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Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Standard Mail Order Cost-Sharing
Tier One- Two- Three- One- Two- Three- One- Two- Three-
month month month month month month month month month
supply supply supply supply supply supply supply supply supply

Tier 1 (Preferred $4 $4 $4 $2 $2 $2 $2 $2 $2
Generic) copay copay copay copay copay copay copay copay copay
Tier 2 (Generic) $8 $16 $16 $6 $12 $12 $6 $12 $12
copay copay copay copay copay copay copay copay copay
Tier 3 (Preferred $45 $90 $90 $45 $90 $90 $45 $90 $90
Brand) copay copay copay copay copay copay copay copay copay
Tier 4 (Non-Preferred $95 $190 $190 $95 $190 $190 $95 $190 $190
Brand) copay copay copay copay copay copay copay copay copay
Tier 5 (Specialty Tier) 26% 26% 26% 25% 25% 25% 26% 26% 26%
of the of the of the of the of the of the of the of the of the
cost cost cost cost cost cost cost cost cost
If you reside in a long- If you reside in a long- If you reside in a long-
term care facility, you term care facility, you term care facility, you
pay the same as at a retail pay the same as at a retail pay the same as at a retail
pharmacy. pharmacy. pharmacy.
You may get drugs You may get drugs You may get drugs
from an out-of-network from an out-of-network from an out-of-network
pharmacy, but may pay pharmacy, but may pay pharmacy, but may pay
more than you pay at an more than you pay at an more than you pay at an
in-network pharmacy. in-network pharmacy. in-network pharmacy.

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