Florida Blue

Photo of pills BlueScript for Medicare Part D^Ž for 2006

Option 1* Option 2*

Generic Preferred Brand Non-preferred Brand Generic Preferred Brand Non-preferred Brand

Deductible: $0 $100 $0 $100

When level 1 drug costs are $0-$100**, the member pays: $5
copayment $100
(deductible) $5
copayment $100
(deductible)

When level 2 drug costs are $101-$2,250**, the member pays: $5
copayment $30
copayment 40%
of the cost $5
copayment $30
copayment 40%
of the cost

When level 3 drug costs are $2,251** until out-of-pocket costs reach $3,600, the member pays: 100% $5
copayment 100%

When level 4 out-of-pocket drug costs are over $3,600, the member pays: Greater of $2 copayment for generic or preferred brand drug that is a multi-source drug or 5% coninsurance Greater of $5 copayment or 5% coninsurance Greater of $2 copayment for generic or preferred brand drug that is a multi-source drug or 5% coninsurance Greater of $5 copayment or 5% coninsurance

*Copayments shown are for in-network pharmacies.
**This figure is based on the member's out-of-pocket costs and what Blue Cross and Blue Shield of Florida pays.

	BlueScript for Medicare Part D^Ž for 2006
	Option 1*			Option 2*
	Generic	Preferred Brand	Non-preferred Brand	Generic	Preferred Brand	Non-preferred Brand
Deductible:	$0	$100		$0	$100
When level 1 drug costs are $0-$100**, the member pays:	$5 copayment	$100 (deductible)		$5 copayment	$100 (deductible)
When level 2 drug costs are $101-$2,250**, the member pays:	$5 copayment	$30 copayment	40% of the cost	$5 copayment	$30 copayment	40% of the cost
When level 3 drug costs are $2,251** until out-of-pocket costs reach $3,600, the member pays:	100%			$5 copayment	100%
When level 4 out-of-pocket drug costs are over $3,600, the member pays:	Greater of $2 copayment for generic or preferred brand drug that is a multi-source drug or 5% coninsurance	Greater of $5 copayment or 5% coninsurance		Greater of $2 copayment for generic or preferred brand drug that is a multi-source drug or 5% coninsurance	Greater of $5 copayment or 5% coninsurance
Copayments shown are for in-network pharmacies. *This figure is based on the member's out-of-pocket costs and what Blue Cross and Blue Shield of Florida pays.