Medicare Supplement - Pehp
Medicare SupplementEnrollment Guide 2022Enrollment information, plan changes,and a brief overview of drug plans» Open enrollment runs October 15 through December 7» Enroll or make changes online (see Page 3)» Join us at a free meeting to learn more (schedule on inside back cover)» Not changing plans? You will be automatically re-enrolledPROUDLY SERVING UTAH PUBLIC EMPLOYEES
IntroductionDid You Know?» Medical plans include out-of-countrycoverage on medical plans (for urgentand emergency care only).» Benefits include out-of-state coveragefor medical plans.» Need dental or vision services? See pages21-28 to find the right coverage.» Check out PEHPplus discounts onhealthy lifestyle products and services(www.pehp.org/pehpplus).Contact InformationPEHP560 East 200 SouthSalt Lake City, UT 84102-2004www.pehp.orgContentsPageCustomer Service: 801-366-7555 or 800-765-7347Billing: 800-765-7347Overview of plans, enrollment . . . . . . . . . . . . 2Online enrollment . . . . . . . . . . . . . . . . . . . . . . . 3Pharmacy Dept: 801-366-7551 or 888-366-7551Hours: Monday-Friday, 8 am-5 pmRates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Medical plan benefits . . . . . . . . . . . . . . . . . 5-13Prescription drug plan benefits . . . . . . 14-19Medicare Administrationwww.medicare.gov800-633-4227Coverage Gap . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Dental options . . . . . . . . . . . . . . . . . . . . . . . . . . 21Prescription Benefits (Medicare Part D)Express Scriptswww.express-scripts.comCustomer Service: 800-590-2239Discount dental benefit . . . . . . . . . . . . . . . . . 21Dental plans . . . . . . . . . . . . . . . . . . . . . . . . 22-24Vision plans . . . . . . . . . . . . . . . . . . . . . . . . . 25-28PEHPplus and Health Coaching . . . . . . . . . . 29Social Security Administrationwww.ssa.gov800-772-1213AgeWell Rebate for Seniors . . . . . . . . . . . . . . 30Creditable Coverage notice . . . . . . . . . . 31-33Notice of privacy practices . . . . . . . . . . 34-37Enrollment form . . . . . . . . . . . . . . . . . . . . 39-409/30/211
IntroductionPEHP Medicare Supplement PlansOPEN ENROLLMENT: OCTOBER 15 – DECEMBER 7Take the time to review your coverage. Not enough? Choose a more generous medical planor add dental and vision. Too much? Change to a lower-costing plan with less coverage.Just right? Do nothing and you’ll continue to be enrolled in the same benefits!» Three supplement plans that cover 100%,75%, or 50% after what Medicare pays.» All medical plans provide coverage optionsnationwide or outside the U.S.» Three pharmacy plans to help cover yourprescriptions.» Three dental plans to choose from.» Four vision plans, covering eyewear and/orexams at various retailers.How to Enroll & Make ChangesIf you don’t want to make changes, you don’t need to do anything.To make changes to your existing plans, you must do so by December 7.Online:Visit www.pehp.org and completethe online enrollment instructions(on Page 3).By Mail:Complete the enclosed enrollmentform (on Page 39) and send it to:First Time Enrolling?Visit this linkPEHPEnrollment Department560 East 200 SouthSalt Lake City, UT 84102-2004For More InformationFor additional information about PEHP Medicare Supplement plans, view and download thePEHP Medicare Supplement Master Policy at www.pehp.org/medsup. To receive a copy, emailpublications@pehp.org or call PEHP.2
Online EnrollmentOPEN ENROLLMENT: OCT. 15 – DEC. 7Online Enrollment for New MembersVisit this link and click green “Enroll Now” button.Online Enrollment for Current MembersSTEP 1: Log into your online account or create oneat www.pehp.org. You will need your Subscriber IDnumber on your current PEHP ID card.STEP 2: Once you log in, click on the My Benefitsmenu and select “Enroll or Change Coverage.”STEP 3: Click on “Enroll/Change” to make planchanges.STEP 4: You’ll receive an enrollment confirmation.Click “Print” for a print-formatted PDF. Thisconfirmation is for your personal records. You canreturn to the Online Enrollment page to makeadditional changes.For assistance with online enrollment,call 801-366-7410 or 800-753-74103
