Summary Of Benefits - EHealthInsurance
Summary of BenefitsSMfor Blue Cross MedicareRx Standard (PDP),Blue Cross MedicareRx Plus (PDP), andBlue Cross MedicareRx Gold (PDP)SMSMAvailable in CaliforniaThis plan is a PDP with a Medicare contract.Anthem Blue Cross Life and Health Insurance Company(Anthem) has contracted with the Centers for Medicare and Medicaid Services (CMS) to offer the MedicarePrescription Drug Plans (PDPs) noted above or herein Anthem is the state-licensed, risk-bearing entityoffering these plans. Anthem has retained the services of its related companies and authorized agents/brokers/producers to provide administrative services and/or to make the PDPs available in this region.Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue CrossAssociation. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Crossname and symbol are registered marks of the Blue Cross Association.Y0071 12 12915 T 001 CMS Approved 09/15/201123463MUSENMUB 001S5596 033 034 035 CA PDP
Section I:Introduction to the Summary of BenefitsThank you for your interest in Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and BlueCross MedicareRx Gold (PDP). Our plans are offered by Anthem Insurance Companies, Inc., a Medicare PrescriptionDrug Plan that contracts with the Federal government. This Summary of Benefits tells you some features of our plan.It doesn't list every drug we cover, every limitation, or exclusion. To get a complete list of our benefits, please call BlueCross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue Cross MedicareRx Gold (PDP)and ask for the "Evidence of Coverage".You Have Choice in Your MedicarePrescription Drug CoverageAs a Medicare beneficiary, you can choose from differentMedicare prescription drug coverage options. One optionis to get prescription drug coverage through a MedicarePrescription Drug Plan, like Blue Cross MedicareRxStandard (PDP), Blue Cross MedicareRx Plus (PDP),and Blue Cross MedicareRx Gold (PDP). Another optionis to get your prescription drug coverage through aMedicare Advantage Plan that offers prescription drugcoverage. You make the choice.How Can I Compare My Options?The charts in this booklet list some important drugbenefits. You can use this Summary of Benefits tocompare the benefits offered by Blue Cross MedicareRxStandard (PDP), Blue Cross MedicareRx Plus (PDP),and Blue Cross MedicareRx Gold (PDP) to the benefitsoffered by other Medicare Prescription Drug Plans orMedicare Advantage Plans with prescription drugcoverage.Where Are Blue Cross MedicareRxStandard (PDP), Blue CrossMedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP) Available?The service area for these plans includes:California.There is more than one plan listed in this Summary ofBenefits. If you are enrolled in one plan and wish toswitch to another plan, you may do so only during certaintimes of the year. Please call Customer Service for moreinformation.Who Is Eligible to Join?You can join these plans if you are entitled to MedicarePart A and/or enrolled in Medicare Part B and live in theservice area.If you are enrolled in an MA coordinated care (HMOor PPO) plan or an MA PFFS plan that includesMedicare prescription drugs, you may not enroll in aPDP unless you disenroll from the HMO, PPO or MAPFFS plan.Enrollees in a private fee-for-service plan (PFFS) thatdoes not provide Medicare prescription drug coverage,or an MA Medical Savings Account (MSA) plan mayenroll in a PDP. Enrollees in an 1876 Cost plan mayenroll in a PDP.Where Can I Get My Prescriptions?Blue Cross MedicareRx Standard (PDP), Blue CrossMedicareRx Plus (PDP), and Blue Cross MedicareRxGold (PDP) have formed a network of pharmacies. Youmust use a network pharmacy to receive plan benefits.We will not pay for your prescriptions if you use anout-of-network pharmacy, except in certain cases.You must live in this area to join these plans.Page 2 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)
