Prescription drug coverage for Medicare beneficiaries

Transcription

1 2012 Blue Medicare Rx (PDP) Prescription drug coverage for Medicare beneficiaries Y0079_5252, CMS Approved U5073a, 8/11

2 Contents Your guide to Blue Medicare Rx... 3 Important information... 9 Summary of benefits Extensive list of covered drugs more than 1,800 Filling prescriptions is easy with a large pharmacy network Virtually no paperwork when you use a network pharmacy Enhanced Plan has no deductible and has gap coverage when you purchase preferred generic drugs WHAT YOU GET PAGE 2 of 32

3 Medicare prescription drug coverage helps cover your drug costs Designed to make prescriptions more affordable Blue Cross and Blue Shield of North Carolina (BCBSNC) offers Medicare prescription drug coverage with more than 1,800 drugs covered to help you pay for prescription drugs at local and network pharmacies and through mail order. Sometimes referred to as Medicare Part D, Medicare prescription drug coverage must be approved by Medicare and provided through private companies like BCBSNC. Coverage is designed to make filling prescriptions more affordable. Access to a large pharmacy network with virtually no paperwork At BCBSNC, we offer two Medicare Prescription Drug Plans: Blue Medicare Rx SM Standard Plan and Blue Medicare Rx SM Enhanced Plan. Both plans give you access to our large pharmacy network. We also take care of your prescription drug claims, so you will have virtually no paperwork when you use a network pharmacy. When you enroll in one of our Medicare Prescription Drug (Part D) Plans, we verify enrollment with Medicare, and Medicare helps pay your prescription costs. 1 Eligibility and types of coverage for beneficiaries Everyone who is entitled to Medicare benefits under Part A or enrolled in Part B is eligible for this coverage; however, you are not enrolled automatically. You must join a plan to receive the coverage. 2 This voluntary program is coverage that you may choose to purchase annually. Unlike Medicare Part A and Part B, this coverage is available solely through private companies, like BCBSNC. Medicare requires that all companies that provide Medicare Part D coverage offer the Medicare standard coverage. Companies may also choose to provide enhanced coverage, like the Blue Medicare Rx Enhanced Plan. Coverage from a local company you can trust We offer dependable prescription drug coverage for Medicare beneficiaries living in North Carolina. North Carolina is our home, and we have over 78 years of experience in the health care industry, so you can count on our expertise and helpful service. HOW IT WORKS FOR YOU 1 BCBSNC is a Medicare-approved Part D sponsor. 2 You must join a plan to receive the coverage unless you are eligible for both Medicare and Medicaid. Contact your State Medicaid or medical assistance office if you have questions about your eligibility. PAGE 3 of 32

4 Compare Part D benefits Please refer to the chart below to review our Blue Medicare Rx plans. The total amount you spend on prescription drugs increases during the calendar year as you move through some or all of the phases of coverage. Remember, you must always present your plan s member ID card to fill your prescriptions. Note: For members who qualify for low-income assistance, benefits may vary. Plan Feature Standard $66.10/month Enhanced $92.50/month Drug list (Formulary) Includes nearly 100% of the drugs covered by Medicare Part D Tier 1: Preferred Generic $10 $7 Tier 2: Non-preferred generic $25 $25 Tier 3: Preferred brand $45 $35 Tier 4: Non-preferred brand $95 $75 Tier 5: Specialty You pay 31% coinsurance. You pay 33% coinsurance. Catastrophic Coverage Gap Initial Annual deductible Retail Preferred Mail Order Retail Preferred Mail Order You pay a $50 annual deductible. You pay $0. You pay no annual deductible. You + Plan = $2,930 You pay the copayment per 30-day supply or coinsurance for your drugs, and the plan pays the remainder until total drug costs reach $2,930. You pay $0 at our preferred mail-order pharmacy for Preferred generic drugs. Pay 2½ times the copayment for a 90-day supply of brand-name drugs at preferred mail-order pharmacy through initial phase. You pay 86% on all generic drugs. You receive a discount for brand-name drugs. You pay 86% for all generic drugs. You pay a $7 copayment for Preferred generic drugs. You pay 86% for all other generic drugs. You pay $0 for Preferred generics; you pay 86% for all other generics. You receive a discount for brand-name drugs. You remain in the coverage gap until your yearly out-of-pocket drug costs (not including premiums) equal $4,700. Catastrophic coverage You pay 5%. After you reach $4,700 in out-of-pocket costs, the plan pays the majority of the drug costs until the end of the year. You pay the greater of $2.60 for generic, $6.50 for brand name or 5% of the total drug cost. PAGE 4 of 32

