BCNEPA - Our Health Plans - Individual Health Plans - Blue Cross Blue Shield 65-Special Benefits

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BlueCare Comprehensive

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BlueCare Senior

Individual Health Plans

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BlueCare Senior
(Prescription Drug Benefit Program Rider)

Effective July 1, 2006.
For experience rated groups, this is an example of the benefits and services offered with BlueCare Senior coverage.

Covered Prescriptions

$8 copayment - tier 1

$15 copayment - tier 2

$30 copayment - tier 3

30-day supply with early refills for vacation only

Prior authorization required for certain prescriptions

Express Scripts network of pharmacies

Preferred formulary program

Mail order program with 90-day supply

$16 copayment - tier 1

$30 copayment - tier 2

$90 copayment - tier 3

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 (Prescription Drug Benefit Program Rider)

BlueCare Senior
(Prescription Drug Benefit Program Rider)