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1 Life offers you many choices. It s time to choose the right 2014 prescription drug plan. Through It All. Y0096_MRK_TMP_PDDG14a Approved

2 Contact Information Blue Cross MedicareRx SM Medicare Call a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voic ) will be on weekends and holidays. TTY/TDD: 711 Web Seminars Find a free seminar near you: Write Blue Cross MedicareRx P.O. Box 3897 Scranton, PA Contact Medicare for more information about Medicare benefits and services, including general information regarding the health, Medicare Advantage Prescription Drug or Part D benefit. Call MEDICARE ( ) TTY hours a day, 7 days a week Web 2

3 Where Part D Fits into Medicare Medicare is the nation s largest health insurance program, covering health care services such as hospital stays, skilled nursing and physician services for about 50 million people. * There are four parts to Medicare. Each provides coverage for different types of health care services. Part D covers prescription. PART A Hospital Insurance Helps pay for inpatient hospital care, skilled nursing facility care, home health care and hospice care. While most Americans are enrolled automatically in Medicare Part A, it alone may not cover all of your health care costs. Parts B, C and D are voluntary programs that provide additional coverage. PART A PART B Medical Insurance PART B Helps pay for covered doctor s services and many other medical services and supplies. If you don t enroll in Part B when you are first eligible for Medicare, you may have to pay a penalty later. PART C Medicare Advantage Plans PART C PART D Prescription Drug Coverage PART D Offers medical coverage through a network of providers, such as an HMO or PPO, that is an alternative to Original Medicare (Parts A & B). These plans may or may not cover prescription. Helps pay for covered prescription medications. As with Part B, selecting a Part D plan when you are first eligible means you may not have to pay a penalty later. Medicare Supplement Insurance Optional coverage helps to pay for expenses beyond what is covered by Medicare. There are several Medicare Supplement insurance plans, each with different benefits and premiums, so you can choose the plan that works best for your specific needs. Medicare Supplement insurance plans are identified by the separate letters A, B, C, D, F, F-HD, G, K, L, M and N. The basic benefits of each plan are exactly alike for all insurance companies. * Kaiser Family Foundation. Medicare at a Glance Fact Sheet; (2012, November). Not connected with or endorsed by the U.S. Government or Federal Medicare Program. Not all of these plans are offered by Blue Cross and Blue Shield of Illinois. 3

4 Eligibility and Enrollment When are you Medicare eligible? If you answer yes to at least one of the following questions, you may be eligible. Are you age 65 or older and have Social Security or Railroad Retirement Board benefits? Are you under age 65 with certain disabilities? Do you have ALS (amyotrophic lateral sclerosis) or, at any age, End-Stage Renal Disease? Have you or your spouse worked for at least 10 years in Medicare-covered employment? To be eligible for a Part D plan, you must be enrolled in Medicare Part A and Medicare Part B. Do you have your Medicare card? If you re turning 65 and getting Social Security or Railroad Retirement Board benefits, you will automatically be enrolled in Medicare Part A and Part B. Part A benefits are free for most Americans and begin on the first day of your birthday month. However, because you must pay a premium for Part B coverage, you have the option of turning it down. Medicare will send you a package with your Medicare card and benefit information about 90 days before your birthday. Enrollment Period When you are new to Medicare, you should enroll in Part D during your Initial Enrollment Period. This is the seven-month period including: Initial Enrollment Period 65th birthday month 3 months prior 3 months after If you didn t sign up for Part A and/or Part B when you were first eligible, you can sign up during the General Enrollment Period between January 1 - March 31 each year. Late Enrollment Penalty If you don t enroll in Medicare Parts B and D when you are first eligible, you may have a late enrollment penalty added to your monthly premium. 4

5 How Medicare Part D Works All Part D plans, including Blue Cross MedicareRx, have the phases below. Benefits offered within the plans can vary. Annual Deductible You pay this amount for your prescriptions before Blue Cross MedicareRx begins to pay. Initial Coverage You pay a copay or coinsurance for each eligible prescription filled. Blue Cross MedicareRx pays the rest until total costs reach $2,850 (the total costs you and Blue Cross MedicareRx have paid together, excluding premiums). Coverage Gap You pay your prescription drug costs until you reach $4,550 in year-to-date True Out-Of-Pocket (TrOOP) costs (payments including deductibles, copays, coinsurance). During this time, you may be eligible for a discount on brand name and a 28% discount on generic at the time of purchase. Catastrophic Coverage You pay $2.55 copay for generics, $6.35 copay or 5% coinsurance (whichever is greater) for other, and 5% coinsurance for specialty after $4,550 in TrOOP costs are reached. Blue Cross MedicareRx pays the majority of expenses until the end of the calendar year. 5