Rates2022 Monthly RatesRates are set for one year based on your age at enrollment. If you’re under age 65, your rates will adjust atage 65.Medical PlansMonthly rates per personAgePlan 100Plan 75Plan 50 65 215.74 166.20 122.4765 130.67 100.65 74.1566 134.92 103.92 76.5867 139.17 107.20 78.9968 143.42 110.47 81.4069 147.67 113.76 83.8270 151.93 117.04 86.2371 156.18 120.30 88.6572 160.43 123.58 91.0773 164.69 126.87 93.4874 168.95 130.14 95.9077 181.75 139.96 103.1678 185.95 143.25 105.5579 190.21 146.53 107.9880 194.46 149.80 110.3981 198.72 153.08 112.8182 202.97 156.37 115.2483 207.23 159.64 117.6484 211.47 162.92 120.0685 215.74 166.20 122.47Monthly rates per personAgePlan 100Plan 75Plan 5075 173.19 133.42 98.3176 177.45 136.70 100.73Pharmacy PlansMonthly rates per personBasicBasic PlusEnhanced 43.20 62.90 194.90Vision PlansDental PlansMonthly rates per person 7.29EyeMed - FullEyeMed Eyewear OnlyOpticare - FullOpticare Eyewear Only 6.31Monthly rates per personDental 1500Dental 1000Basic Dental 8.61 6.704 Ways to Pay Your PremiumSelect the method of payment under the Authorization to Deduct Premiums section of the PEHPMedicare enrollment form in the back of this book.1. Deduct premiums from your URS retirement check.2. Receive a monthly bill and send payment to PEHP.3. Deduct from your PEHP Health Reimbursement Account (HRA).4. Automatic bank withdrawal.4 44.22 28.36 17.50
Medical PlansMedical Plan 100Medicare Part AMedicare PaysPEHP Plan PaysYou PayInpatient Hospital Services – Per Benefit Period (see definition below)Semi-private room and board, miscellaneous expensesDeductiblePer Benefit PeriodNot a covered benefit100% of the MedicaredeductibleNothingFirst 60 DaysAll approved charges afterthe Medicare deductibleNothingNothingDays 61 to 90All approved charges, exceptfor the Medicare co-pay100% of the Medicareco-payNothing91 Days & BeyondWhile using your 60lifetime reserve daysAll approved charges, exceptfor the Medicare co-pay per“lifetime reserve day”100% of the Medicareco-pay per “lifetimereserve day”NothingAdditional 365 DaysOnce lifetime reservedays are used*Preauthorization requiredNothing100% of the Medicareeligible expensesNothingNote: Medicare will cover your stay in a hospital for up to 90 days in any given benefit period. Medicarewill cover an additional 60 lifetime reserve days for days 91 and beyond. PEHP will provide you with anadditional 365 days that can be used over the course of your lifetime.Benefit Period: Begins the day you are admitted inpatient in a hospital or skilled nursing facility (SNF). The benefitperiod ends when you haven’t received any inpatient hospital care or skilled care in a SNF for 60 days in a row.Medicare Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.*When Medicare Part A hospital benefits are exhausted, PEHP will pay the amount Medicare would have paid for upto 365 lifetime inpatient days. During this time the hospital is prohibited from billing you for the balance between itsbilled charges and the amount Medicare would have paid.5
Medical PlansMedical Plan 100Medicare Part AcontinuedMedicare PaysPEHP Plan PaysYou Pay100% of Medicare-approvedallowance after first threepints each calendar year100% of the first threepints of bloodNothingBloodWhole BloodSkilled Nursing FacilityShort-term, non-custodial care only; Confinement must follow a three-day stay in the hospitalFirst 20 Days100% of Medicare approvedchargesNothingNothingDays 21 to 100100% of approved charges,except for the Medicareco-pay per day100% of the Medicareco-pay per dayNothingDay 101 & BeyondNo benefits are payableNo benefits arepayable100%6
