How Emeriti's Medical Plans Work With Medicare

Transcription

1 POST65NATPCC 2015 Post-65 Medical and Rx Comparison Chart National Group Insurance Options Underwritten by Aetna Emeriti offers two types of medical plans aligning in different ways with Medicare Parts A and B coverage. You also have a choice of three different Medicare-approved Part D prescription drug plans, with varying levels of coverage. You may also add Emeriti's optional dental plan (see separate sheet for information). How Emeriti's Medical Plans Work With Medicare All of Aetna's Medicare PPO Plans replace Original Medicare. The Plans will provide you with all benefits and services covered under Original Medicare Parts A and B, and the Plans provide additional benefits not covered by Medicare. In all of the PPO Plans, you will have no Medicare Part A and Part B deductibles and no plan deductible to pay. The Premium Plan has no network requirements. The Plus and Standard Plans have in-network and out-ofnetwork features, and you may choose providers within the network or select out-of-network providers as long as they receive Medicare payment and agree to accept the plan. Coinsurance, copays, and cost sharing will vary according to your plan and network choices. If you live outside of the Aetna network area, there is a Medicare PPO Extended Service Area (ESA) option. The ESA option provides you with the same benefits as in the in-network PPO option, and you will pay the in-network level of cost sharing for all services, even when you are accessing care from outof-network providers. The Aetna Supplemental Retiree Medical Plans K and L build on services covered under Original Medicare. These plans have no annual plan deductible, but you will pay a portion of the Medicare Part A deductible, and you will be responsible for 100% of the Medicare Part B deductible. These plans operate on a coinsurance basis, meaning that after Medicare pays its share, you pay a percentage of the balance. The Aetna Supplemental Retiree Medical Plans are subject to state insurance laws, and are not available in VT, MN, and MD. Plans K and L are available in some U.S. Territories (Guam, Puerto Rico, U.S. Virgin Islands). 1SRM Plans K and L are not available in Florida. Therefore, Emeriti will offer Aetna Group Medicare Supplement Insurance (GMS) Plans A and L to retirees living in Florida. Please refer to all footnotes about the SRM Plans listed in this brochure.

2 Emeriti 2015 Post-65 Health Plans - what you pay Plan Features Premium ESA Plan Plus PPO and ESA Plans (In-Network) Plus PPO Plan (Out-of-Network) Standard PPO and ESA Plans (In-Network) Standard PPO Plan (Out-of-Network) Annual Plan Deductible $0 $0 $0 $0 $0 $0 $0 N/A Aetna SRM Plan L2 Aetna SRM Plan K2 HOW ORIGINAL MEDICARE COVERAGE WORKS Medicare Deductibles $0 $0 $0 $0 $0 $304 (25% of Part A) $147 (100% of Part B) $608 (50% of Part A) $147 (100% of Part B) Annual Out-of-Pocket Limit $2,000 $2,750 $5,500 $6,700 $10,000 $2,470 $4,940 N/A Primary Care Visit $15 15% 25% $15 30% 25% of balance after Medicare payment & Part B deductible Specialist Visit $15 15% 25% $40 30% 25% after Medicare Payment % Part B deductible Outpatient Mental Health & Substance Abuse Treatment 50% after Medicare payment & Part B deductible 50% after Medicare payment & Part B deductible Part A: $1,216 Part B: $147 Part D: $320 20% coinsurance 20% coinsurance $15 15% 25% $40 30% 25% after Medicare 50% after Medicare 45% coinsurance Preventive Care $0 $0 25% $0 30% 0% after Medicare3 50% after Medicare3 $0 on some services Inpatient Hospitalization 0% Emergency Room $50 (waived if $500 per admission $50 (waived if 25% per admission. $200 per day (days 1-7). Plan pays 100% thereafter. $50 (waived if $65 (waived if X-Ray $15 15% 25% $35 basic x-ray $200 complex imaging 30% per admission. $65 (waived if 25% of the Medicare Part A deductible each benefit period1 30% 25% after Medicare's 80% & Part B deductible Lab $15 15% 25% $35 30% $0 preventive 25% after Medicare payment & Part B deductible for maintenance Skilled Nursing: Days 1-20 Days Days $0 $75/day Limited to 100 days per 0% 15% Limited to 100 days per 25% 25% Limited to 100 days per $0 $125/day Limited to 100 days per 30% 30% Limited to 100 days per 50% of the Medicare Part A deductible each 25% after Part Part B deductible 50% after Part B deductible 100% $0 (covered by Medicare) 25% of $152/day each benefit period¹ 100% 50% after Medicare's 80% & Part B deductible $0 preventive 50% after Medicare payment & Part B deductible for maintenance $0 (covered by Medicare) 50% of $152/day each benefit period¹ 100% Home Health Care 0% 0% 25% 0% 30% 0% 0% 0% Hospice Care 0% except for $5 copay per prescription for pain management and 5% for inpatient respite care. 0% except for $5 copay per prescription for pain management and 5% for inpatient respite care. 0% except for $5 copay per prescription for pain management and 5% for inpatient respite care. 0% except for $5 copay per prescription for pain management and 5% for inpatient respite care. 0% except for $5 copay per prescription for pain management and 5% for inpatient respite care. 0% except 25% after Medicare for pain management & inpatient respite care 0% except 50% after Medicare for pain management & inpatient respite care Days 1-60: $0 Days 61-90: $304 per day Days 91+: $608 per day per each "lifetime reserve day" after day 90 for each 20% coinsurance 0% $0 $152/day each Durable Medical Equipment 15% 15% 25% 20% 30% 25% after Medicare's 80% 50% after Medicare's 80% 20% coinsurance Foreign Travel Emergency $0 except for $50 ER $0 except for $50 ER $0 except for $50 ER $0 except for $50 ER $0 except for $50 ER 100% 100% 100% 100% $0 except $5 copay per prescription for pain management. 2 NOTE: Disclaimers for medical comparison chart on page 9. 3