5 Prescription drugs covered by the plans 1 2 Here are three ways to find out if your prescriptions are covered by our formulary Search online for specific drugs by visiting the Blue Medicare Rx section of bcbsnc.com/medicare (You may also download the complete formulary in PDF format). Call or visit your local Authorized Sales Representative. Many of the most commonly used drugs are covered The Blue Medicare Rx Enhanced Plan and the Blue Medicare Rx Standard Plan have a formulary that lists the generic, brand-name and specialty drugs covered by the plans. The formulary covers many drugs eligible for coverage under Medicare Part D more than 1,800 drugs. Medicare Part D plans do not cover certain drugs, or classes of drugs, that are excluded by law, such as over-the-counter medications, prescription vitamins, benzodiazepines and barbiturates. 3 Call days a week, 8 a.m. 8 p.m. and speak to an authorized agent. Hearing and speech impaired (TTY/TDD) users call Representatives can help you determine whether or not a specific drug is covered. Extensive network of pharmacies makes getting your medications easy Except under certain non-routine circumstances, you need to use a network pharmacy to obtain the full benefit of your Medicare Part D plan. Quantity limitations and restrictions may apply. BCBSNC offers an extensive network of pharmacies of the following types: retail, national chain, mail-order, home infusion, long-term care or Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacies. Compare Medicare drug plans + Find out which Medicare drug plans are available in your area + Learn about plan benefits and costs + Compare ratings by quality, premium, estimated annual costs and more + Compare BCBSNC plan ratings, included in the Enrollment kit, or visit Plan ratings are available upon request for this plan by calling BCBSNC directly at , 7 days a week, 8 a.m. 8 p.m. For the hearing and speech impaired (TTY/TDD), call You can use our convenient mail-order pharmacy Our plans also offer the convenience of using preferred mail-order pharmacy at a reduced cost to you. You pay a $0 copayment on both plans for all Preferred generic drugs ordered through mail order, and a reduced copayment for a 90-day supply of covered brand drugs, up to $2,930 of total drug costs. PAGE 5 of 32

6 Paying for Medicare Part D coverage Here are three ways to find out if you qualify to receive financial assistance Call Medicare at MEDICARE ( ), 24 hours a day/ 7 days a week. Hearing and speech impaired (TTY/TDD) users call Or, visit Medicare s Web site, and click the Prescription Drug Plan link. Call the Social Security Administration at between 7 a.m. and 7 p.m., Monday Friday. Hearing and speech impaired (TTY/TDD users) call Call your State Medicaid Office. Premiums for Medicare Part D plans vary based on the plan that you choose If you have Medicare Part B, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You may qualify for extra help to pay for plan premiums and prescription drug costs If you have Medicare and have limited income and resources, you may qualify for special financial assistance to help you pay for your Medicare Part D plan premiums and prescription drug costs. The amount of assistance you qualify for will depend on your income and resources: + If your annual income is below $16,335 for a single person (or $22,065 if you are married and living with your spouse) for 2010, you may qualify for financial assistance. Slightly higher income levels may apply if you provide half support to other family members living with you. 3 + If your resources (including your savings and stocks, but not counting your home or car) are under $12,640 (for a single person) or under $25,260 (for a married couple), you may qualify for financial assistance. 3 If you receive an application for financial assistance, fill it out and return it in the Social Security Administration s postage-paid envelope. 3 CMS Medicare and You 2011, February PAGE 6 of 32