Medical PlansMedical Plan 100Medicare Part BcontinuedMedicare PaysPEHP Plan PaysYou PayMedical Expenses Inpatient and outpatient physician’s services, surgical services and supplies, physical andspeech therapy, diagnostic tests, durable medical equipment.DeductiblePer calendar yearNot a covered benefit100% of the MedicaredeductibleNothingApproved Charges80% of Medicareapproved charges, afterthe Medicare deductible20% of Medicareapproved charges, afterthe Medicare deductibleNothingExcess ChargesAbove Medicare approvedamountsNothing100% of the MedicarePart B excess chargesNothingMental Health Services Outpatient treatment (Benefits may vary)Diagnosisof your condition80% of Medicareapproved charges, afterthe Medicare deductible20% of Medicareapproved charges, afterthe Medicare deductibleNothingServices Outside the United States For Urgent and Emergent Care only, 50,000 per lifetimeInpatient HospitalNo day limit. Includesancillary chargesNot a covered benefit100% of billed charges,up to 700 per day;80% thereafterBalanceOutpatient HospitalNot a covered benefit80% of billed chargesBalanceSurgeon/Surgical ServicesNot a covered benefit100% of billed chargesNothingOther Physician/Professional Services(Office visits, diagnostic laband X-ray services, etc.)Not a covered benefit80% of billed chargesBalanceAmbulance (Ground or Air)For medical emergencies only,as determined by PEHPNot a covered benefit80% of billed chargesBalancePrescription DrugsOut-of-country prescriptions are not eligible under the policy.For additional information, see the PEHP Medicare Supplement Master Policy7
Medical PlansMedical Plan 75Medicare Part AMedicare PaysPEHP Plan PaysYou PayInpatient Hospital Services – Per Benefit Period (see definition on page 4)Semi-private room and board, miscellaneous expensesDeductiblePer Benefit PeriodNot a covered benefit75% of the Medicaredeductible25% of theMedicaredeductible First 60 DaysAll approved charges afterthe Medicare deductibleNothingNothingDays 61 to 90All approved charges, exceptfor the Medicare co-pay75% of the Medicareco-pay25% of theMedicare co-pay 91 Days & BeyondWhile using your 60lifetime reserve daysAll approved charges, exceptfor the Medicare co-pay per“lifetime reserve day”75% of the Medicareco-pay per “lifetimereserve day”25% of theMedicare copay per “lifetimereserve day” Additional 365DaysOnce lifetime reservedays are used*PreauthorizationrequiredNothing100% of the Medicareeligible expensesNothingNote: Medicare will cover your stay in a hospital for up to 90 days in any given benefit period.Medicare will cover an additional 60 lifetime reserve days for days 91 and beyond. PEHP will provideyou with an additional 365 days that can be used over the course of your lifetime. Applies to the annual out-of-pocket maximum limit of 3,110. Once the maximum out of pocket is met, PEHPpays 100% of Medicare eligible services based on Medicare’s eligible fee schedule. Co-insurance for Part Bexcess fees and out-of-country coverage does not apply.Benefit Period: Begins the day you are admitted inpatient in a hospital or skilled nursing facility (SNF). The benefitperiod ends when you haven’t received any inpatient hospital care or skilled care in a SNF for 60 days in a row.Medicare Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.*When Medicare Part A hospital benefits are exhausted, PEHP will pay the amount Medicare would have paidfor up to 365 lifetime inpatient days. During this time the hospital is prohibited from billing you for the balancebetween its billed charges and the amount Medicare would have paid.8
Medical PlansMedical Plan 75Medicare Part AcontinuedMedicare PaysPEHP Plan PaysYou Pay100% of Medicare-approvedallowance after first threepints each calendar year75% of the first threepints of blood25% of the firstthree pints ofblood BloodWhole BloodSkilled Nursing FacilityShort-term, non-custodial care only; Confinement must follow a three-day stay in the hospitalFirst 20 Days100% of Medicare approvedchargesNothingNothingDays 21 to 100100% of approved charges,except for the Medicareco-pay per day75% of the Medicareco-pay per day25% of theMedicare co-payper day Day 101 & BeyondNo benefits are payableNo benefits arepayable100% Applies to the annual out-of-pocket maximum limit of 3,110. Co-insurance for Part B excess fees and out-ofcountry coverage does not apply. For additional information, see the PEHP Medicare Supplement Master Policy.9