The pharmacies in our network can change at any time.You can ask for a Pharmacy Directory or visit us atwww.anthem.com/ca/medicare. Our customer servicenumber is listed at the end of this introduction.Does My Plan Cover Medicare Part Bor Part D Drugs?Blue Cross MedicareRx Standard (PDP), Blue CrossMedicareRx Plus (PDP), and Blue Cross MedicareRxGold (PDP) do not cover drugs that are covered underMedicare Part B as prescribed and dispensed. Generally,we only cover drugs, vaccines, biological products andmedical supplies that are covered under the MedicarePrescription Drug Benefit (Part D) and that are on ourformulary.What Is a Prescription Drug Formulary?Blue Cross MedicareRx Standard (PDP), Blue CrossMedicareRx Plus (PDP), and Blue Cross MedicareRxGold (PDP) use a formulary. A formulary is a list of drugscovered by your plan to meet patient needs. We mayperiodically add, remove, or make changes to coveragelimitations on certain drugs or change how much youpay for a drug. If we make any formulary change thatlimits our members' ability to fill their prescriptions, wewill notify the affected enrollees before the change ismade. We will send a formulary to you and you can seeour complete formulary on our Web site atwww.anthem.com/ca/medicare.If you are currently taking a drug that is not on ourformulary or subject to additional requirements or limits,you may be able to get a temporary supply of the drug.You can contact us to request an exception or switch toan alternative drug listed on our formulary with yourphysician's help. Call us to see if you can get a temporarysupply of the drug or for more details about our drugtransition policy.What Should I Do If I Have OtherInsurance in Addition to Medicare?If you have a Medigap (Medicare Supplement) policythat includes prescription drug coverage, you mustcontact your Medigap Issuer to let them know that youhave joined a Medicare Prescription Drug Plan. If youdecide to keep your current Medigap supplement policy,your Medigap Issuer will remove the prescription drugcoverage portion of your policy. Call your Medigap Issuerfor details.If you or your spouse has, or is able to get, employergroup coverage, you should talk to your employer to findout how your benefits will be affected if you join BlueCross MedicareRx Standard (PDP), Blue CrossMedicareRx Plus (PDP), and Blue Cross MedicareRxGold (PDP). Get this information before you decide toenroll in these plans.How Can I Get Extra Help With MyPrescription Drug Plan Costs or GetExtra Help With Other Medicare Costs?You may be able to get extra help to pay for yourprescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify forgetting extra help, call:* 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048, 24 hours a day/7 daysa week and see www.medicare.gov 'Programs for Peoplewith Limited Income and Resources' in the publicationMedicare & You.* The Social Security Administration at 1-800-772-1213between 7 a.m. and 7 p.m., Monday through Friday.TTY/TDD users should call 1-800-325-0778 or* Your State Medicaid Office.What Are My Protections in theseplans?All Medicare Prescription Drug Plans agree to stay in theprogram for a full calendar year at a time. Plan benefitsand cost-sharing may change from calendar year toPage 3 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)
calendar year. Each year, plans can decide whether tocontinue to participate with the Medicare PrescriptionDrug Plan Program. A plan may continue in their entireservice area (geographic area where the plan acceptsmembers) or choose to continue only in certain areas.Also, Medicare may decide to end a contract with a plan.Even if your Medicare Prescription Plan leaves theprogram, you will not lose Medicare coverage. If a plandecides not to continue for an additional calendar year,it must send you a letter at least 90 days before yourcoverage will end. The letter will explain your optionsfor Medicare coverage in your area.As a member of Blue Cross MedicareRx Standard (PDP),Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP), you have the right to requesta coverage determination, which includes the right torequest an exception, the right to file an appeal if we denycoverage for a prescription drug, and the right to file agrievance. You have the right to request a coveragedetermination if you want us to cover a Part D drug thatyou believe should be covered. An exception is a type ofcoverage determination. You may ask us for an exceptionif you believe you need a drug that is not on our list ofcovered drugs or believe you should get a non-preferreddrug at a lower out-of-pocket cost. You can also ask foran exception to cost utilization rules, such as a limit onthe quantity of a drug. If you think you need anexception, you should contact us before you try to fillyour prescription at a