2015 Summary of Benefits Pennsylvania and West Virginia

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1 Blue Rx PDP 2015 Summary of Benefits Pennsylvania and West Virginia S5593_14_0232 Accepted

2 SECTION ONE: INTRODUCTION TO SUMMARY OF BENEFITS Blue Rx Plus (PDP) and Blue Rx Complete (PDP) January 1, 2015 December 31, 2015 PENNSYLVANIA AND WEST VIRGINIA 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. 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 Rx Plus (PDP) or Blue Rx Complete (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. TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Blue Rx Plus (PDP) and Blue Rx Complete (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 s 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 Rx Plus (PDP) and Blue Rx Complete (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 Braille and large print. 1 This document may be available in a non-english language. For additional information, call us at (800) (TTY/TDD 711)

3 THINGS TO KNOW ABOUT BLUE RX PLUS (PDP) AND BLUE RX COMPLETE (PDP) HOURS OF OPERATION You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. Blue Rx Plus (PDP) and Blue Rx Complete (PDP) Phone Numbers and Website If you are a member of this plan, call toll-free (800) (TTY/TDD 711) If you are not a member of this plan, call toll-free (866) (TTY/TDD (800) ) Our website: WHO CAN JOIN? To join Blue Rx Plus (PDP) or Blue Rx Complete (PDP), you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, and live in our service area. Our service area includes the following: Pennsylvania, West Virginia. WHICH DRUGS ARE COVERED? You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website ( 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 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 after you meet your deductible: 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. You can see our plan s pharmacy directory at our website ( Or, call us and we will send you a copy of the pharmacy directory. 2 If you have any questions about this plan s benefits or s, please contact HM Health Insurance Company for details.

4 SECTION TWO: SUMMARY OF BENEFITS: JANUARY 1, DECEMBER 31, 2015 BENEFIT CATEGORY BLUE RX PLUS (PDP) Blue Rx Complete (PDP) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $80.40 per month. $ per month. How much is the deductible? PRESCRIPTION DRUG BENEFITS Initial Coverage $320 per year for Part D prescription drugs. After you pay your yearly deductible, you pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing This plan does not have a deductible. You pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier One-month Three-month Tier One-month Three-month Tier 1 ( $2 copay $6 copay Tier 1 ( $4 copay $12 copay Tier 2 (Non- $12 copay $36 copay Tier 2 (Non- $12 copay $36 copay Tier 3 ( 25% of the 25% of the Tier 3 ( $40 copay $120 copay Tier 4 (Non- 50% of the 50% of the Tier 4 (Non- $70 copay $210 copay 3 Tier 5 (Specialty Tier) 25% of the 25% of the Tier 5 (Specialty Tier) 33% of the 33% of the

5 Initial Coverage (continued) Standard Mail Order Cost-Sharing Tier Tier 1 ( Three-month $5 copay Standard Mail Order Cost-Sharing Tier Tier 1 ( Three-month $10 copay Tier 2 (Non- $30 copay Tier 2 (Non- $30 copay Tier 3 ( 25% of the Tier 3 ( $100 copay Tier 4 (Non- 50% of the Tier 4 (Non- $175 copay Tier 5 (Specialty Tier) 25% of the Tier 5 (Specialty Tier) 33% of the Coverage Gap If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. 4 If you have any questions about this plan s benefits or s, please contact HM Health Insurance Company for details.

6 SECTION TWO: SUMMARY OF BENEFITS: JANUARY 1, DECEMBER 31, 2015 BENEFIT CATEGORY PRESCRIPTION DRUG BENEFITS Coverage Gap (continued) BLUE RX PLUS (PDP) Blue Rx Complete (PDP) Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will you. Standard Retail Cost-Sharing Tier Drugs Covered Onemonth Tier 1 ( All Threemonth Tier 2 (Non- All Standard Mail Order Cost-Sharing Tier Drugs Covered Threemonth Tier 1 ( All 5 Tier 2 (Non- All

7 Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. 6 If you have any questions about this plan s benefits or s, please contact HM Health Insurance Company for details.

8 7 MultilanguageInterpreterServices English:Wehavefreeinterpreterservicestoansweranyquestionsyoumayhaveaboutourhealthordrugplan.Togetan interpreter,justcallusat someonewhospeaksenglish/languagecanhelpyou.thisisafreeservice. Spanish:Tenemosserviciosdeintérpretesinoalgunopararespondercualquierpreguntaquepuedatenersobrenuestroplan desaludomedicamentos.parahablarconunintérprete,porfavorllameal alguienquehableespañollepodrá ayudar.esteesunserviciogratuito. ChineseMandarin: ChineseCantonese: Tagalog:Mayroonkaminglibrengserbisyosapagsasalingwikaupangmasagotanganumangmgakatanunganninyohinggilsa amingplanongpangkalusuganopanggamot.upangmakakuhangtagasalingwika,tawaganlamangkamisa MaaarikayongtulunganngisangnakakapagsalitangTagalog.Itoaylibrengserbisyo. French:Nousproposonsdesservicesgratuitsd'interprétationpourrépondreàtoutesvosquestionsrelativesànotrerégimede santéoud'assurancemédicaments.pouraccéderauserviced'interprétation,ilvoussuffitdenousappelerau un interlocuteurparlantfrançaispourravousaider.ceserviceestgratuit. Vietnamese:Chúngtôicódchvthôngdchminphítrlicáccâuhivchngsckhevàchngtrìnhthucmen.Nu quívcnthôngdchviênxingi scónhânviênnóitingvitgiúpquív.âylàdchvminphí. German:UnserkostenloserDolmetscherservicebeantwortetIhrenFragenzuunseremGesundheitsundArzneimittelplan.Unsere DolmetschererreichenSieunter ManwirdIhnendortaufDeutschweiterhelfen.DieserServiceistkostenlos. Korean:

9 Russian:,., ,p.. Arabic: Italian:Èdisponibileunserviziodiinterpretariatogratuitoperrispondereaeventualidomandesulnostropianosanitarioe farmaceutico.peruninterprete,contattareilnumero unnostroincaricatocheparlaitalianoviforniràl'assistenza necessaria.èunserviziogratuito. Portugués:Dispomosdeserviçosdeinterpretaçãogratuitospararesponderaqualquerquestãoquetenhaacercadonossoplano desaúdeoudemedicação.paraobterumintérprete,contactenosatravésdonúmero iráencontraralguémque faleoidiomaportuguêsparaoajudar.esteserviçoégratuito. FrenchCreole:Nougenyensèvisentèprètgratispoureponntoutkesyonoutagenyenkonsènanplanmedikaloswadwògnouan. Poujwennyonentèprèt,jisrelenounan YonmounkipaleKreyòlkapabedew.Saaseyonsèviskigratis. Polish:Umoliwiamybezpatneskorzystaniezusugtumaczaustnego,którypomoewuzyskaniuodpowiedzinatematplanu zdrowotnegolubdawkowanialeków.abyskorzystazpomocytumaczaznajcegojzykpolski,naleyzadzwonipodnumer Tausugajestbezpatna. Hindi:., Japanese:

10 Blue Shield and the Shield symbol are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. Blue Rx is a service mark of the Blue Cross and Blue Shield Association. Highmark is a registered mark of Highmark Inc (R9/14)

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