Medical PlansMedical Plan 75continuedMedicare Part BMedicare PaysPEHP Plan PaysYou PayMedical Expenses Inpatient and outpatient physician’s services, surgical services and supplies, physicaland speech therapy, diagnostic tests, durable medical equipment.DeductibleNot a coveredbenefit75% of the Medicaredeductible25% of thedeductible Approved Charges80% of Medicareapproved charges,after the Medicaredeductible15% of Medicareapproved charges,after the Medicaredeductible5% of Medicareapprovedcharges, afterdeductible Excess ChargesAbove Medicare approvedamountsNothing75% of the MedicarePart B excess charges25% of theMedicare Part Bexcess chargesMental Health Services Outpatient treatment (Benefits may vary)Diagnosisof your condition80% of Medicareapproved charges,after the Medicaredeductible15% of Medicareapproved charges,after the Medicaredeductible5% of Medicareapprovedcharges, afterdeductible Services Outside the United States For Urgent and Emergent Care only, 50,000 per lifetimeInpatient HospitalNo day limit. Includesancillary servicesNot a coveredbenefit75% of billedcharges, up to 700per dayBalanceOutpatient Hospital RoomChargesIncluding ERNot a coveredbenefit75% of billedchargesBalanceSurgeon/Surgical ServicesNot a covered benefit75% of billed chargesBalanceOther Physician/Professional Services(Office visits, diagnostic laband X-ray services, etc.)Not a coveredbenefit75% of billedchargesBalanceAmbulance (Ground or Air)For medical emergencies only, asdetermined by PEHPNot a covered benefit75% of billedchargesBalancePrescription DrugsOut-of-country prescriptions are not eligible under the policy. Applies to the annual out-of-pocket maximum limit of 3,110. Co-insurance for Part B excess fees and out-ofcountry coverage does not apply. For additional information, see the PEHP Medicare Supplement Master Policy.10
Medical PlansMedical Plan 50Medicare Part AMedicare PaysPEHP Plan PaysYou PayInpatient Hospital Services – Per Benefit Period (see definition on page 4)Semi-private room and board, miscellaneous expensesDeductibleNot a covered benefit50% of the Medicaredeductible50% ofdeductible First 60 DaysAll approved charges afterthe Medicare deductibleNothingNothingDays 61 to 90All approved charges, exceptfor the Medicare co-pay50% of the Medicareco-pay50% of theMedicare co-pay 91 Days & BeyondWhile using your 60lifetime reserve daysAll approved charges, exceptfor the Medicare co-pay per“lifetime reserve day”50% of the Medicareco-pay per “lifetimereserve day”50% of theMedicare copay per “lifetimereserve day” Additional 365DaysOnce lifetime reservedays are used*PreauthorizationrequiredNothing100% of the Medicareeligible expensesNothingNote: Medicare will cover your stay in a hospital for up to 90 days in any given benefit period.Medicare will cover an additional 60 lifetime reserve days for days 91 and beyond. PEHP will provideyou with an additional 365 days that can be used over the course of your lifetime. Applies to the annual out-of-pocket maximum limit of 6,220. Once the maximum out of pocket is met,PEHP pays 100% of Medicare eligible services based on Medicare’s eligible fee schedule. Co-insurance for PartB excess fees and out-of-country coverage does not apply.Benefit Period: Begins the day you are admitted inpatient in a hospital or skilled nursing facility (SNF). The benefitperiod ends when you haven’t received any inpatient hospital care or skilled care in a SNF for 60 days in a row.Medicare Part A only pays for up to 190 days of inpatient psychiatric hospital services during your lifetime.*When Medicare Part A hospital benefits are exhausted, PEHP will pay the amount Medicare would have paidfor up to 365 lifetime inpatient days. During this time the hospital is prohibited from billing you for the balancebetween its billed charges and the amount Medicare would have paid.11