7 How to join Choose a plan Before you select a plan, gather any documentation you may have on your prescription drug purchases over the past year. This information will help you determine how much you might save with a Medicare Part D plan. Then you can choose a plan that best fits your needs and your budget. Enroll in a plan Then you must fill out an enrollment form. You will be enrolled in the Medicare Part D plan you select, and Medicare will be informed that you have enrolled. In addition to the paper enrollment form, Blue Medicare Rx applicants can enroll online at bcbsnc.com/medicare. Changing Medicare Part D plans Congress designed Medicare prescription drug coverage to work on an annual enrollment cycle. This means that each year, you will have the option to remain with your existing Medicare Part D plan or change plans between October 15 and December 7. You may also have another opportunity during the year to switch plans, under limited circumstances. For example, if you move out of your plan s service area, you will have an opportunity to choose another plan that serves your new area. Please contact BCBSNC if you would like more information about other situations in which you may qualify for coverage or changes in coverage outside the annual enrollment cycle. Important enrollment information Here are three ways to enroll in Medicare Part D: Enroll directly with the Medicare Part D plan you choose via paper or online application at bcbsnc.com/medicare. Visit the Centers for Medicare & Medicaid Services (CMS) Online Enrollment Center at Call MEDICARE ( ). + Generally, you can join or change Medicare Part D plans during the annual enrollment period any time between October 15 and December 7, with an effective date of January 1 of the following year. + If you are enrolling at a different time of year, the effective date of your coverage will depend on your situation and whether or not you qualify for a special election period. + You may only be enrolled in one Medicare Part D plan at a time. HOW to join + If you enroll in a stand-alone Medicare Part D plan while enrolled in a Medicare Advantage plan, you will be disenrolled automatically from the Medicare Advantage plan and returned to Original Medicare. PAGE 7 of 32

8 Penalties for late enrollment You can join a Medicare Part D plan any time during your initial enrollment period for Medicare. Generally, a Medicare beneficiary s initial enrollment is a seven-month period: three months prior to becoming Medicare eligible, the month you become Medicare eligible, and three months following the month you become Medicare eligible. If you were eligible for Medicare on or prior to January 1, 2006 and did not enroll in a Medicare Part D plan or Medicare Advantage Prescription Drug Plan by May 15, 2006, you may have to pay a penalty for late enrollment. This penalty will not apply to Medicare beneficiaries who have equal or better prescription drug benefits through their employer or another plan. As of January 1, 2009, these penalties no longer apply to Medicare individuals with Low Income Subsidy (LIS). The penalty was designed to help hold down the overall costs of the drug program and is similar to the penalty imposed for late enrollment in Medicare Part B. The late penalty equals one percent of the national base benchmark premium amount for each month that enrollment is delayed beyond your initial enrollment period. For example, if you delay enrollment in a Medicare Part D plan for two years, you will pay the regular monthly plan premium, plus 24 percent of the national base benchmark premium each month. IMPORTANT DATES October 15, 2011 First day you can enroll in a Medicare Part D plan for 2012, or the first day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period). December 7, 2011 Last day you can enroll in a Medicare Part D plan for 2012, or the last day you can elect to switch to a different Medicare Part D plan (unless you qualify for a special election period). January 1, 2012 First day coverage begins (if you join a plan or switch plans by December 7, 2011). PAGE 8 of 32

9 (PDP) Important information about our Medicare prescription drug plans U5073b, 8/11 Y0079_5255 File & Use PAGE 9 of 32

10 Important information Eligibility for beneficiaries Eligibility for beneficiaries Everyone who is entitled to Medicare benefits under Part A or enrolled in Part B is eligible for this coverage; however, you are not enrolled automatically. You must join a plan to receive the coverage. 6 This voluntary program is coverage that you may choose to purchase annually. This product is available to Medicare beneficiaries living in North Carolina. Additional enrollment criteria You may enroll in only one Part D plan at a time. If you are enrolled in a Medicare Advantage plan, your enrollment in either of the PDP plans from Blue Cross and Blue Shield of North Carolina (BCBSNC) may automatically disenroll you from your Medicare Advantage Plan, and re-enroll you in Original Medicare for medical coverage. Check with your plan for more information. Financial assistance Financial assistance available People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY users should call This document may be available in alternate formats upon request. Social Security Administration Phone a.m. 7 p.m., Monday Friday TTY/TDD Phone MEDICARE ( ) 24 hours a day, 7 days a week TTY/TDD You must join a plan to receive the coverage unless you are eligible for both Medicare and Medicaid. Contact your State Medicaid or medical assistance office if you have questions about your eligibility. PAGE 10 of 32

