three standard Prescription Drug Plans described below. Some groups have variations on these plans. Please ask your human resources department for the plan available from your employer.


 Coinsurance Plan Comparison

Benefit Category Original Medicare Standard Plan Enhanced Enhanced Plus
Medicare Part B prescription drugs You pay 100% for most prescription drugs, unless you enroll in the Medicare Prescription Drug Plan. This plan does not cover Medicare Part B prescription drugs. This plan does not cover Medicare Part B prescription drugs. This plan does not cover Medicare Part B prescription drugs.
Formulary   This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsnm.com on the web.

 This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsnm.com on the web.

 This plan uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing before the change. To view the plan's formulary, go to www.bcbsnm.com on the web.
Indian/ Tribal/ Urban (Indian Health Service)   People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.

 People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.

 People who have low incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact the plan for details.
Deductible   You pay 100% per prescription for the first $250 in eligible charges.

 You pay 50% per prescription for the first $250 in eligible charges.

 You pay 25% per prescription for the first $250 in eligible charges.
Expenses from $250 - $2,250   You pay 25% per prescription for eligible charges from $250 to $2,250.

 You pay 25% per prescription for eligible charges from $250 to $2,250.

 You pay 25% per prescription for eligible charges from $250 to $2,250.
Expenses from $2,250 - $5,100 (or $8,200 for Enhanced and $14,400 for Enhanced Plus)

   You pay 100% per prescription for eligible charges from $2,250 to $5,100. You pay 50% per prescription for eligible charges from $2,250 to $8,200. You pay 25% per prescription for eligible charges from $2,250 to $14,400.
Expenses beyond $5,100 (or $8,200 for Enhanced and $14,400 for Enhanced Plus)   After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
- $2 for generic or preferred brand name drug that is a multi-source drug
- $5 for other brand name drugs and all other drugs
   or
- 5% per prescription
After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
- $2 for generic or preferred brand name drug that is a multi-source drug
- $5 for other brand name drugs and all other drugs
   or
- 5% per prescription
After your yearly out-of-pocket drug costs reach $3,600, you pay the greater of:
- $2 for generic or preferred brand name drug that is a multi-source drug
- $5 for other brand name drugs and all other drugs
   or
- 5% per prescription
Day supply
Retail in-network preferred and non-preferred pharmacy		  
You may receive drugs from an in-network preferred and non-preferred pharmacy for a 30-day supply and a 90-day supply.
You may receive drugs from an in-network preferred and non-preferred pharmacy for a 30-day supply and a 90-day supply.
You may receive drugs from an in-network preferred and non-preferred pharmacy for a 30-day supply and a 90-day supply.

Mail Order		  
You may receive drugs from a Mail Order Pharmacy for a 90-day supply.
You may receive drugs from a Mail Order Pharmacy for a 90-day supply.
You may receive drugs from a Mail Order Pharmacy for a 90-day supply.
Quantity limits   Certain prescription drugs will have maximum quantity limits. Contact plan for details.

 Certain prescription drugs will have maximum quantity limits. Contact plan for details.

 Certain prescription drugs will have maximum quantity limits. Contact plan for details.
Prior Authorization   Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.

 Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.

 Your provider must get prior authorization from Blue MedicareRx for certain prescription drugs. Contact plan for details.
Out-of-network pharmacy   Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside the Plan's service area where there is no network pharmacy. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside the Plan's service area where there is no network pharmacy. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside the Plan's service area where there is no network pharmacy.

 		  
You may receive drugs from an out-of-network pharmacy for a 30-day supply and a 90-day supply.
You may receive drugs from an out-of-network pharmacy for a 30-day supply and a 90-day supply.
You may receive drugs from an out-of-network pharmacy for a 30-day supply and a 90-day supply.



 Copay Plan Comparison

Benefit Category Standard Copay Plan Enhanced Copay Enhanced Plus Copay
Lifetime Benefit Unlimited Unlimited Unlimited
Deductible There is no deductible.

 There is no deductible.

 There is no deductible.
Eligible expenses from $0 to $2,250 Before total annual eligible charges (total paid by plan and the member) reach $2,250, member pays the following copay per prescription.

 Before total annual eligible charges (total paid by plan and the member) reach $2,250, member pays the following copay per prescription.

