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Subsidies for People Who Need Extra Help

MedicareBlue Rx

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. 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 of extra help	Monthly Premium for MedicareBlue Rx Option 1*	Monthly Premium for MedicareBlue Rx Option 2*	Monthly Premium for MedicareBlue Rx Option 3*
100%	$0.00	$31.90	$63.40
75%	$6.20	$39.50	$71.00
50%	$12.30	$47.20	$78.70
25%	$18.50	$54.80	$86.30

*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). TTY/TDD 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 are a current member and have any questions, please call MedicareBlue Rx Customer Service at 1-888-832-0075, (TTY/TDD: 1-800-693-3819) from 8 a.m. – 8 p.m., daily, Central and Mountain Time.

S5743_091707_B01 RE CMS

May 16, 2008

Important Information

This page last updated and accepted by CMS January 2008.

MedicareBlue PPO and MedicareBlue Rx coverage is provided by only one of the following plans, depending on the state in which the policy is issued: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.*

*Independent licensees of the Blue Cross and Blue Shield Association.

R5566_122007_B07 RE

S5743_122007_B08 RE