11 Important information Pharmacy network Pharmacy network information Your Medicare prescription drug benefits are available at any of the pharmacies in BCBSNC s large network. Our network includes retail, mail order, Indian/Tribal/Urban, long-term care and home infusion pharmacies. Under certain emergency circumstances, you may be able to receive benefits out-of-network. For more information about our pharmacy network and out-of-network policies, please contact us at (see chart on right): Mail order contact information For information on our mail order service, or to obtain forms, please call us toll-free at or TTY/TDD , 7 days a week, 8 a.m. 8 p.m. Phone TTY/ TDD Mail Web BCBSNC Customer Service PO Box Winston-Salem, NC days a week, 8 a.m. 8 p.m. For a comprehensive list of all pharmacies, please visit us on the Web at bcbsnc.com/medicare Coverage determination What is a coverage determination? When we make a coverage determination, we are making a decision about whether or not to provide or pay for a Part D drug and what your share of the cost is for the drug (also see the description of the exceptions process). You must contact us if you would like to request a coverage determination, including an exception. You cannot request an appeal if we have not issued a coverage determination. The following are examples of when you may ask us for a coverage determination: If you are not getting a prescription drug that you believe may be covered by us. If you have received a Part D prescription drug that you believe may be covered by us while you were a member, but we have refused to pay for the drug. If you are being told that coverage for a Part D prescription drug that you have been getting will be reduced or stopped and you believe you have special circumstances that should exclude you from the reduction/non-coverage. If there is a limit on the quantity (or dose) of the drug, and you disagree with the requirement or dosage limitation. If you bought a drug at a pharmacy that is not in our network and you want to request reimbursement for the expense. PAGE 11 of 32

12 Important information Coverage determination (continued) How do I make a request for coverage determination? Standard: To ask for a standard decision, you or your appointed representative may call our Customer Service Department at the numbers listed on the back cover. You can also deliver a written request to: BCBSNC 5660 University Parkway, Winston-Salem, NC Monday Friday, 8 a.m. 5 p.m. You may fax your request to Fast: To ask for a fast decision, you, your physician, or your appointed representative may call the Customer Service Department at the numbers listed on the back cover. You can also deliver a written request to: BCBSNC 5660 University Parkway Winston-Salem, NC Monday Friday, 8 a.m. 5 p.m. You may fax your request to Note: You cannot ask for a fast decision on a request for coverage of a drug already purchased. After regular business hours, you should consult with a network pharmacy regarding your need for an emergency or temporary supply of medication until you can contact the Plan the next business day. You may also call our Customer Service Department and leave a message on the Part D After Hours Exception Request voic . Be sure to ask for a fast, expedited, or 24-hour review. When will I hear back with a decision? Standard: Generally, we must give you our decision no later than 72 hours after we have received your request, but we will make it sooner if your health condition requires. Fast: If you get a fast review, we will give you our decision within 24 hours after you or your doctor ask for a fast review sooner if your health requires. PAGE 12 of 32

13 Important information Exceptions process What is an exception request? Exception requests are a kind of coverage determination. You, your authorized representative, or your prescribing physician may request an exception to seek coverage of a drug that: + Is not on the formulary (list of drugs the plan covers) + Requires prior authorization + Has quantity limitations Example of an exception request: If the Plan s formulary does not include a drug that you or your prescribing physician feel is necessary, then you or your prescribing physician may request an exception so that you may obtain coverage of this drug. If the Plan does not grant the requested exception, then you or your prescribing physician may file an appeal. When will I receive a decision on my exception request? If your exception request includes a formulary exception or an exception from utilization management rules, such as dosage or quantity limits, we must make our decision no later than 72 hours after we have received your doctor s supporting statement, which explains why the drug you are asking for is medically necessary. If you have asked for a fast or expedited exception request, we must make our decision no later than 24 hours after we get your doctor s supporting statement. You will be notified by phone, followed by a written notice, of our decision. If the decision is not in your favor, you have the right to appeal. How do I make an exception request? You or your prescribing physician may request an exception to the coverage rules for your Medicare Prescription Drug Plan. A specific form is not required for you to make an exception request. The request must include your prescribing physician s statement that he/ she has determined that the preferred drug either would not be as effective or would have adverse effects for you. Phone Hearing and speech impaired (TTY/TDD) users, days a week, 8 a.m. 8 p.m. Physicians, call Mail BCBSNC Attn: PDP Exception Requests PO Box Winston-Salem, NC PAGE 13 of 32