pharmacy. Your doctor mustprovide a statement to support your exception request.If we deny coverage for your prescription drug(s), youhave the right to appeal and ask us to review our decision.Finally, you have the right to file a grievance if you haveany type of problem with us or one of our networkpharmacies that does not involve coverage for aprescription drug. If your problem involves quality ofcare, you also have the right to file a grievance with theQuality Improvement Organization (QIO) for your state.Please refer to the Evidence of Coverage (EOC) for theQIO contact information.What Is a Medication TherapyManagement (MTM) Program?A Medication Therapy Management (MTM) Programis a free service we offer. You may be invited to participatein a program designed for your specific health andpharmacy needs. You may decide not to participate butit is recommended that you take full advantage of thiscovered service if you are selected. Contact Blue CrossMedicareRx Standard (PDP), Blue Cross MedicareRxPlus (PDP), and Blue Cross MedicareRx Gold (PDP)for more details.Where Can I Find Information On PlanRatings?The Medicare program rates how well plans perform indifferent categories (for example, detecting and preventingillness, ratings from patients and customer service). Ifyou have access to the web, you may use the web toolson www.medicare.gov and select "Health and DrugPlans" then "Compare Drug and Health Plans" tocompare the Plan Ratings for Medicare plans in yourarea. You can also call us directly to obtain a copy of thePlan Ratings for these plans. Our customer servicenumber is listed below.Page 4 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)
Please call Anthem Blue Cross for more information about Blue Cross MedicareRxStandard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue Cross MedicareRxGold (PDP).Visit us at www.anthem.com/ca/medicare or, callus:Customer Service Hours: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. PacificCurrent members should call toll-free1-800-928-6201(TTY/TDD 711)Prospective members should call toll-free1-866-892-5340(TTY/TDD 711)Current members should call locally1-800-928-6201(TTY/TDD 711)Prospective members should call locally1-866-892-5340(TTY/TDD 711)For more information about Medicare, please callMedicare at 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. You can call24 hours a day, 7 days a week.Or, visit www.medicare.gov on the Web.This document may be available in other formats suchas Braille, large print or other alternate formatsThis document may be available in a non-Englishlanguage. For additional information, call customerservice at the phone number listed above.Esta información está disponible en otros idiomas demanera gratuita. Comuníquese con el número denuestro Servicio de Atención al Cliente al1-800-928-6201 (o a la línea TTY/TDD al 711) de8 a. m. a 8 p. m., los 7 días de la semana, hasta el 14de febrero de 2012, para obtener informaciónadicional.** A partir del 15 de febrero de 2012, puede llamar alServicio de Atención al Cliente al 1-800-928-6201(o a la línea TTY/TDD al 711) de 8 a. m. a 8 p. m.,de lunes a viernes, excepto feriados.Page 5 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)
If you have any questions about this plan's benefits or costs, please contact Anthem Blue Cross for detailsSection II:Summary of BenefitsBenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)Blue CrossMedicareRxGold (PDP)OutpatientPrescription DrugsMost drugs are notcovered underOriginal Medicare.You can addprescription drugcoverage to OriginalMedicare by joining aMedicare PrescriptionDrug Plan, or you canget all your Medicarecoverage, includingprescription drugcoverage, by joining aMedicare AdvantagePlan or a MedicareCost Plan that offersprescription drugcoverage.Drugs CoveredUnder MedicarePart DGeneralThis plan uses aformulary. The planwill send you theformulary. You canalso see the formularyat www.anthem.com/medicare on the web.Drugs CoveredUnder MedicarePart DGeneralThis plan uses aformulary. The planwill send you theformulary. You canalso see the formularyat www.anthem.com/medicare on the web.Drugs CoveredUnder MedicarePart DGeneralThis plan uses aformulary. The planwill send you theformulary. You canalso see the formularyat www.anthem.com/medicare on the web.Differentout-of-pocket costsmay apply for peoplewhoDifferentout-of-pocket costsmay apply for peoplewhoDifferentout-of-pocket costsmay apply for peoplewhohave limitedincomes,live in long termcare facilities, orhave access toIndian/Tribal/Urban (IndianHealth Service)providers. 