6 Your 2014 Blue Cross MedicareRx Plan Options Basic Plan Value Plan Plus Plan Monthly Premium* $23 $37.50 $97.70 Annual Deductible Amount you pay before Blue Cross MedicareRx begins to pay $310 for All Tiers $275 for Tiers 3, 4 & 5 only $0 Initial Coverage Period Copays (30-day supply) Annual drug costs up to $2,850 Tier 1 - Preferred Generic Drugs $1/$6 Tier 2 - Non-Preferred Generic Drugs $2/$8 Tier 3 - Preferred Brand Drugs $39/$45 Tier 4 - Non-Preferred Brand Drugs $85/$95 Tier 5 - Specialty Drugs 25% Preferred Pharmacy/Non-Preferred Pharmacy Tier 1 - Preferred Generic Drugs $0/$5 Tier 2 - Non-Preferred Generic Drugs $2/$7 Tier 3 - Preferred Brand Drugs $39/$44 Tier 4 - Non-Preferred Brand Drugs $85/$95 Tier 5 - Specialty Drugs 25% Tier 1 - Preferred Generic Drugs $0/$5 Tier 2 - Non-Preferred Generic Drugs $2/$7 Tier 3 - Preferred Brand Drugs $33/$40 Tier 4 - Non-Preferred Brand Drugs $80/$95 Tier 5 - Specialty Drugs 33% Gap Coverage Annual drug costs exceeding $2,850 (up to a total of $4,550 out-ofpocket costs) You will receive a discount on Brand Name Drugs and pay only 72% of the costs of Generic Drugs. You will receive a discount on Brand Name Drugs and pay only 72% of the costs of Generic Drugs. $0/$5 copay for Preferred Generic Drugs $2/$7 copay for Non- Preferred Generic Drugs Member will receive a discount on Brand Name Drugs. After the Gap Copays After your total out-of-pocket costs exceed $4,550 You pay whichever is greater: Tier 1 - Preferred Generic Drugs: $2.55 copay or 5% coinsurance for your drug Tier 2 - Non-Preferred Generic Drugs: $2.55 copay or 5% coinsurance for your drug Tier 3 - Preferred Brand Drugs: $6.35 copay or 5% coinsurance for your drug Tier 4 - Non-Preferred Brand Drugs: $6.35 copay or 5% coinsurance for your drug Tier 5 - Specialty Drugs: 5% coinsurance for your drug * You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. 6

7 Prescription Drug List List all your prescription in one place as you consider your choices. My Prescription Drug List Instructions Write the names of your prescription. Look for them on the Comprehensive Formulary at and check the Tiers in which they are listed. Add the you buy at a Preferred Pharmacy in the tan boxes for Tiers 1 4. (A Preferred Pharmacy allows you a larger discount on copays.) Add the you buy at a Non-Preferred Pharmacy in the teal boxes for Tiers 1 4. Add your Specialty under Tier 5. Make a note of their cost. My Prescription Drug List Name of Prescription Drug/Dose Warfarin Tier 1 Preferred Generics Tier 2 Non- Preferred Generics Tier 3 Preferred Brand Tier 4 Non- Preferred Brand Tier 5 Specialty Preferred Pharmacy: Use the number of under Tiers 1-4 to complete the tan boxes on the Pick A Plan worksheet. Non-Preferred Pharmacy: Use the number of under Tiers 1-4 to complete the teal boxes on the Pick A Plan worksheet. Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Total Cost Use your My Prescription Drug List to complete the Pick A Plan worksheet on pages 8-9. The totals are not final costs, but are only estimates of what you could spend annually in each plan. Or, use our online Plan Selector tool at 7

8 Pick A Plan Worksheet Annual Deductible Basic Plan $310 for All Tiers Annual Premium Cost $23 x 12 = Monthly Premium Months $276 A Estimated Monthly Drug Costs* Using your Drug List totals from page 7, write the number of prescription you will fill at a Preferred Pharmacy in the tan boxes and the number of prescription you will fill at a Non-Preferred Pharmacy in the teal boxes. Multiply the number in each tan box and each teal box by the copay amount listed next to it. Write the total in the green boxes. Multiply the cost of Tier 5 in the gray box by 25% coinsurance and write the total amount in the green box. of Tier 1 of Tier 2 of Tier 3 x $1.00 copay = x $6.00 copay = x $2.00 copay = x $8.00 copay = x $39.00 copay = x $45.00 copay = * Assumes a 30-day eligible prescription at an in-network pharmacy and that out-of-pocket costs have not reached $2,850 (coverage gap). Many factors can affect your calculations. This worksheet is not intended to reflect all costs. of Tier 4 x $85.00 copay = x $95.00 copay = Total cost of Tier 5 x 25% coinsurance = B Estimated Monthly Drug Cost Add the green boxes together and write total in the pink box. Add drug costs from green boxes = C Estimated Annual Drug Cost Multiply the pink box by 12. This is what 12 months of your prescription may cost. Write the total in the blue box. x 12 months = D Estimated Total Annual Costs Add the blue box with the numbers entered in Line D. This is your estimated total cost for one year in the plan. Annual Deductible: Annual Premium: Estimated Annual Drug Cost (Line C): Estimated Total: + + = $310 for All Tiers $276 8