14 Important information Appeals process What is an appeal? An appeal is your opportunity to request a redetermination of an adverse coverage determination, which includes denied exception requests. Example of an appeal: If we deny your request for an exception to cover a non-formulary drug, then you may file an appeal of the denial. An appeal can only be filed after an exception has been requested and denied by the Plan. How do I file an appeal? If you receive a coverage determination denial, you or your appointed representative or your doctor or other prescriber may file an appeal. A specific form is not required for you to file an appeal. An appeal must be filed within 60 calendar days of the date of a denial notice and must be in writing, unless you are filing an expedited or fast appeal. You must submit it via: Mail BCBSNC Attn: Appeals & Grievance Unit PO Box Winston-Salem, NC When will I receive a decision on my appeal? We will perform a standard review of your appeal within seven calendar days of receipt of your appeal, or sooner if your health requires. We will review requests for an expedited or fast appeal as soon as possible, but no later than 72 hours following our receipt of the request. An individual who was not involved with your original coverage determination will make a decision on your appeal. You will receive a written response to your appeal. The decision on an expedited appeal will be provided by phone followed by the written notice. If our decision is to deny the appeal, the notice will advise you of your right to submit your appeal to the Independent Review Entity (IRE) with instructions on how to do so. If we miss our time frames for claims adjudication or review of the appeal, we will automatically forward the appeal to the IRE for a decision. There may be additional levels of appeal available to you. We will inform you of your additional rights in the notice, or you may refer to your Evidence of Coverage for further details. Fax or In Person BCBSNC 5660 University Pkwy. Winston-Salem, NC PAGE 14 of 32

15 Important information Grievance process What is a grievance? A grievance is a complaint that you may file if you are dissatisfied with the Plan or a contracted provider for reasons other than a decision on a coverage determination. Grievances also include complaints regarding the timeliness, appropriateness, access to, or setting of a covered prescription drug. Example of a grievance: If you are dissatisfied with the service you received from a pharmacist or plan representative, then you could file a grievance. How do I file a grievance? The grievance must be filed within 60 days after the event or incident that caused you to be dissatisfied. A specific form is not required for you to file a grievance. You or your appointed representative may file a grievance via the phone, by mail, fax, or in person. When will I receive a decision on my grievance? The resolution of a grievance will be made as quickly as your concern requires, but no more than 30 calendar days after our receipt of the grievance. We may extend the time frame by up to 14 calendar days if you request the extension, or if we justify a need for additional information and the delay is in your best interest. If you request a written response to an oral grievance, one will be provided within 30 days after receipt of the grievance. A written response will be provided to all written grievances. Our decision on a grievance is final and is not subject to an appeal. You have the right to an expedited review of a grievance concerning our refusal to grant an expedited coverage determination or expedited appeal. This type of grievance will be responded to within 24 hours after our receipt of the grievance. Phone days a week, 8 a.m. 8 p.m. Mail BCBSNC Attn: Appeals & Grievance Unit PO Box Winston-Salem, NC Fax or In Person BCBSNC 5660 University Pkwy. Winston-Salem, NC PAGE 15 of 32

16 Important information Quality improvement What if I have a concern about the quality of services I received? If you have a concern relating to the quality of services that you received under the Medicare Part D plan, then in addition to our review, you can also request review by the following organizations: The Carolinas Center for Medical Excellence (CCME)Quality Improvement Organization (QIO) in North Carolina CCME, formerly known as Medical Review of North Carolina, Inc., is a nonprofit, medical care quality improvement organization. CCME has been designated by the Centers for Medicare & Medicaid Services as the Quality Improvement Organization (QIO) for North Carolina. The QIO conducts case reviews to ensure that Medicare beneficiaries receive the quality of medical care that they expect and are entitled to. CCME serves as an independent, impartial third party to review Medicare beneficiary complaints. Seniors Health Insurance Information Program (SHIIP) SHIIP is a state consumer division of the North Carolina Department of Insurance. SHIIP assists senior citizens with Medicare, Medicare Part D, Medicare Advantage, Medicare supplements, Medicare fraud and abuse, and long-term care insurance questions. Assistance is available by calling: Phone Monday Friday, 8 a.m. 5 p.m. Quality of care complaints filed with the QIO must be made in writing. You can write to CCME at The Carolinas Center for Medical Excellence, 100 Regency Forest Drive, Suite 200, Cary, NC Assistance is available, Monday Friday, 8 a.m. 5 p.m. by calling: TYY/TDD users You may also send an to ncshiip@ncdoi.net or visit SHIIPS s Web site at The Carolinas Center for Medical Excellence (CCME) Phone TTY/TDD users Web inquiries PAGE 16 of 32