39.30 monthlypremiumhave limitedincomes,live in long termcare facilities, orhave access toIndian/Tribal/Urban (IndianHealth Service)providers. 62.80 monthlypremiumhave limitedincomes,live in long termcare facilities, orhave access toIndian/Tribal/Urban (IndianHealth Service)providers. 107.30 monthlypremiumMost people will paytheir Part Dpremium. However,some people will paya higher premiumbecause of their yearlyincome (over 85,000Most people will paytheir Part Dpremium. However,some people will paya higher premiumbecause of their yearlyincome (over 85,000Most people will paytheir Part Dpremium. However,some people will paya higher premiumbecause of their yearlyincome (over 85,000Page 6 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)Blue CrossMedicareRxGold (PDP)for singles, 170,000for married couples).For more informationabout Part Dpremiums based onincome, call Medicareat1-800-MEDICARE(1-800-633-4227).TTY users should call1-877-486-2048. Youmay also call SocialSecurity at1-800-772-1213.TTY users should call1-800-325-0778.for singles, 170,000for married couples).For more informationabout Part Dpremiums based onincome, call Medicareat1-800-MEDICARE(1-800-633-4227).TTY users should call1-877-486-2048. Youmay also call SocialSecurity at1-800-772-1213.TTY users should call1-800-325-0778.for singles, 170,000for married couples).For more informationabout Part Dpremiums based onincome, call Medicareat1-800-MEDICARE(1-800-633-4227).TTY users should call1-877-486-2048. Youmay also call SocialSecurity at1-800-772-1213.TTY users should call1-800-325-0778.The plan offersnational in-networkprescription coverage(i.e., this wouldinclude 50 states andthe District ofColumbia). Thismeans that you willpay the samecost-sharing amountfor your prescriptiondrugs if you get themat an in-networkpharmacy outside ofthe plan's service area(for instance whenyou travel).The plan offersnational in-networkprescription coverage(i.e., this wouldinclude 50 states andthe District ofColumbia). Thismeans that you willpay the samecost-sharing amountfor your prescriptiondrugs if you get themat an in-networkpharmacy outside ofthe plan's service area(for instance whenyou travel).The plan offersnational in-networkprescription coverage(i.e., this wouldinclude 50 states andthe District ofColumbia). Thismeans that you willpay the samecost-sharing amountfor your prescriptiondrugs if you get themat an in-networkpharmacy outside ofthe plan's service area(for instance whenyou travel).Total yearly drug costsare the total drug costspaid by both you anda Part D plan.Total yearly drug costsare the total drug costspaid by both you anda Part D plan.Total yearly drug costsare the total drug costspaid by both you anda Part D plan.The plan may require The plan may require The plan may requireyou to first try oneyou to first try oneyou to first try onedrug to treat yourdrug to treat yourdrug to treat yourPage 7 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)Blue CrossMedicareRxGold (PDP)condition before itwill cover anotherdrug for thatcondition.condition before itwill cover anotherdrug for thatcondition.condition before itwill cover anotherdrug for thatcondition.Some drugs havequantity limits.Some drugs havequantity limits.Some drugs havequantity limits.Your provider mustget prior authorizationfrom Blue CrossMedicareRx Standard(PDP) for certaindrugs.Your provider mustget prior authorizationfrom Blue CrossMedicareRx Plus(PDP) for certaindrugs.Your provider mustget prior authorizationfrom Blue CrossMedicareRx Gold(PDP) for certaindrugs.You must go tocertain pharmacies fora very limited numberof drugs, due tospecial handling,provider coordination,or patient educationrequirements thatcannot be met bymost pharmacies inyour network. Thesedrugs are listed on theplan's website,formulary, printedmaterials, as well as onthe MedicarePrescription DrugPlan Finder onMedicare.gov.You must go tocertain pharmacies fora very limited numberof drugs, due tospecial handling,provider coordination,or patient educationrequirements thatcannot be met bymost pharmacies inyour network. Thesedrugs are listed on theplan's website,formulary, printedmaterials, as well as onthe