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Anthem Blue Cross Medicare Plan D Prescriptions  Anthem Blue Cross Medicare
Part D Prescription Plan 		 Anthem Blue Cross Medicare Plan D Prescriptions
Toll Free (877)566-5454

AVAILABLE ONLY FOR CALIFORNIA RESIDENTS!

Anthem Blue Cross MEDICARE PART D PLANS 2010 CA MONTHLY RATES
 
MedicareRx Standard
MedicareRx Plus
MedicareRx Gold
 Rates $28.40 $42.10 $78.50
 
 In-Network In-Network In-Network
 Deductibles $310 Deductible $0 Deductible $0 Deductible
Initial Coverage:

After you pay your yearly deductible, you pay a copay (or coinsurance) until total yearly drug costs reach $2,830.

You pay a copay (or coinsurance) until total yearly drug costs reach $2,830.

You pay a copay (or coinsurance) until total yearly drug costs reach $2,830.
Coverage Gap:

After your total yearly drug costs reach $2,830, you pay 100% until your yearly out-of-pocket drug costs reach $4,550.

After your total yearly drug costs reach $2,830, you pay 100% until your yearly out-of-pocket drug costs reach $4,550.

Generics only covered through the gap. You will pay the same copay amount as in Initial Coverage. For all other covered drugs, after your total yearly drug costs reach $2,830, you pay 100% until your yearly out-of-pocket drug costs reach $4,550.
Catastrophic Coverage:

After your yearly out-of-pocket drug costs reach $4,550, you pay the greater of: $2.50 copay for generic (including brand drugs treated as generic) and $6.30 copay for all other drugs, or 5% coinsurance.
 Part D prescription drug benefits - (30 day-retail/90 day-retail/90 day-mail order)
 Generic copays - Tier 1 $6.50/19.50/$9.75 $7/$21/$10.50 $7/$21/$10.50
 Preferred Brand copays - Tier 2 25%/25%/25% $43/$129/$107.50 $43/$129/$107.50
 Non-Preferred Brand - Tier 3 NA $85/$255/$212.50 $85/$255/$212.50
 Specialty Injectibles - Tier 4 25%/25%/25%
(Tier 3 for Standard)		 33% 33%
 Non-Specialty Injectibles - Tier 5 25%
(Tier 4 for Standard)		 33% 33%
 Coverage Gap NA NA Low Cost Generics
 Generic Benzos & Barbs $6.50/19.50/$9.75 $7/$21/$10.50 $7/$21/$10.50
 Additional Information: This plan uses a formulary which they will send you.
You can also see the formulary at www.rxtools.partdcoverage.com

ANNUAL ELECTION PERIOD:

You can only disenroll or switch plans once per year during the Annual Election Period (AEP) November 15 to December 31 of each year for benefits that will begin January 1st.

INITIAL ENROLLMENT PERIOD AT AGE 65:

When you reach age 65 and you sign up for Medicare Part B, you have a one-time seven-month period (three months before, three months after and the month of your birthday) during which you may purchase a Plan D Prescription Drug policy.

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Mail all applications to:

BARRICKS INSURANCE SERVICES
13900 NW PASSAGE #302
MARINA DEL REY, CA 90292

OR FAX TO 1-310-827-0256

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Fill in this form to have your Anthem Blue Cross Medicare Part D Prescription Drug brochure with pricing & application mailed to you. Further information on our plans is shown below. Or just call us Toll-free at 1-877-566-5454.
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Barricks Insurance Services
13900 NW Passage #302, Marina Del Rey, CA 90292
Phone:   (310) 827-7286    |   Fax:   (310) 827-0256
Toll-Free 1-877-Look4Life  (1-877-566-5454)

©1995  Barricks Insurance Services. CA License #0383850
Licensed in AL, AR, AZ, CA, CO, CT, FL, GA, IA, IL, IN, KS, KY,
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