17 Important information Additional information Notice of possible contract termination BCBSNC has a contract with the Centers for Medicare & Medicaid Services (CMS), the government agency that runs Medicare, to provide a Medicare Prescription Drug Plan (PDP). This contract renews each year. At the end of each year, the contract is reviewed, and either BCBSNC or CMS can decide to end it. Members will get 90 days advance, written notice in this situation. It is also possible for our contract to end at some other time. If the contract is going to end, we will generally tell members 90 days in advance. Advance notice may be as little as 30 days or even fewer days if CMS ends our contract in the middle of the year. In this notice, we would provide a written description of alternatives available for obtaining qualified prescription drug coverage in North Carolina. We are also required to notify the general public of a contract termination via local newspapers. If BCBSNC decides to stop offering the Medicare PDP or change our service area so that it no longer includes the area where you live, membership in BCBSNC s Medicare PDP will end for everyone in that service area, and members will have to change to a different prescription drug plan. Members will continue to get prescription drugs through BCBSNC s Medicare PDP until the contract ends. PAGE 17 of 32

18 For more information: Blue Cross and Blue Shield of North Carolina Phone TTY/TDD Seven days a week, 8:00 a.m. 8:00 p.m. Online bcbsnc.com/medicare Medicare Phone TTY/TDD You can call these numbers 24 hours a day, seven days a week You can also visit Medicare s Web site and click the Prescription Drug Plan link Web BCBSNC is a Medicare-approved Part D sponsor. Benefits, formulary, pharmacy, network, premium and/or copayments/coinsurance may change on January 1, Please contact BCBSNC for details. An independent licensee of the Blue Cross and Blue Shield Association. PAGE 18 of 32

19 2012 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard) (PDP) Contract S5540, Plans 004 and 002 January 1, 2012 December 31, 2012 U5073c, 8/11 Y0079_5253 CMS Approved PAGE 19 of 32

20 Introduction to the Summary of benefits for (PDP) Thank you for your interest in Blue Medicare Rx (PDP) plans. Our plans are offered by Blue Cross and Blue Shield of North Carolina, a Medicare Prescription Drug Plan that contracts with the Federal government. This Summary of Benefits tells you some features of our plans. It doesn t list every drug we cover, every limitation, or exclusion. To get a complete list of our benefits, please call Blue Medicare Rx and ask for the Evidence of Coverage. You have choices in your Medicare prescription drug coverage As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through a Medicare Prescription Drug Plan, like Blue Medicare Rx plans. Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice. How can I compare my options? The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by Blue Medicare Rx plans to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage. Where are Blue Medicare Rx Plans available? The service area for these plans includes: North Carolina. You must live in one of these areas to join one of these plans. Who is eligible to join? You can join one of these plans if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. If you are enrolled in an MA coordinated care (HMO or PPO) plan or an MA PFFS plan that includes Medicare prescription drugs, you may not enroll in a PDP unless you disenroll from the HMO, PPO or MA PFFS plan. Enrollees in a private fee-for-service plan (PFFS) that does not provide Medicare prescription drug coverage, or an MA Medical Savings Account (MSA) plan may enroll in PDP. Enrollees in an 1876 Cost plan may enroll in a PDP. Where can I get my prescriptions? Blue Medicare Rx plans have formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Blue Medicare Rx plans have a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or coinsurance. A non-preferred pharmacy is still a network pharmacy, but you may have to pay more for your prescription drugs. The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or visit us at Our customer service number is listed at the end of this introduction. Does my plan cover Medicare Part B or Part D drugs? Blue Medicare Rx Standard and Enhanced plans do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary. What is a prescription drug formulary? Blue Medicare Rx plans use a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at If you are currently taking a drug that is not on our formulary 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 to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. PAGE 20 of 32

21 Introduction to the Summary of benefits (continued) What should I do if I have other insurance in addition to Medicare? If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy. Call your Medigap Issuer for details. If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join a Blue Medicare Rx plan. Get this information before you decide to enroll in this plan. How can I get extra help with my prescription drug plan costs or get extra help with other medicare costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: MEDICARE ( ). TTY/TTD users should call hours a day/7 days a week and see Programs for People with Limited Income and Resources in the publication Medicare You. + The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call or + Your State Medicaid Office. What are my protections in this plan? All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of a Blue Medicare Rx plan, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What is a Medication Therapy Management (MTM) program? A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Blue Medicare Rx for more details. PAGE 21 of 32