MedicarePrescription DrugPlan Finder onMedicare.gov.You must go tocertain pharmacies fora very limited numberof drugs, due tospecial handling,provider coordination,or patient educationrequirements thatcannot be met bymost pharmacies inyour network. Thesedrugs are listed on theplan's website,formulary, printedmaterials, as well as onthe MedicarePrescription DrugPlan Finder onMedicare.gov.If the actual cost of adrug is less than thenormal cost-sharingamount for that drug,you will pay the actualcost, not the highercost-sharing amount.If the actual cost of adrug is less than thenormal cost-sharingamount for that drug,you will pay the actualcost, not the highercost-sharing amount.If the actual cost of adrug is less than thenormal cost-sharingamount for that drug,you will pay the actualcost, not the highercost-sharing amount.Page 8 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)Blue CrossMedicareRxGold (PDP)If you request aformulary exceptionfor a drug and BlueCross MedicareRxStandard (PDP)approves theexception, you willpay Tier 4:Non-Preferred BrandDrugs cost sharing forthat drug.If you request aformulary exceptionfor a drug and BlueCross MedicareRxGold (PDP) approvesthe exception, youwill pay Tier 4:Non-Preferred BrandDrugs cost sharing forthat drug.If you request aformulary exceptionfor a drug and BlueCross MedicareRxPlus (PDP) approvesthe exception, youwill pay Tier 4:Non-Preferred BrandDrugs cost sharing forthat drug.In-NetworkIn-Network 320 deductible on all 0 deductible.drugs except Tier 1:Preferred GenericDrugs.In-Network 0 deductible.Initial CoverageAfter you pay youryearly deductible, youpay the followinguntil total yearly drugcosts reach 2,930:Initial CoverageYou pay the followinguntil total yearly drugcosts reach 2,930:Initial CoverageYou pay the followinguntil total yearly drugcosts reach 2,930:Retail PharmacyTier 1: PreferredGeneric DrugsRetail PharmacyTier 1: PreferredGeneric DrugsRetail PharmacyTier 1: PreferredGeneric Drugs 2 copay for a 2 copay for a 2 copay for aone-monthone-monthone-month(30-day) supply of(30-day) supply of(30-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tier 6 copay for a 6 copay for a 6 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 2: Non-Preferred Tier 2: Non-Preferred Tier 2: Non-PreferredGeneric DrugsGeneric DrugsGeneric DrugsPage 9 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)Blue CrossMedicareRxGold (PDP) 7 copay for a 7 copay for a 7 copay for aone-monthone-monthone-month(30-day) supply of(30-day) supply of(30-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tier 21 copay for a 21 copay for a 21 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 3: PreferredTier 3: PreferredTier 3: PreferredBrand DrugsBrand DrugsBrand Drugs 40 copay for a 45 copay for a 45 copay for aone-monthone-monthone-month(30-day) supply of(30-day) supply of(30-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tier 120 copay for a 135 copay for a 135 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 4: Non-Preferred Tier 4: Non-Preferred Tier 4: Non-PreferredBrand DrugsBrand DrugsBrand Drugs 90 copay for a 90 copay for a 90 copay for aone-monthone-monthone-month(30-day) supply of(30-day) supply of(30-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tier 270 copay for a 270 copay for a 270 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 5: InjectableTier 5: InjectableTier 5: InjectableDrugsDrugsDrugs25% coinsurance33% coinsurance33% coinsurancefor a one-monthfor a one-monthfor a one-month(30-day) supply of(30-day) supply of(30-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tier25% coinsurance33% coinsurance33% coinsurancefor a three-monthfor a three-monthfor a three-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 6: Specialty Tier Tier 6: Specialty Tier Tier 6: Specialty TierDrugsDrugsDrugsPage 10 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)25% coinsurancefor a one-month(30-day) supply ofdrugs in this tierLong-Term CarePharmacyTier 1: PreferredGeneric Drugs33% coinsurancefor a one-month(30-day) supply ofdrugs in this tierLong-Term CarePharmacyTier 1: PreferredGeneric DrugsBlue CrossMedicareRxGold (PDP)33% coinsurancefor a one-month(30-day) supply ofdrugs in this tierLong-Term CarePharmacyTier 1: PreferredGeneric Drugs 2 copay for a 2 copay for a 2 copay for aone-monthone-monthone-month(34-day) supply of(34-day) supply