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Important information about enrolling in Blue Medicare HMO. |
How your Medicare prescription drug benefits work
See the diagrams below to learn how both the Standard and Enhanced Medicare prescription drug packages work. To read the diagrams, start at Phase 1. As the total amount you spend on prescription drugs increases during a calendar year, you will move through some or all of the phases of coverage.
A person who takes very few prescription drugs may not move beyond Phase 1 during the calendar year, while someone who takes several prescription drugs may move down to Phase 3 or 4. Remember, no matter what phase of coverage you are in, you should always present your Plan ID card when filling your prescription. NOTE: For members who qualify for low income assistance, benefits will vary.
To learn more about Medicare prescription drug coverage, download the printable guide below.
Guide to Medicare Prescriptions Drug Coverage
Standard benefit
The Standard plan’s benefits and amounts are set by Medicare. Companies offering Medicare Advantage plans which include Medicare prescription drug coverage must offer at least the Standard benefits.
| All drug types | Coverage starts here |
|---|---|
| You pay 100% |
Phase 1: You pay the first $275 of your prescription drug costs for a given calendar year. |
| You pay 25% |
Phase 2: Once your total annual drug costs exceed $275, you will pay 25% of the total cost of covered prescription drugs. Your plan will pay 75%. |
| You pay 100% |
Phase 3: Once your total annual drug costs exceed $2,510, you will pay 100% of your prescription drug costs until your true out-of-pocket expenses reach $4,050. This period is referred to as the "coverage gap." |
| You pay 5% |
Phase 4: Once you have spent $4,050 in true out-of-pocket costs, you will pay very little for prescription drugs. For the rest of the year, you will pay just 5% ($2.25 generic/$5.60 brand, whichever is greater) of the total cost of covered prescription drugs; your plan will pay 95%. |
Enhanced benefit
The Enhanced plan’s benefits are richer than the Standard plan’s benefits.
| Generic drugs | Brand name drugs | Specialty drugs | Coverage starts here | ||
|---|---|---|---|---|---|
| You pay $10 |
You pay $30 |
You pay 25% |
Phase 1: Your coverage starts right away. You pay convenient copayments of just $10 for generic and $30 for most brand name drugs. You pay 25% of the total cost for specialty drugs. There is no deductible. | ||
| You pay $10 |
You pay $30 |
You pay 25% |
Phase 2: You continue to pay convenient copayments for most drugs: $10 for generic drugs, $30 for brand name drugs and 25% of the total cost for specialty drugs. | ||
| You pay $10 |
You pay 100% |
You pay 100% |
Phase 3: Once your total annual drug costs exceed $2,510, you can 1) avoid the "coverage gap" when you purchase generic drugs with our enhanced package or 2) purchase brand name or specialty drugs and you will pay 100% of your prescription drug costs until you have spent $4,050 in true out-of-pocket costs on prescription drugs. | ||
| You pay 5% |
Phase 4: Once you have spent $4,050 in true out-of-pocket costs, you will pay very little for prescription drugs. For the rest of the year, you will pay just 5% ($2.25 generic/$5.60 brand, whichever is greater) of the total cost of covered prescription drugs; your plan will pay 95%. | ||||
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Blue Medicare HMO and Blue Medicare PPO plans are offered by PARTNERS National Health Plans of North Carolina, Inc., a subsidiary of Blue Cross and Blue Shield of North Carolina (BCBSNC). PARTNERS is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. Plans are administered by BCBSNC. BCBSNC and PARTNERS do not discriminate based on color, gender, religion, national origin, age, race, disability, handicap, sexual orientation, genetic information, source of payment or health status as defined by the Centers for Medicare & Medicaid Services (CMS). All qualified Medicare beneficiaries may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or another third party. BCBSNC and PARTNERS are independent licensees of the Blue Cross and Blue Shield Association.
The information on this page is current as of 03/18/08.