22 Introduction to the Summary of benefits (continued) Where can I find information on plan ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select Health and Drug Plans then Compare Drug and Health Plans to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call BCBSNC for more information about our Blue Medicare Rx plans. Visit us at or call us: Customer Service Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. 8:00 p.m. Eastern Current members should call toll-free TTY/TDD Prospective members should call toll-free TTY/TDD Current members should call locally TTY/TDD Prospective members should call locally TTY/TDD For more information about Medicare, please call Medicare at MEDICARE ( ) TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the Web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call customer service at the phone number listed above. If you have any questions about this plan s benefits or costs, please contact Blue Cross and Blue Shield of North Carolina for details. PAGE 22 of 32

23 Section 2 Summary of benefits for Contract S5540, Plan 004 and Plan 002 (PDP) Benefit: Outpatient Prescription Drugs Original Medicare Most drugs are not covered under Original Medicare. You can: Add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, OR You can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Original Medicare Blue Medicare Rx Enhanced (PDP) (Plan 004) Blue Medicare Rx Standard (PDP) (Plan 002) Drugs covered under Medicare Part D General: This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. Different out-of-pocket costs may apply for people who: have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service) providers. $92.50 Monthly premium $66.10 Monthly premium Most people will pay their Part D premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Blue Medicare Rx Enhanced (PDP) for certain drugs. Your provider must get prior authorization from Blue Medicare Rx Standard (PDP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan s website, formulary, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. PAGE 23 of 32

24 Section 2 - Summary of benefits for Contract S5540, Plan 004 and Plan 002 Benefit: Outpatient Prescription Drugs Original Medicare Blue Medicare Rx Enhanced (PDP) (Plan 004) If you request a formulary exception for a drug and Blue Medicare Rx Enhanced (PDP) approves the exception, you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. In-network: $0 deductible. Initial Coverage: You pay the following until total yearly drug costs reach $2,930. Retail pharmacy Tier 1 - Preferred Generic Drugs + $7 copay for a one-month (30-day) + $21 copay for a three-month (90-day) + $14 copay for a 60-day supply of drugs in this tier Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (30-day) + $75 copay for a three-month (90-day) + $50 copay for a 60-day supply of drugs in this tier Tier 3 - Preferred Brand Drugs + $35 copay for a one-month (30-day) + $105 copay for a three-month (90-day) + $70 copay for a 60-day supply of drugs in this tier Tier 4 - Non-Preferred Brand Drugs + $75 copay for a one-month (30-day) + $225 copay for a three-month (90-day) + $150 copay for a 60-day supply of drugs in this tier Tier 5 - Specialty Tier Drugs + 33% coinsurance for a one-month (30-day) + 33% coinsurance for a three-month (90- day) + 33% coinsurance for a 60-day Blue Medicare Rx Standard (PDP) (Plan 002) If you request a formulary exception for a drug and Blue Medicare Rx Standard (PDP) approves the exception, you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. In-network: $50 annual deductible. Initial Coverage: After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,930. Retail pharmacy Tier 1 - Preferred Generic Drugs + $10 copay for a one-month (30-day) + $30 copay for a three-month (90-day) + $20 copay for a 60-day supply of drugs in this tier Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (30-day) + $75 copay for a three-month (90-day) + $50 copay for a 60-day supply of drugs in this tier Tier 3 - Preferred Brand Drugs + $45 copay for a one-month (30-day) + $135 copay for a three-month (90-day) + $90 copay for a 60-day supply of drugs in this tier Tier 4 - Non-Preferred Brand Drugs + $95 copay for a one-month (30-day) + $285 copay for a three-month (90-day) + $190 copay for a 60-day supply of drugs in this tier Tier 5 - Specialty Tier Drugs + 31% coinsurance for a one-month (30-day) + 31% coinsurance for a three-month (90-day) + 31% coinsurance for a 60-day supply of drugs in this tier PAGE 24 of 32