of(34-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 2: Non-Preferred Tier 2: Non-Preferred Tier 2: Non-PreferredGeneric DrugsGeneric DrugsGeneric Drugs 7 copay for a 7 copay for a 7 copay for aone-monthone-monthone-month(34-day) supply of(34-day) supply of(34-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 3: PreferredTier 3: PreferredTier 3: PreferredBrand DrugsBrand DrugsBrand Drugs 40 copay for a 45 copay for a 45 copay for aone-monthone-monthone-month(34-day) supply of(34-day) supply of(34-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 4: Non-Preferred Tier 4: Non-Preferred Tier 4: Non-PreferredBrand DrugsBrand DrugsBrand Drugs 90 copay for a 90 copay for a 90 copay for aone-monthone-monthone-month(34-day) supply of(34-day) supply of(34-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 5: InjectableTier 5: InjectableTier 5: InjectableDrugsDrugsDrugs25% coinsurance33% coinsurance33% coinsurancefor a one-monthfor a one-monthfor a one-month(34-day) supply of(34-day) supply of(34-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 6: Specialty Tier Tier 6: Specialty Tier Tier 6: Specialty TierDrugsDrugsDrugsPage 11 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)25% coinsurancefor a one-month(34-day) supply ofdrugs in this tierMail OrderTier 1: PreferredGeneric Drugs33% coinsurancefor a one-month(34-day) supply ofdrugs in this tierMail OrderTier 1: PreferredGeneric DrugsBlue CrossMedicareRxGold (PDP)33% coinsurancefor a one-month(34-day) supply ofdrugs in this tierMail OrderTier 1: PreferredGeneric Drugs 3 copay for a 3 copay for a 3 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 2: Non-Preferred Tier 2: Non-Preferred Tier 2: Non-PreferredGeneric DrugsGeneric DrugsGeneric Drugs 10.50 copay for a 10.50 copay for a 10.50 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 3: PreferredTier 3: PreferredTier 3: PreferredBrand DrugsBrand DrugsBrand Drugs 100 copay for a 112.50 copay for 112.50 copay forthree-montha three-montha three-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 4: Non-Preferred Tier 4: Non-Preferred Tier 4: Non-PreferredBrand DrugsBrand DrugsBrand Drugs 225 copay for a 225 copay for a 225 copay for athree-monththree-monththree-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 5: InjectableTier 5: InjectableTier 5: InjectableDrugsDrugsDrugs25% coinsurance33% coinsurance33% coinsurancefor a three-monthfor a three-monthfor a three-month(90-day) supply of(90-day) supply of(90-day) supply ofdrugs in this tierdrugs in this tierdrugs in this tierTier 6: Specialty Tier Tier 6: Specialty Tier Tier 6: Specialty TierDrugsDrugsDrugsPage 12 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP)25% coinsurancefor a one-month(30-day) supply ofdrugs in this tierBlue CrossMedicareRxGold (PDP)33% coinsurancefor a one-month(30-day) supply ofdrugs in this tier33% coinsurancefor a one-month(30-day) supply ofdrugs in this tierAdditional CoverageGapThe plan covers someformulary generics(10%-64% offormulary genericdrugs) through thecoverage gap.Additional CoverageGapThe plan covers manyformulary generics(65%-99% offormulary genericdrugs), someformulary brands(10%-64% offormulary branddrugs) through thecoverage gap.Coverage GapAfter your total yearlydrug costs reach 2,930, you receive adiscount on brandname drugs and pay86% of the plan'scosts for all genericdrugs until your yearlyout-of-pocket drugcosts reach 4,700.You pay thefollowing:You pay thefollowing:Retail PharmacyTier 1: PreferredGeneric DrugsRetail PharmacyTier 1: PreferredGeneric DrugsPage 13 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP) 7 copay for aone-month(30-day) supply ofall drugs coveredin this tier 21 copay for athree-month(90-day) supply ofall drugs coveredin this tierBlue CrossMedicareRxGold (PDP) 7 copay for aone-month(30-day) supply ofall drugs coveredin this tier 21 copay for athree-month(90-day) supply ofall drugs coveredin this tierTier 2: Non-PreferredGeneric Drugs 7 copay for aone-month(30-day) supply ofall drugs coveredin this tier 21 copay for athree-month(90-day) supply ofall drugs coveredin this tierTier 3: PreferredBrand Drugs69% coinsurancefor a one-month(30-day) supply ofselect drugscovered in this tier69% coinsurancefor a three-month(90-day) supply ofselect drugscovered in this tierLong-Term CarePharmacyTier 1: PreferredGeneric DrugsLong-Term CarePharmacyTier 1: PreferredGeneric DrugsPage 14 – Blue Cross MedicareRx Standard (PDP), Blue Cross MedicareRx Plus (PDP), and Blue CrossMedicareRx Gold (PDP)23463MUSENMUB 001