Medical PlansMedical Plan 50Medicare Part AcontinuedMedicare PaysPEHP Plan PaysYou Pay100% of Medicare-approvedallowance after first threepints each calendar year50% of the first threepints of blood50% of the firstthree pints ofblood BloodWhole BloodSkilled Nursing FacilityShort-term, non-custodial care only; Confinement must follow a three-day stay in the hospitalFirst 20 Days100% of Medicare approvedchargesNothingNothingDays 21 to 100100% of approved charges,except for the Medicareco-pay per day50% of the Medicareco-pay per day50% of theMedicare co-payper day Day 101 & BeyondNo benefits are payableNo benefits arepayable100% Applies to the annual out-of-pocket maximum limit of 6,220. Co-insurance for Part B excess fees and out-ofcountry coverage does not apply. For additional information, see the PEHP Medicare Supplement Master Policy.12
Medical PlansMedical Plan 50continuedMedicare Part BMedicare PaysPEHP Plan PaysYou PayMedical Expenses Inpatient and outpatient physician’s services, surgical services and supplies, physicaland speech therapy, diagnostic tests, durable medical equipment.DeductibleNot a coveredbenefit50% of the Medicaredeductible50% ofdeductible Approved Charges80% of Medicareapproved charges,after the Medicaredeductible10% of Medicareapproved charges,after the Medicaredeductible10% of Medicareapproved charges,after deductible Excess ChargesAbove Medicare approvedamountsNothing50% of the MedicarePart B excess charges50% of theMedicare Part Bexcess chargesMental Health Services Outpatient treatment (Benefits may vary)Diagnosisof your condition80% of Medicareapproved charges,after the Medicaredeductible10% of Medicareapproved charges,after the Medicaredeductible10% of Medicareapproved charges,after deductible Services Outside the United States For Urgent and Emergent Care only, 50,000 per lifetimeInpatient HospitalNo day limit. Includesancillary servicesNot a coveredbenefit50% of billedcharges, up to 700per dayBalanceOutpatient HospitalRoom ChargesIncluding ERNot a coveredbenefit50% of billed chargesBalanceSurgeon/Surgical ServicesNot a covered benefit50% of billed chargesBalanceOther Physician/Professional Services(Office visits, diagnostic laband X-ray services, etc.)Not a coveredbenefit50% of billed chargesBalanceAmbulance (Ground or Air)For medical emergencies only,as determined by PEHPNot a covered benefit50% of billed chargesBalancePrescription DrugsOut-of-country prescriptions are not eligible under the policy. Applies to the annual out-of-pocket maximum limit of 6,220. Co-insurance for Part B excess fees and out-ofcountry coverage does not apply. For additional information, see the PEHP Medicare Supplement Master Policy13
Pharmacy PlansBasic Drug PlanPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Initial Coverage Stage: After you pay your yearly deductible, you will pay the following until your totalyearly drug costs (what you and the plan pay) reaches 4,430.TierTier 1Generic DrugsPreferredCost-SharingStandardCost-SharingTier 2PreferredBrand DrugsPreferredCost-SharingStandardCost-SharingTier 3Non-PreferredBrand DrugsPreferredCost-SharingStandardCost-SharingTier 4Specialty DrugsPreferred andStandardCost-SharingRetail31-day SupplyRetail60-day SupplyRetail90-day Supply10% co-insurance 5 minimum/no maximum10% co-insurance 7 minimum/no maximum10% co-insurance 7 minimum/no maximum10% co-insurance 10 minimum/no maximum10% co-insurance 12 minimum/no maximum10% co-insurance 12 minimum/no maximum25% co-insurance 25 minimum/no maximum25% co-insurance 50 minimum/no maximum25% co-insurance 75 minimum/no maximum25% co-insurance 55 minimum/no maximum25% co-insurance 80 minimum/no maximum50% co-insurance 50 minimum/no maximum50% co-insurance 100 minimum/no maximum50% co-insurance 150 minimum/no maximum50% co-insurance 55 minimum/no maximum50% co-insurance 105 minimum/no maximum50% co-insurance 155 minimum/no maximum25% co-insurance 30 minimum/no maximum25% co-insuranceno minimum/no maximum25% co-insuranceno minimum/no maximum*Tier 3 contains both generic and brand drugs.1425% co-insuranceno minimum/no maximumHome Delivery90-day Supply10% co-insurance 5 minimum/ 75 maximum25% co-insurance 50 minimum/ 100 maximum50% co-insurance 100 minimum/no maximum25% co-insuranceno minimum/maximums:0-31 days: 15032-60 days: 30061-90 days: 450