 Before total annual eligible charges (total paid by plan and the member) reach $2,250, member pays the following copay per prescription.
Drug Tier Generic Preferred Brand Brand Generic Preferred Brand Brand Generic Preferred Brand Brand
Retail
Member copay for 30-day supply

 $5 $40 $60 $8 $30 $70 $5 $20 $50
Mail order
Member copay for 90-day supply

 $10 $80 $120 $16 $60 $140 $10 $40 $100
Expenses above $2,250 Once the total annual eligible charges (total paid by the plan and the member) reach $2,250, the member pays 100% of eligible charges from $2,250 to $5,100.

 The copay amounts noted above will also apply to eligible expenses from $2,250 to $8,200 (approximately). The copay amounts noted above will also apply to eligible expenses from $2,250 to $14,400 (approximately).
Total annual charges to reach 'true-out-of-pocket' maximum

Medicare's 'true out-of-pocket' maximum is reached once the member pays $3,600. Medicare's 'true out-of-pocket' maximum is reached once the member pays $3,600. Medicare's 'true out-of-pocket' maximum is reached once the member pays $3,600.
Annual charges once member reaches out-of-pocket maximum Member copay is the greater of:
- 5%
   or
- $2 for generic or preferred brand name drug that is a multi-source drug or $5 for non-preferred brand name drugs and all other drugs
Member copay is the greater of:
- 5%
   or
- $2 for generic or preferred brand name drug that is a multi-source drug or $5 for non-preferred brand name drugs and all other drugs
Member copay is the greater of:
- 5%
   or
- $2 for generic or preferred brand name drug that is a multi-source drug or $5 for non-preferred brand name drugs and all other drugs

If you have special needs, this document may be available in other formats.


Note: If you qualify for extra help with your Medicare prescription drug plan costs, your premium and drug costs will be lower. When you join Blue MedicareRx, Medicare will tell us how much extra help you are getting and then we will let you know the amount you will pay. If you are not getting extra help, you can see if you qualify by calling:

(800) MEDICARE (633-4227)
(877) 486-2048  TTY
24 hours a day/7 days a week

Or, contact the Social Security Administration at:

(800) 772-1213
(800) 325-0778   TTY
7 a.m. – 7 p.m, Monday through Friday

Important Terms and Definitions

Brand Name drugs - This is the term for prescription drugs that are sold under a trademarked brand name. Preferred Brand Drugs are drugs which Blue MedicareRx is able to offer with a lower copayment because of favorable terms with the drug’s maker.

Coinsurance - This is the percentage of the cost of the drugs that you pay for. For example, for a $100 prescription with 25% coinsurance, you would pay $25 and Blue MedicareRx would pay $75. Back to top

Copayment - This is a fixed amount that you pay each time a prescription is filled. For example, a $3 copayment means that you pay $3, regardless of how much filling the prescription costs.

Deductible - This is the amount you pay before your insurance benefits start. In the Standard Coinsurance plan, you pay the full cost for the first $250 worth of drugs. In the Enhanced and Enhanced Plus Coinsurance plans, you pay 50% of the first $250 worth of drugs. There is no deductible for the Standard, Enhanced and Enhanced Plus Copayment plans.

Generic drugs - These drugs are lower-cost alternatives to brand-name drugs. These drugs are rated by the FDA to be as safe and effective as brand name drugs. They contain the same active ingredient formula as the brand name drug they can replace. You can usually save money by switching from brand-name drugs to generic drugs. Back to top

Mail Order - This is the term for prescriptions you get filled at a pharmacy that typically mails you a 90 day supply of a drug.  Mail order often provides savings because you can get 90 days worth of drugs but only have a copayment equal to the amount for a 60-day supply if you bought them at retail.  View list of mail order pharmacies in your area*.

Preferred Pharmacies - Blue MedicareRx makes it even easier to save on your medications when you visit a preferred network pharmacy.  Visit Wal-Mart, Albertson's, or Kroger pharmacies and their affiliates.  You'll save on copayments when you fill a 90-day supply.  Pay just two copayments instead of three!  View complete list of preferred pharmacies in your area.

Retail - This is the term for prescriptions you get filled at a regular pharmacy, usually a 30-day supply of a drug.  View list of retail pharmacies in your area.

 

 


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Last updated 12/19/2005 - S5715-MRK-NMWebsite
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