BenefitOriginalMedicareBlue CrossBlue CrossMedicareRxMedicareRxStandard (PDP) Plus (PDP) 7 copay for aone-month(34-day) supply ofall drugs coveredin this tierBlue CrossMedicareRxGold (PDP) 7 copay for aone-month(34-day) supply ofall drugs coveredin this tierTier 2: Non-PreferredGeneric Drugs 7 copay for aone-month(34-day) supply ofall drugs coveredin this tierTier 3: PreferredBrand Drugs69% coinsurancefor a one-month(34-day) supply ofselect drugscovered in this tierMail OrderTier 1: PreferredGeneric DrugsMail OrderTier 1: PreferredGeneric Drugs 10.50 copay for athree-month(90-day) supply ofall drugs coveredin this tierAfter your total yearlydrug costs reach 2,930, you receivelimited coverage bythe plan on certaindrugs. You will alsoreceive a discount onbrand name drugs andgenerally pay no moreth
for Blue Cross MedicareRx StandardSM (PDP), Blue Cross MedicareRx PlusSM (PDP), and Blue Cross MedicareRx GoldSM (PDP) Available in California This plan is a PDP with a Medicare contract.Anthem Blue Cross Life and Health Insurance Company (Anthem) has contracted with the Centers for M edica
Benefits For Dummies. Contributing authors from eHealthInsurance include licensed health insurance agents as well as executives and members of the eHealthInsurance communications team, many of whom contribute to the eHealthInsurance consumer blog, "Get Smart — Get Covered." ISBN: 978--470-94750- Book not for resale Go to Dummies.com
benefits of caring for country. These benefits include: health and wellbeing benefits; cultural and socio-political benefits; economic benefits; and, environmental benefits. The discussion includes some of the barriers to achieving benefits, as well as anticipated and realised benefits of caring for country.
Health and Welfare Benefits Plan Summary Plan Description January 20192020 . This summary plan description (SPD) provides a summary of your benefits updated as of January 1, . It describes benefits provided to you by the Sony Pictures Entertainment Inc. Health and Welfare Benefits Plan (the "plan" or "SPE Benefits Plan") your plans .
834 Other long-term employee benefits are all employee benefits other than short-term employee benefits, post-employment benefits and termination benefits. Termination benefits are employee benefits provided in exchange for the termination of an employee's employment as a result of either: (a) an entity's decision to terminate an employee's employment before the normal retirement
company offers thousands of individual, family and small business health plans underwritten by more than 180 of the nation's leading health insurance companies. eHealthInsurance is licensed to sell health insurance in all 50 states and the District of Columbia and has used its proprietary technology to enroll over 3 million Americans in coverage.
2022 Benefits Summary & Guide Welcome to the Macalester College benefits program. The 2022 Benefits Summary & Guide will acquaint you with the benefits available to faculty and staff of Macalester College. We hope you find this guide helpful as you weigh . Employee (1) 200.00 0.00 243.50 43.50 287.00 87.00 Employee (2 ) 200.00 0 .
Blue Shield Gold 80 PPO Plan Summary of Benefits The Summary of Benefits is provided with, and is incorporated as part of, the Evidence of Coverage. It sets forth the Member’s share-of-costs for Covered Services under the benefit plan. Please read both documents carefullyFile Size: 860KBPage Count: 107Explore furtherIndividual and Family Plan PPO Plan Summary of Benefits .www.blueshieldca.com2021 Summary of Benefits - Producer Connectionwww.blueshieldca.comHow are bronze, silver and gold plans different? bcbsm.comwww.bcbsm.comMember Services - Blue Cross Blue Shield Associationwww.bcbs.comFind a Doctor - Blue Cross Blue Shield Associationwww.bcbs.comRecommended to you b
Safety-sensitive employees of city, county or other public transit services are subject to alcohol and drug testing requirements under rules issued by the Federal Transit Administration (FTA), a DOT agency. Additionally, employees who operate a vehicle requiring a commercial driver's license (CDL) are subject to substance abuse testing. This expansion of the scope of the Federal Motor Carrier .