Pharmacy PlansBasic Drug Plan continuedPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Coverage Gap Stage: After your total yearly drug costs reach 4,430, you will pay the following untilyour yearly out-of-pocket drug costs reach 7,050.Brand Drugs25% of the cost of covered Medicare Part D brand drugs, plus a portion of thedispensing fee. (The manufacturer provides a 70% discount and the plan pays thedifference.)Generic Drugs25% of the plan’s costs for all covered generic drugs.Catastrophic Coverage Stage: After your yearly out-of-pocket drug costs (what you and others payon your behalf, including manufacturer discounts, but excluding payments made by your Medicareprescription drug plan) reach 7,050, you will pay the greater of 5% co-insurance or the following.Retail» a 3.95 co-pay for covered generic drugs (including brand drugs treated as generics)» a 9.85 co-pay for all other covered drugs.Home DeliveryGeneric Drugs (inPreferred Brandcluding brand drugs Drugs:treated as generics):Non-Preferred Brand Specialty Tier Drugs:Drugs: 3.95 minimum/ 75 maximum 9.85 minimum/no maximum 9.85 minimum/ 100 maximum 3.95 minimum forgenerics and 9.85minimum for branddrugs, with maximums of:0-31 days: 15032-60 days: 30061-90 days: 45015
Pharmacy PlansBasic Plus Drug PlanPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Initial Coverage Stage: After you pay your yearly deductible, you will pay the following until your totalyearly drug costs (what you and the plan pay) reaches 4,430.Retail31-day SupplyRetail60-day SupplyRetail90-day SupplyTier 1Generic DrugsPreferredCost-Sharing 10 co-pay 20 co-pay 30 co-payStandardCost-Sharing 15 co-pay 25 co-pay 35 co-payTier 2PreferredBrand DrugsPreferredCost-Sharing25% co-insurance 25 minimum/ 50 maximum25% co-insurance 50 minimum/ 100 maximum25% co-insurance 75 minimum/ 150 maximum25% co-insurance 55 minimum/ 100 maximum25% co-insurance 80 minimum/ 150 maximum50% co-insurance 50 minimum/no maximum50% co-insurance 100 minimum/no maximum50% co-insurance 150 minimum/no maximum50% co-insurance 55 minimum/no maximum50% co-insurance 105 minimum/no maximum50% co-insurance 155 minimum/no maximumTierStandardCost-SharingTier 3Non-PreferredBrand DrugsPreferredCost-SharingStandardCost-SharingTier 4Specialty DrugsPreferred andStandardCost-SharingHome Delivery90-day Supply 20 co-pay25% co-insurance 30 minimum/ 50 maximum25% co-insuranceno minimum/no maximum25% co-insuranceno minimum/no maximum*Tier 3 contains both generic and brand drugs1625% co-insuranceno minimum/no maximum25% co-insurance 50 minimum/ 100 maximum50% co-insurance 100 minimum/no maximum25% co-insuranceno minimum/maximums:0-31 days: 15032-60 days: 30061-90 days: 450
Pharmacy PlansBasic Plus Drug Plan continuedPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Coverage Gap Stage: After your total yearly drug costs reach 4,430, you will pay the following untilyour yearly out-of-pocket drug costs reach 7,050.Brand Drugs25% of the cost of covered Medicare Part D brand drugs, plus a portion of thedispensing fee. (The manufacturer provides a 70% discount and the plan pays thedifference.)Generic DrugsTier 1 generic drugs are paid at the same co-pay as in the Initial Coverage Stage.All other covered generic drugs (not on Tier 1) you pay 25% of the plan’s costs.Catastrophic Coverage Stage: After your yearly out-of-pocket drug costs (what you and others payon your behalf, including manufacturer discounts, but excluding payments made by your Medicareprescription drug plan) reach 7,050, you will pay the greater of 5% co-insurance or the following.Retail» a 3.95 co-pay for covered generic drugs (including brand drugs treated as generics)» a 9.85 co-pay for all other covered drugs.Home DeliveryGeneric Drugs (inPreferred Brandcluding brand drugs Drugs:treated as generics):Non-Preferred Brand Specialty Tier Drugs:Drugs: 3.95 minimum/ 75 maximum 9.85 minimum/no maximum 9.85 minimum/ 100 maximum 3.95 minimum forgenerics and 9.85minimum for branddrugs, with maximums of:0-31 days: 15032-60 days: 30061-90 days: 45017
