Monthly Plan Premium for People who get Extra Help from Medicare

Blue Cross Medicare Rx (PDP) SM
Monthly Plan Premium for People who get Extra Help from Medicare
to Help Pay for their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly
plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of
extra help you get will determine your total monthly plan premium as a member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
Your level
Monthly Premium for
of extra help Blue Cross MedicareRx
Value (PDP) SM*
100%
$36.80
75%
$44.00
50%
$51.20
25%
$58.30
Monthly Premium for
Blue Cross MedicareRx
Plus (PDP) SM*
$135.00
$142.20
$149.40
$156.50
Monthly Premium for
Blue Cross MedicareRx
Basic (PDP) SM*
$0.00
$6.50
$13.00
$19.60
*This does not include any Medicare Part B premium you may have to pay.
If you aren’t getting extra help, you can see if you qualify by calling:
 1-800-Medicare (1-800-633-4227) or TTY users call 1-877-486-2048 (24 hours a day/7 days a week),
 Your State Medicaid Office, or
 The Social Security Administration at 1-800-772-1213. TTY/TDD users should call 1-800-325-0778
between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call Customer Service at 1-888-285-2249, (TTY/TDD: 711). We are open
8:00 a.m. – 8:00 p.m., local time, 7 days a week. If you are calling from February 15 through September 30,
alternate technologies (for example, voicemail) will be used on weekends and holidays.
This information is available for free in other languages. Please call our Customer Service number at 1-888285-2249 (TTY/TDD users should call 711). We are open between 8:00 a.m. and 8:00 p.m., local time, 7 days a
week. If you are calling from February 15 through September 30, alternate technologies (for example,
voicemail) will be used on the weekends and holidays.
Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de
Servicio al cliente al 1-888-285-2249 (los usuarios de TTY/TDD deben llamar al 711). Nuestro horario es de
8:00 a.m. a 8:00 p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 de septiembre,
durante los fines de semana y feriados, se usarán tecnologías alternas (por ejemplo, correo de voz).
You must continue to pay your Medicare Part B premium.
Blue Cross MedicareRx is a prescription drug plan provided by HCSC Insurance Services Company
(HISC), an Independent Licensee of the Blue Cross and Blue Shield Association. A Medicare approved
Part D sponsor. Enrollment in HISC’s plan depends on contract renewal.
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