25 Original Medicare Blue Medicare Rx Enhanced (PDP) (Plan 004) Long Term Care Pharmacy Tier 1 - Preferred Generic Drugs + $7 copay for a one-month (31-day) supply of drugs in this tier Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (31-day) supply of drugs in this tier Tier 3 - Preferred Brand Drugs + $35 copay for a one-month (31-day) supply of drugs in this tier Tier 4 - Non-Preferred Brand Drugs + $75 copay for a one-month (31-day) supply of drugs in this tier Tier 5 - Specialty Tier Drugs + 33% coinsurance for a one-month (31-day) Blue Medicare Rx Standard (PDP) (Plan 002) Long Term Care Pharmacy Tier 1 - Preferred Generic Drugs + $10 copay for a one-month (31-day) Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (31-day) Tier 3 - Preferred Brand Drugs + $45 copay for a one-month (31-day) Tier 4 - Non-Preferred Brand Drugs + $95 copay for a one-month (31-day) Tier 5 - Specialty Tier Drugs + 31% coinsurance for a one-month (31-day) Mail order Tier 1 - Preferred Generic Drugs + $0 copay for a one-month (30-day) preferred mail order pharmacy. + $0 copay for a three-month (90-day) preferred mail order pharmacy. + $0 copay for a 60-day from a preferred mail order pharmacy. + $7 copay for a one-month (30-day) + $21 copay for a three-month (90-day) + $14 copay for a 60-day supply of drugs in this tier from a Mail order Tier 1 - Preferred Generic Drugs + $0 copay for a one-month (30-day) preferred mail order pharmacy. + $0 copay for a three-month (90-day) preferred mail order pharmacy. + $0 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $10 copay for a one-month (30-day) + $30 copay for a three-month (90-day) + $20 copay for a 60-day from a PAGE 25 of 32

26 Section 2 - Summary of benefits for Contract S5540, Plan 004 and Plan 002 Benefit: Outpatient Prescription Drugs Original Medicare Blue Medicare Rx Enhanced (PDP) (Plan 004) Mail order (continued) Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (30-day) preferred mail order pharmacy. + $62.50 copay for a three-month (90-day) preferred mail order pharmacy. + $50 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $25 copay for a one-month (30-day) + $75 copay for a three-month (90-day) + $50 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. Blue Medicare Rx Standard (PDP) (Plan 002) Mail order (continued) Tier 2 - Non-Preferred Generic Drugs + $25 copay for a one-month (30-day) preferred mail order pharmacy. + $62.50 copay for a three-month (90-day) preferred mail order pharmacy. + $50 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $25 copay for a one-month (30-day) + $75 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. + $50 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 3 - Preferred Brand Drugs + $35 copay for a one-month (30-day) preferred mail order pharmacy. + $87.50 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. + $70 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $35 copay for a one-month (30-day) + $105 copay for a three-month (90-day) + $70 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 3 - Preferred Brand Drugs + $45 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. + $ copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. + $90 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $45 copay for a one-month (30-day) + $135 copay for a three-month (90-day) + $90 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. PAGE 26 of 32

27 Original Medicare Blue Medicare Rx Enhanced (PDP) (Plan 004) Mail order (continued) Tier 4 - Non-Preferred Brand Drugs + $75 copay for a one-month (30-day) preferred mail order pharmacy. + $ copay for a three-month (90-day) preferred mail order pharmacy. + $150 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $75 copay for a one-month (30-day) + $225 copay for a three-month (90-day) + $150 copay for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. Tier 5 - Specialty Tier Drugs + 33% coinsurance for a one-month (30-day) from a preferred mail order pharmacy. + 33% coinsurance for a three-month (90-day) from a preferred mail order pharmacy. + 33% coinsurance for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + 33% coinsurance for a one-month (30-day) from a + 33% coinsurance for a three-month (90-day) from a + 33% coinsurance for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. Blue Medicare Rx Standard (PDP) (Plan 002) Mail order (continued) Tier 4 - Non-Preferred Brand Drugs + $95 copay for a one-month (30-day) preferred mail order pharmacy. + $ copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. + $190 copay for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + $95 copay for a one-month (30-day) + $285 copay for a three-month (90-day) + $190 copay for a 60-day supply of drugs in this tier from a Tier 5 - Specialty Tier Drugs + 31% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy. + 31% coinsurance for a three-month (90-day) preferred mail order pharmacy. + 31% coinsurance for a 60-day supply of drugs in this tier from a preferred mail order pharmacy. + 31% coinsurance for a one-month (30-day) + 31% coinsurance for a three-month (90-day) + 31% coinsurance for a 60-day supply of drugs in this tier from a non-preferred mail order pharmacy. PAGE 27 of 32