Pharmacy PlansEnhanced Drug PlanPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Initial Coverage Stage: After you pay your yearly deductible, you will pay the following until your totalyearly drug costs (what you and the plan pay) reaches 4,430.Retail31-day SupplyRetail60-day SupplyRetail90-day SupplyTier 1Generic DrugsPreferredCost-Sharing 10 co-pay 20 co-pay 30 co-payStandardCost-Sharing 15 co-pay 25 co-pay 35 co-payTier 2PreferredBrand DrugsPreferredCost-Sharing25% co-insurance 25 minimum/ 50 maximum25% co-insurance 50 minimum/ 100 maximum25% co-insurance 75 minimum/ 150 maximum25% co-insurance 55 minimum/ 100 maximum25% co-insurance 80 minimum/ 150 maximum50% co-insurance 50 minimum/no maximum50% co-insurance 100 minimum/no maximum50% co-insurance 150 minimum/no maximum50% co-insurance 55 minimum/no maximum50% co-insurance 105 minimum/no maximum50% co-insurance 155 minimum/no maximumTierStandardCost-SharingTier 3Non-PreferredBrand DrugsPreferredCost-SharingStandardCost-SharingTier 4Specialty DrugsPreferred andStandardCost-SharingHome Delivery90-day Supply 20 co-pay25% co-insurance 30 minimum/ 50 maximum25% co-insuranceno minimum/no maximum25% co-insuranceno minimum/no maximum*Tier 3 contains both generic and brand drugs1825% co-insuranceno minimum/no maximum25% co-insurance 50 minimum/ 100 maximum50% co-insurance 100 minimum/no maximum25% co-insuranceno minimum/maximums:0-31 days: 15032-60 days: 30061-90 days: 450
Pharmacy PlansEnhanced Drug Plan continuedPlan pays balance after deductible and your co-insurance.Annual Plan Deductible: 480 (combined for both retail and home delivery)Coverage Gap Stage: After your total yearly drug costs reach 4,430, you will pay no more than thecost-sharing amounts in the initial coverage stage until your yearly out-of-pocket drug costs reach 7,050.Catastrophic Coverage Stage: After your yearly out-of-pocket drug costs (what you and others payon your behalf, including manufacturer discounts, but excluding payments made by your Medicareprescription drug plan) reach 7,050, you will pay the greater of 5% co-insurance or the following.Retail» a 3.95 co-pay for covered generic drugs (including brand drugs treated as generics)» a 9.85 co-pay for all other covered drugs.Home DeliveryGeneric Drugs (inPreferred Brandcluding brand drugs Drugs:treated as generics):Non-Preferred Brand Specialty Tier Drugs:Drugs: 3.95 minimum/ 75 maximum 9.85 minimum/no maximum 9.85 minimum/ 100 maximum 3.95 minimum forgenerics and 9.85minimum for branddrugs, with maximums of:0-31 days: 15032-60 days: 30061-90 days: 45019
Coverage GapUnderstanding the Coverage GapMost will not reach the Coverage Gap. When the total cost of your Part D drugsreaches 4,430, you move on to the Coverage Gap stage. The 4,430 includes theamount you have paid toward your deductible, your co-pays and the amount PEHPhas paid.How the Coverage Gap WorksAs your yearly drug spending increases, your benefit changesYourYou’ve met yourYou’ve reached theDeductible Stage Deductible ( 480) Coverage Gap 0to 480You pay allexpenses 480.01to 4,430Total Drug Costs*You payaccordingto your planbenefits 4,430.01to 7,050You pay . . .Basic: 25% forgeneric, 25%for brand name**Basic Plus:Co-pay for Tier 1generic, 25% forother coveredgeneric, 25% forbrand name**Enhanced: Nocoverage gapYou’ve reached yourCatastrophic benefit 7,050.01and upOut-of-Pocket***You payaccordingto the planbenefits* Total Drug Costs What you’ve paid, including deductible, and what the plan pays.**Plus a portion of the dispensing fee.***What you’ve paid, including deductible, co-pays, and co-insurances.20
