2015 Amounts in Excess of Medicare Part D Benchmark to Apply as Medical Expense
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1 2015 s in Excess of art enchmark to Apply as edical Expense ocument olumns efined enchmark art lan olumn ode Explanation art benchmark plan that is affiliated with a lan (art ). art benchmark plan that is not affiliated with a lan (art ). Also known as a stand-alone benchmark plan. art plan that is not a benchmark plan olumn The amount listed, if any, is the amount of the art premium for which an A client receiving Extra elp is responsible, even if covered by a art lan. This is the amount in excess of the benchmark amount. This amount can be applied as a medical expense. art lan olumn A Yes in this column indicates that the art benefits are being received in conjunction with a lan (art ). art The amount listed, if any, is the amount of the art premium for which the client is responsible. This amount can be applied as a medical expense, in addition to the art excess amount found in the column. ote: The total premium amount for which the client is responsible is the lan (art ) premium amount plus the amount listed in the column. pecial eeds lan () An X in one of the three columns indicates that the plan is an for that managed care product. Rev. 11/7/2014 age 1
2 2015 s in Excess of art enchmark to Apply as edical Expense arrier ame lan ame enchmark art RUG LY Aetna RX remier $ art + art remium LA ost pecial eeds Aetna (ew) RX aver $0.00 lue Rx tandard $21.20 lue Rx remier $94.20 lue RX Value lus $11.80 latinum lue hoice with RX $16.90 latinum lue omplete with RX $16.90 latinum lue ore with RX $0.00 lue lus ecure lue $0.00 Yes $0.00 X igna Rx ecure () $2.80 igna Rx ecure ax () $86.30 igna Rx ecure Xtra () $13.30 EnvisionRx lus ilver () $2.40 Express cripts hoice () $62.70 Express cripts Value () $20.00 First art remier lus () $73.80 First art Value lus () $8.50 Gundersen Lutheran enior referred Value with Rx () $2.40 Yes $20.00 Rev. 11/7/2014 age 2
3 2015 s in Excess of art enchmark to Apply as edical Expense arrier ame lan ame enchmark art RUG LY art + art remium LA ost Gundersen Lutheran enior referred Elite with Rx () $22.50 Yes $ artners artners $0.00 Yes $0.00 X artners Freedom alance with Rx (T) $4.70 artners Freedom Ultimate with Rx (T) $9.70 artners Freedom Ultimate with Enhanced Rx $ (T) artners Freedom Vital with Rx (T) $2.20 umana hoice (005) $0.00 Yes $41.00 umana referred RX lan () $0.00 umana Enhanced () $19.30 umana Walmart RX plan () $11.60 umana (ew) hoice (074) $0.00 Yes $ umana (ew) Gold hoice $0.00 Yes Itasca edical are Iare lassic $0.00 Yes $0.00 X edica ual olution $0.00 Yes $0.00 X pecial eeds edica rime olution asic with art ption 1 (T) edica rime olution asic with art ption 2 (T) edica rime olution Enhanced with art ption 1 (T) edica rime olution Enhanced with art ption 2 (T) $0.00 $36.60 $0.00 $36.60 Rev. 11/7/2014 age 3
4 2015 s in Excess of art enchmark to Apply as edical Expense arrier ame lan ame enchmark art RUG LY art + art remium LA ost edica rime olution Thrift with art ption 1 $0.00 (T) edica rime olution Value art ption 1 $0.00 (T) edica rime olution Value art ption 2 $36.60 (T) rimewest rime omplete $0.00 Yes $0.00 X X rimewest enior omplete $0.00 Yes $0.00 ilvercript (ew) hoice () $0.00 ilvercript (ew) lus () $49.60 outh ountry Ability are $0.00 Yes $0.00 X Alliance outh ountry eniorare omplete $0.00 Yes $0.00 X Alliance tonebridge Life Transamerica Rx hoice () $16.40 Insurance ompany tonebridgelife Transamerica Rx lassic () $8.90 Insurance ompany ymphonix Value RX () $0.20 ymphonix (ew) remier RX () $54.20 Ucare Ucare for eniors lassic- $20.10 Yes $ Ucare Uare for eniors Essentials Rx $0.00 Yes $42.30 Ucare Ucare for eniors Value lus- $15.50 Yes $77.30 Ucare Ucare $0.00 Yes $0.00 X United American Enhanced () $49.00 pecial eeds Rev. 11/7/2014 age 4
5 2015 s in Excess of art enchmark to Apply as edical Expense arrier ame lan ame enchmark art RUG LY United American elect () $18.60 art + art remium LA ost pecial eeds United American (ew) Essential () $5.30 United care AAR Rx referred () $21.20 United care AAR Rx aver lus () $0.00 Wellare lassic () $3.70 Wellare Extra () $21.10 Rev. 11/7/2014 age 5
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