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BlueCare Senior
(BlueCare Major Medical with Prescription Drug Benefits)

Effective July 1, 2006.
This is an example of the benefits and services offered with BlueCare Senior.

Annual deductible	$250
Coinsurance	20% after deductible; 50% after deductible for outpatient mental health
Coinsurance maximum	$1,000
Lifetime maximum	$1,000,000
Covered prescriptions	20% after deductible
30-day supply with early refills for vacation only
Mail order program available with up to a 90-day supply
Prior authorization required for certain prescriptions
Express Scripts network of pharmacies
Drug formulary (certain drugs not covered)

This summary is an abridged overview of the benefits covered by this plan. It highlights general features and is not intended to be a substitute for the terms, provisions, limitations and conditions imposed by the controlling Blue Cross of Northeastern Pennsylvania and Highmark Blue Shield agreement(s). For more information regarding your specific coverage needs, please call your Group Administrator or contact Customer Service at 1-800-829-8599 or (TTY) 1-866-280-0486.

BlueCare Senior (BlueCare Major Medical with Prescription Drug Benefits)

BlueCare Senior
(BlueCare Major Medical with Prescription Drug Benefits)