Dental PlansPEHP Dental Coverage at a GlanceTo enroll in a PEHP Dental Plan, use the enrollment form in the back of this book orenroll online at this link.DENTAL PLANDental 1500 Dental 1000 Basic DentalMonthlyPremium 44.22 28.36 17.50 0Deductible 0 50 50 0AnnualBenefitMaximumBenefits 1,500 1,000 500 0Preventive/CleaningYou pay 0You pay 20% ofin-network rateYou pay 0You pay 100% ofin-network rate*Root CanalFor a molarYou pay 20% ofin-network rateYou pay 20% ofin-network rateafter deductibleNot coveredYou pay 100% ofin-network rate*CrownPorcelain fused tohigh noble metalYou pay 50% ofin-network rateYou pay 50% ofin-network rateafter deductibleNot coveredYou pay 100% ofin-network rate*DentalNetworkVisit www.pehp.org/providerlookup and select “Dental Network” for acomplete list.DiscountDental*Use in-network PEHP dentist for discount.PEHP Discount Dental BenefitIf you enroll in a PEHP Medicare Supplement Medical Plan, you receive our discount dentalbenefit at no extra cost. If you want dental coverage during retirement, consider enrolling ina PEHP Dental Plan. Members with the Discount Dental Benefit get an average discount of25% on dental services when using PEHP’s dental network. PEHP will adjust the claim to thecontracted discount rate and you pay for the service out-of-pocket See pages 2
PEHP Medicare Supplement Plans » Three supplement plans that cover 100%, 75%, or 50% after what Medicare pays. » All medical plans provide coverage options nationwide or outside the U.S. » Three pharmacy plans to help cover your prescriptions. » Three dental plans to choose from. » Four vision plans, covering eyewear and/or exams at various retailers.
Medicare supplement plan; If, within 12 months of enrolling in your first Medicare Advantage plan, you disenroll and choose Medicare Supplement Plans A, B, C, or F, or you are re-enrolling with Blue Cross and Blue Shield of North Carolina and this coverage is the same Medicare supplement plan you had prior to enrolling in Medicare Advantage .
Centers for Medicare & Medicaid Services National Train‐the‐Trainer Workshops Instructor Information Sheet Module 1: Understanding Medicare Module Description Original Medicare, Medicare Advantage and Other Medicare Health Plans, and Medicare Prescription Drug Coverage are choices in the Medicare program.
Medicare 101: The Basics of Medicare. . Original Medicare, Medicare Advantage, and Medicare Cost plans Other COVID-19 related benefits are available if Medicare guidelines are met Those who are in a Medicare Advantage Plan should check . PowerPoint Presentation Author:
Medicare Supplement Insurance (Medigap) policies, Medicare Advantage Plans, or Medicare prescription drug coverage (Part D). For more information . Remember, this guide is about Medigap policies. To learn more about Medicare, visit Medicare.gov, look at your “Medicare & You” handbook, or call 1‑800‑MEDICARE (1‑800‑633‑4227).
Iowa Medicare Supplement and Premium Comparison Guide Medicare Advantage & Other Health Plans in Iowa Guide SHIIP Counselors can help you: Understand your Medicare benefits Compare and evaluate Medicare Supplement policies Understand and compare Medicare Advantage plans Compare Medicare Part D plans 20
Issued by Forethought Life Insurance Company 2011 STANDARD Medicare Supplement/ Life Insurance Plans MS3000-01-IN. You can rely on Forethought Standard Medicare Supplement Plans to help pay your Medicare Part A and Medicare Part B charges that Medicare doesn't cover. What's more, you have:
A Medicare Supplement insurance plan isn't only about the security. It's about the care. Medicare Supplement insurance plans provide coverage to help pay healthcare costs not paid by Medicare Parts A and B. As with any health plan, I match the right Humana Achieve Medicare Supplement Insurance Plan to your needs and your budget.
Abrasive water jet machining (AWJM) process is one of the most recent developed non-traditional machining processes used for machining of composite materials. In AWJM process, machining of work piece material takes place when a high speed water jet mixed with abrasives impinges on it. This process is suitable for heat sensitive materials especially composites because it produces almost no heat .
