Arkansas BlueCross Blue Shield Medi-Pak Choice
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2011 Medi-Pak Rx (PDP) Detailed Plan Benefits
Plan Benefits With Basic,
YOU pay: 		With Premier,
YOU pay:
Monthly Premium $31.30 $83.50
Formulary Standard Enhanced
Deductible $250 $0
Generic drug copay $6* $6*
Preferred brand name drug copay $39* $39*
Non-preferred brand name drug copay $69* $69*
Specialty drugs 25%* 25%*
You move to Level 2 once YOU and the Medi-Pak Rx plan you have chosen pay $2,840.
Generic drugs 93% coinsurance* $6 copay*
For preferred brand,
non-preferred brand and specialty drugs 		100%** 100%**
You move to Level 3 after your True Out-of-Pocket (TrOOP) reaches $4,550. The $4,550 includes your deductible, if applicable, plus the amount YOU (not Medi-Pak Rx) paid in Level 1 and Level 2†. (To ensure your TrOOP is captured accurately, use network pharmacies that will file your claims electronically.)
For generic drugs $2.50 or 5% coinsurance, whichever is greater. $2.50 or 5% coinsurance, whichever is greater.
For preferred brand,
non-preferred brand and specialty drugs 		$6.30 or 5% coinsurance, whichever is greater. $6.30 or 5% coinsurance, whichever is greater.
You remain in Level 3 the remainder of the calendar year.
Medicare Plans
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Remember, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.


* 34-day supply.

** Important Note: Beginning in 2011, the Medicare Coverage Gap Discount Program will provide manufacturer discounts on brand-name prescription drugs to Part D enrollees who have reached the coverage gap and are not already receiving “Extra Help.” A 50% discount will be available for those brand-name drugs from manufacturers that have agreed to pay the discount. This discount is applied automatically at the time of purchase. Want to hear more good news? Even when you pay 50%, the total cost of the drug (not just the discounted amount) is applied toward your True Out-of-Pocket (TrOOP).


† Prescription drugs that are not covered do not count toward your TrOOP.


The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. This is an advertisement; for more information, contact a benefits specialist.

S5795_Rx 2011 Website Submission CMS Approved 11082010

Web Page Last Updated: 8/30/2011