Blue MedicareRxSM Plans




Blue MedicareRx offers two plan designs, Value and Plus. Below is an overview of each plan. To compare the plans to determine which best meets your needs, use the Plan Selector Tool.

Before picking a plan, be sure you are eligible for Blue MedicareRx.
Learn more about eligibility.

You must continue to pay your Medicare Part B premium.


Print Value Plan Plus Plan
Monthly Premium $43.20 $92.60
Deductible $125 for tiers 2, 3 and 4 only $0
Copays
Tier 1 – Generic Drugs $9.00 $5.00
Tier 2 – Preferred Brand Drugs $39.00 $38.00
Tier 3 – Non-Preferred Brand Drugs $89.00 $75.00
Tier 4 – Specialty Drugs 29% 33%
Gap Coverage You will receive a discount on brand-name drugs and pay only 86% of the costs of generic drugs. $5 copay for Generic drugs only. You will receive a discount on brand-name drugs.
After the Gap
You pay whichever is greater:
Tier 1 – Generic Drugs: $2.60 copay or 5% coinsurance for your drug.
Tier 2 – Preferred Brand Drugs: $6.50 copay or 5% coinsurance for your drug.
Tier 3 – Non-Preferred Brand Drugs: $6.50 copay or 5% coinsurance for your drug.
Tier 4 – Specialty Drugs: 5% coinsurance of your drug.
Evidence of Coverage Evidence of Coverage: Value Plan
S5715_BEN_OK_ANOCEOCVALUE2012 File and Use 09022011

Evidence of Coverage: Value Plan en Español
S5715_BEN_OK_ANOCEOCVALUE2012SPA File and Use 09022011		 Evidence of Coverage: Plus Plan 
S5715_BEN_OK_ANOCEOCPLS2012 File and Use 09062011

Evidence of Coverage: Plus Plan en Español
S5715_BEN_OK_ANOCEOCPLS2012aSPA File and Use 09062011
Summary of Benefits Summary of Benefits 
S5715_OK_BEN_BNFTSMRY12 CMS Approved 09122011

Summary of Benefits en Español 
S5715_OK_BEN_BNFTSMRY12SPA CMS Approved 09122011

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
  • Your State Medicaid Office.

The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact the plan.

Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2013.

Limitations, copayments, and restrictions may apply. Find more information here .

If you would like to submit feedback directly to Medicare, please use the Medicare Complaint Form  or contact the Office of the Medicare Ombudsman .

Need Assistance?


Blue MedicareRx

Call 1-877-282-3785


This information is available for free in other languages. Please contact our Customer Service number at 1-877-282-3785 for additional information. (TTY/TDD users should call 711). Hours are 8 a.m. - 8 p.m., local time, 7 days a week. From February 15th through October 14th alternate technologies (for example, voicemail) will be used on the weekends and holidays. Customer Service also has free language interpreter services available for non-English speakers. en Español

Contact us: Blue MedicareRx
                      P.O. Box 3897
                      Scranton, PA 18505-9947