Benefit Summary

Blue MedicareRx offers you the affordability, savings and flexibility you need from your Medicare-approved prescription drug coverage. You’ll also have the option of more coverage than the minimum standard established by Medicare. Take a close look at our plan description.

	Value			Plus			Standard
Blue MedicareRX Participating Providers	50,000 pharmacies total nationwide			50,000 pharmacies total nationwide			50,000 pharmacies total nationwide
Lifetime Benefit	Unlimited			Unlimited			Unlimited
Individual Deductible	$0	$0	$0	$0	$0	$0	$250
	Preferred			Preferred
Retail Benefits Annual Drug Costs up to $2,250	Generic $5 copay	Brand $40 copay	Brand $59 copay	Generic $3 copay	Brand $20 copay	Brand $50 copay	25%
Annual Drug Costs exceeding $2,251 (up to $3,600 out-of-pocket maximum	You pay 100%			You pay 100%			You pay 100%
After your out-of-pocket annual drug costs exceed $3,600	You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance			You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance			You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance
	Preferred			Preferred
Mail-order Benefits (90 day supply) Annual Drug Costs up to $2,250	Generic $10 copay	Brand $80 copay	Brand $118 copay	Generic $6 copay	Brand $40 copay	Brand $100 copay	25%
Annual Drug Costs exceeding $2,251(up to $3,600 out-of-pocket maximum	You pay 100%			You pay 100%			You pay 100%
After your out-of-pocket annual drug costs exceed $3,600	You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance			You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance			You pay the greater of $2 copayment for generic ($5 copayment for brand and preferred brand) or 5% coinsurance
Monthly Plan Premium	$25.73			$43.32			$25.53

Last updated 09/26/2005 - S5715-MRK-TX Website