9 Value Plan Plus Plan $275 for Tiers 3, 4 & 5 only $0 $37.50 x 12 = Monthly Premium Months $97.70 x 12 = $450 Monthly Premium Months $1, of Tier 1 of Tier 2 of Tier 3 of Tier 4 x $0.00 copay = x $5.00 copay = of Tier 1 x $0.00 copay = x $5.00 copay = x $2.00 copay = of Tier 2 x $2.00 copay = x $7.00 copay = x $7.00 copay = x $39.00 copay = of Tier 3 x $33.00 copay = x $44.00 copay = x $40.00 copay = x $85.00 copay = of Tier 4 x $80.00 copay = x $95.00 copay = x $95.00 copay = Total cost of Tier 5 Total cost of Tier 5 x 25% coinsurance = x 33% coinsurance = Add drug costs from green boxes = Add drug costs from green boxes = x 12 months = x 12 months = Annual Deductible: Annual Premium: Estimated Annual Drug Cost (Line C): Estimated Total: $275 for Tiers 3, 4 & 5 only Annual Deductible: $0 + + = $450 Annual Premium: $1, Estimated Annual Drug Cost (Line C): Estimated Total: + + = 9

10 Formulary and Pharmacy Facts Thousands of prescription are in our formulary. Thousands of pharmacies are in our network. Blue Cross MedicareRx Formulary You can save money by switching to a generic. Ask your doctor/pharmacist if this is an option for you. Save time and money by using our convenient mail-order service. View the most current formulary at Blue Cross MedicareRx Pharmacies Blue Cross MedicareRx has pharmacies nationwide, giving you peace of mind while traveling. For you to receive benefits, Blue Cross MedicareRx network pharmacies or mail-order service must be, except in an emergency. Blue Cross MedicareRx Preferred Pharmacies and their affiliates include: CVS Good Neighbor Sam s Club SUPERVALU Walmart Other network pharmacies are available in our network. Visit for a current network pharmacy listing. See page 11 for more ways to save. 10

11 More Choices and More Savings Choose Generics If your prescription is for a preferred or non-preferred brand drug, talk to your doctor or pharmacist about switching to a generic. This example shows how switching could save you money. Save with Generics at a Preferred Pharmacy Drug Tier 30-Day Supply Annually Estimated* Savings Compared to Tier 4 Tier 1: Preferred Generic Drug Tier 2: Non-Preferred Generic Drug Tier 3: Preferred Brand Drug Tier 4: Non-Preferred Brand Drug $1 copay $12 copay You save $1,008 $2 copay $24 copay You save $996 $39 copay $468 copay You save $552 $85 copay $1,020 copay $0 Visit to view the Comprehensive Formulary. Choose a Preferred Pharmacy When you fill your prescription at a Preferred Pharmacy, you may purchase a 90-day supply of an eligible generic or brand prescription drug and pay only two and a half months of copays instead of three. Here s an example of the possible savings. Save at the Pharmacy Drug Tier Preferred Pharmacy 30-Day Supply Preferred Pharmacy 90-Day Supply Non-Preferred Pharmacy 90-Day Supply Estimated* Savings Tier 1: Preferred Generic Drug Tier 3: Preferred Brand Drug $1 copay $2.50 copay $18 copay $15.50 $39 copay $97.50 copay $135 copay $37.50 Visit to view the pharmacies in our network. * For illustrative purposes only, using the Basic Plan and Preferred Pharmacy. Copay amounts are per prescription and assume member has not reached $2,850 in annual drug costs. 11

12 Should you stay with your plan or switch? Use this chart to confirm your decision. Your plan may still meet your needs if any of these is true: I don t currently take any prescription. I use the same prescription as last year, and they are still on my plan s formulary. My costs (premiums, deductible, copays), while different, are still within my budget. If your current plan still meets your needs, you don t need to do anything. Consider switching to another plan if any of these is true: I need more coverage. I need a lower-cost plan. My current plan may not cover my prescription next year. Select a plan to meet your current needs and see page 13 for enrollment options. If you ve decided to switch plans, it s time to enroll. Have these items handy: Your red, white and blue Medicare card Information about any other health insurance you may have Bank account information if you choose automatic payment. Paper bill or Social Security deduction also available. 12

