Summary of Benefits. Blue Shield of California Medicare Rx Plan (PDP)

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1 Summary of Benefits Blue Shield of California Medicare Rx Plan (PDP) An employer-sponsored Medicare Prescription Drug Plan for University of California (UC) retirees January 1, 2015 December 31, 2015 State of California This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. UC_Hi-Opt S2468_14_236N_

2 You have choices about how to get your Medicare prescription drug benefits One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan, like Blue Shield of California Medicare Rx Plan (PDP). Another choice is to get your prescription drug coverage through a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D) through these plans. You may have other options offered by your former employer group/union. This plan is offered as part of our former employer group/union s medical plan. If you decide you don t want Medicare prescription drug coverage through this plan, check with your Benefits Administrator to understand how that decision will impact your retiree benefits coverage. Tips for comparing your Medicare choices This Summary of benefits booklet gives you a summary of what Blue Shield of California Medicare Rx Plan (PDP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to know about Blue Shield of California Medicare Rx Plan (PDP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Prescription Drug Benefits This document is available in other formats such as large print. For additional information, call us at (888) [TTY: 711]. Things to Know About Blue Shield of California Medicare Rx Plan (PDP) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 7:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 7:00 a.m. to 8:00 p.m. Pacific time. However, your call will be handled by our automated phone system on weekends and holidays. Blue Shield of California Medicare Rx Plan (PDP) Phone Numbers and Website If you are a member of this plan, call toll-free (888) [TTY: 711]. If you are not a member of this plan, call toll-free (888) [TTY: 711]. Our website:

3 Who can join? To join Blue Shield of California Medicare Rx Plan (PDP), you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, meet your former employer group/union s eligibility requirements, and live in the plan service area. Your Medicareeligible spouse and dependents may also join Blue Shield of California Medicare Rx Plan (PDP) if they meet these requirements. Our service area includes the following: California. What drugs are covered? You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website (http://www.blueshieldca.com/med_formulary). Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Which pharmacies can I use? We have a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan s pharmacy directory at our website (http://www.blueshieldca.com/med_pharmacy). Or, call us and we will send you a copy of the pharmacy directory.

4 Summary of Benefits January 1, 2015 December 31, 2015 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Your benefits administrator is responsible for paying premiums beyond your monthly Medicare Part B premium. If you are responsible for any contribution to the premiums, your benefits administrator will tell you the amount you and your former employer group/union contribute to the premium. This plan does not have a deductible. Blue Shield of California is a PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. PRESCRIPTION DRUG BENEFITS Initial Coverage You pay the following until your yearly out-of-pocket drug costs reach $1,000. You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Retail Cost-Sharing Tier One-month supply Three-month supply Tier 1 (Preferred Generic Drugs) $10 copay $20 copay Tier 2 (Preferred Brand Drugs) $30 copay $60 copay Tier 3 (Non-Preferred Brand Drugs) $45 copay $90 copay Tier 4 (Injectable Drugs) $30 copay $60 copay Tier 5 (Specialty Tier Drugs) $30 copay $60 copay

5 Standard Retail Cost-Sharing Tier One-month supply Three-month supply Tier 1 (Preferred Generic Drugs) $10 copay $30 copay Tier 2 (Preferred Brand Drugs) $30 copay $90 copay Tier 3 (Non-Preferred Brand Drugs) $45 copay $135 copay Tier 4 (Injectable Drugs) $30 copay $90 copay Tier 5 (Specialty Tier Drugs) $30 copay $90 copay Standard Mail Order Cost-Sharing Tier Three-month supply Tier 1 (Preferred Generic Drugs) $20 copay Tier 2 (Preferred Brand Drugs) $60 copay Tier 3 (Non-Preferred Brand Drugs) $90 copay Tier 4 (Injectable Drugs) $60 copay Tier 5 (Specialty Tier Drugs) $60 copay If you reside in a long-term care facility, you pay the same as at a a network pharmacy offering standard cost sharing; You may get drugs from an out-of-network pharmacy at the same cost as at a network pharmacy offering standard cost sharing. Brand drugs with generic equivalent Coverage Gap Catastrophic Coverage You pay the difference in cost between the brand and generic drug, plus the generic copay for the applicable pharmacy type. Because there is no coverage gap for the plan, this payment stage does not apply to you. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing. PDP00037_UC_Hi_Opt_10/14

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