2017 Enrollment kit. Basic Blue Rx. a stand-alone prescription drug plan. Rx (PDP) Basic Blue

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1 Basic Blue Rx 2017 Enrollment kit a stand-alone prescription drug plan Basic Blue Rx (PDP) S _B01 CMS Approved 09/06/2016

2 Welcome! Thank you for your interest in Basic Blue Rx, a stand-alone prescription drug plan. The plan works with your medical coverage to provide additional prescription drug coverage. We have served millions of members for generations and can guide you through your Medicare plan decision-making process. Easy ways to enroll Enroll online at BasicBlueRx.com Call , 8 a.m. to 8 p.m., daily, local time (TTY hearing impaired users call 711) Contact your licensed sales representative Fill out the enrollment form and place in mail Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments and restrictions may apply. This information is not a complete description of benefits. Contact the plan for more information. The formulary and pharmacy network may change at any time. You will receive notice when necessary.

3 Benefits at a glance Basic Blue Rx is a convenient, easy-to-use plan backed by Blue Cross and Blue Shield. This plan features a nationwide network of more than 67,000 pharmacies, many of which offer preferred cost sharing. You ll often pay less when you fill prescriptions at pharmacies that offer preferred cost sharing. Benefits Basic Blue Rx Monthly plan premium $28.60 amount you pay Annual deductible amount you $0 on Tier 1 (Preferred Generic) drugs; pay before initial coverage begins $400 on Tier 2 (Generic), Tier 3 (Preferred Brand), Tier 4 (Non-Preferred drug) and Tier 5 (Specialty) drugs Initial coverage amount you pay Preferred Cost Sharing Standard Cost Sharing for a 30-day supply After you pay the applicable deductible After you pay the applicable deductible Tier 1: Preferred Generic drugs $0 copay $15 copay Tier 2: Generic drugs $2 copay $20 copay Tier 3: Preferred Brand drugs 15% coinsurance 22% coinsurance Tier 4: Non-Preferred drugs 40% coinsurance 45% coinsurance Tier 5: Specialty drugs 25% coinsurance 25% coinsurance Coverage gap amount you pay for a 30-day supply after your total yearly covered prescription drug costs reach $3,700 1 Generic drugs Brand-name drugs Catastrophic coverage amount you pay for a 30-day supply after you have paid $4,950 in out-ofpocket prescription drug costs 2 51% of the plan s costs 40% of the plan s costs The greater of $3.30 copay for generic drugs and $8.25 copay for all other covered drugs OR 5% coinsurance 1 Your total drug costs means the total amount you have paid for covered drugs plus what the plan has paid for the calendar year. This does not include the plan premium you pay. 2 Your out-of-pocket costs means the amount you have paid for covered drugs for the calendar year. This does not include the amount the plan has paid or the plan premium you pay. 1

4 Learning about your plan We make it easy to learn more about your plan. Find out about the cost, medications and pharmacies: 1. Cost: Review the 2017 Prescription Drug Coverage Options overview and Summary of Benefits. 2. Medication: Look in the 2017 Formulary to see which medications are covered. 3. Pharmacies: Look in the Pharmacy Directory to see which pharmacies are in network. After learning about your plan, choose a premium payment option (you must also continue to pay your Medicare Part B premium, and Part A if applicable): A paper bill each month Deduction from your Social Security or Railroad Retirement Board (RRB) check. In most cases, Social Security or the RRB will accept your request for automatic deduction. Electronic Funds Transfer (EFT). This allows the plan to withdraw your monthly premium directly from your checking or savings account. Note: Do NOT send a payment with your enrollment form. Who is eligible? Regardless of your income or health, you can enroll in Basic Blue Rx if you meet these criteria: You are age 65 or older, or are under age 65, permanently disabled and have received Social Security disability payments for at least two years. You currently have Medicare Part A, Part B or both. You live in the service area. When can you enroll? Initial Enrollment Period is the first time you can enroll. It is a seven-month period that begins three months before you first become eligible for Medicare. Annual Enrollment Period is when you can enroll or switch plans from October 15 to December 7 with changes effective January 1. Medicare Advantage Disenrollment Period is the 45- day period from January 1 to February 14 each year. During this time, you can disenroll from a Medicare Advantage plan and enroll in Original Medicare and a stand-alone Part D plan. Special Enrollment Periods allow you to enroll at other times of the year if you: Move into or out of the plan s service area Lose coverage from an employer or union group plan, or Medicaid, or your current plan is no longer offering coverage Have other special circumstances Call Basic Blue Rx if you have questions. 2

5 Basic Blue Rx a low-cost choice from a trusted brand How Cost Sharing Works You share in the cost of your prescription drugs through copays, coinsurance and a deductible, if applicable. Pharmacies in your network are categorized into two groups: those offering standard cost sharing and those offering preferred cost sharing. Basic Blue Rx For Tier 1 drugs: No deductible at pharmacies offering preferred cost sharing and a $0 copay No deductible at pharmacies offering standard cost sharing and a $15 copay For Tiers 2, 3, 4, 5 drugs: A $400 deductible at pharmacies offering both preferred and standard cost sharing, then: Tier 2 copay: $2 preferred; $20 standard Tier 3 coinsurance: 15% preferred; 22% standard Tier 4 coinsurance: 40% preferred; 45% standard Tier 5 coinsurance: 25% for both preferred and standard Tier 1 Preferred Generic drug Cost at Pharmacies offering Preferred Cost Sharing $0 $15 Cost at Pharmacies offering Standard Cost Sharing 3

6 Extra help for those who need it You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: MEDICARE ( ). TTY users should call hours a day, seven days a week The Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call Your State Medicaid office 4

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8 MII Life, Inc., a Medicare contractor, is an independent licensee of the Blue Cross and Blue Shield Association and the underwriter for Basic Blue Rx, a prescription drug plan. Enrollment in Basic Blue Rx depends on contract renewal. Blue Cross and Blue Shield of Michigan is an independent licensee of the Blue Cross and Blue Shield Association. For more information Visit BasicBlueRx.com Call , 8 a.m. to 8 p.m., daily, local time (TTY hearing impaired users call 711) Contact your licensed sales representative For information about Medicare MEDICARE ( ) TTY hearing impaired users call hours a day, seven days a week MII0001 (09/16)