13 Enroll in Blue Cross MedicareRx Choose one of these easy ways to enroll. Web Our secure online form has simple, step-by-step instructions that make enrollment easy. Go to: com/enroll/il Medicare beneficiaries may also enroll in Blue Cross MedicareRx through the CMS Medicare Online Enrollment Center located at Mail Fill out the enclosed enrollment form. To avoid processing delays, check that you: Select the plan (Basic, Value or Plus) you want. Copy your Medicare number exactly as printed on your Medicare ID card. Sign the form. Mail the white copy in the postage-paid envelope. The blue copy is for your records. Call Our product specialist will walk you through enrolling in Blue Cross MedicareRx. Call: TTY/TDD 711 Attend a free seminar. medicare/seminars Meet with a local agent. medicareagents 13

14 After you enroll Look for these communications. Acknowledgement Letter We will send you a letter within 10 days of receiving your enrollment form. If you enrolled with an agent or broker, you ll get a phone call to confirm your enrollment and to answer any questions you may have. Confirmation Letter/ID Card After your enrollment has been approved, we ll send you a confirmation letter. It will include your Blue Cross MedicareRx ID card and the date your coverage will be effective. Welcome Kit About two weeks after you get your ID card, you ll receive your Welcome Kit. It will include your Evidence of Coverage along with everything you ll need to know about being a member of Blue Cross MedicareRx. LifeTimes offers news you can use Watch your mailbox for LifeTimes, our quarterly newsletter filled with information and articles you re sure to enjoy, or view it online at Blue Access for Members SM (BAM) BAM is your one-stop online source for information about your plan, claim status and benefits. You also will find health and wellness tools and resources. 14

15 Important Information Limitations and Exclusions There are items and services not covered by Blue Cross MedicareRx. These are called limitations and exclusions. A full list can be found in the Evidence of Coverage. Here is a limited list. Blue Cross MedicareRx cannot cover a drug purchased outside the U.S. and its territories. Blue Cross MedicareRx does not cover: Over-the-counter (OTC) Drugs when to aid fertility Drugs when to ease signs of cough or cold Drugs when for cosmetic purposes or to aid hair growth Vitamins and mineral products ordered by a doctor, except vitamins for pregnant women and fluoride preparations Drugs when for the care of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject Drugs when for care of anorexia, weight loss, or weight gain Outpatient for which the manufacturer calls for tests or monitoring services to be bought only from the drug maker as a term of sale Barbiturates and Benzodiazepines (starting January 1, 2013 a limited number of these products will be covered for specific indications) Quantity limits, step therapy, and prior authorization may apply. Look in the online Comprehensive Formulary for more information. What are my protections under Blue Cross MedicareRx? Blue Cross MedicareRx agrees to stay in the program for a full year at a time. Each year, the plan decides whether to carry on for another year. Even if Blue Cross MedicareRx leaves the program, you will not lose Medicare coverage. Grievances and Appeals If you have a problem with our plan, there are two formal processes in place to address your issue: appeal and grievance. An appeal is something you do if you disagree with a decision to deny a request for prescription or payment for services or you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn t pay for a drug, item, or service you think you should be able to receive. A grievance is a type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. For more information, please call us. PLEASE NOTE: This information is available for free in other languages. Please contact our Customer Service number at for additional information. (TTY/TDD users should call 711). We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voic ) will be on the weekends and holidays. TTY/TDD: 711. Esta información está disponible en otros idiomas de forma gratuita. Comuníquese a nuestro número de Servicio al Cliente llamando al para obtener información adicional. (Los usuarios de TTY/TDD deberán llamar al 711). Estamos a su disposición de 8:00 a.m. a 8:00 p.m., los siete días de la semana. Si llama del 15 de febrero al 30 de septiembre, se utilizarán tecnologías alternas (por ejemplo, correo de voz) durante los fines de semana y días feriado. TTY/TDD: 711.

16 Make the right choice for your peace of mind. Use our online selection tool or call us. Web Our secure online selection tool has simple, step-by-step instructions that make it easy: Seminars Find an educational seminar near you: Call Our product specialist will walk you through your options: TTY/TDD 711 Medicare Supplement Insurance Plan Notice: Medicare Supplement insurance plans are offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association. Medicare Part D Plan Notice: Prescription drug plan provided by Blue Cross and Blue Shield of Illinois, which refers to HCSC Insurance Services Company (HISC), an independent licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC s plan depends on contract renewal.

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