3 2015 Medicare Part D Prescription Drug Coverage 2015 Health Care Reform Provisions You will have a choice of three Medicare Part D drug plans for 2015: the Rx Premium, Rx Plus, and Rx Standard Plans.1 You must choose an Rx Plan when you choose your medical plan. If you don t need medical coverage at this time, but want to keep your options open to enroll in medical coverage at a later time, you can choose to enroll in the Rx Standard Plan only. Emeriti's Part D plans are derived from the Medicare Part D benefit each year. In order to understand how Emeriti's plan provisions work, it s helpful to review Medicare s Part D design in the diagram below. Health Care Reform (ACA) will include the following in 2015: The Medicare Coverage Gap Discount Program will continue to provide manufacturer discounts on brand name drugs to Part D beneficiaries who reach the Coverage Gap and are not already receiving Extra Help. A 50% discount on the negotiated price of preferred and non-preferred brand drugs (excluding the dispensing fee) will be available from manufacturers that have agreed to provide the discount. All covered (formulary) brand drugs on Aetna's formulary for your respective plan will be part of this discount program. Deductible YOU PAY FIRST $320 AS DEDUCTIBLE 2015 MEDICARE PART D DESIGN (non low-income subsidy eligibles) Initial Coverage Period YOU PAY 25% OF DRUG COSTS Coverage Gap YOU PAY 45% OF BRAND DRUGS (50% MANUFACTURERS DISCOUNT AND PLAN PAYS 5%) YOU PAY65% OF GENERIC DRUGS Catastrophic Coverage YOU PAY 5%1 1Greater of $2.65 or 5% for covered generic (including brand drugs treated as generic) drugs. Greater of $6.60 or 5% for all other drugs. This manufacturer discount is applied first to the total cost of your prescribed brand drug before you and the PDP plan pay your respective share of total drug costs at a retail pharmacy or through Aetna s mail order service. The amount that the pharmaceutical company pays, in addition to the amount that the members pays, contributes towards the True Out Of Pocket (TrOOP) amount. The discount program applies to all brand drugs in the gap, regardless of the plan or formulary. Which plan you choose will determine how much you pay for your drugs if you reach the coverage gap. If you elect Emeriti's Rx Standard Plan, and are not already receiving Extra Help, your cost share in the Coverage Gap in 2015 can be no more than 65% for covered Part D generic drugs. For the Rx Premium and Rx Plus plans, you continue to pay your generic drug cost share during the Coverage Gap 4 You reach the Coverage Gap at $2,960 in total Part D covered drug expenses 4 You reach Catastrophic Coverage at $4,700 in true out-of-pocket costs As required by CMS, Aetna plans will continue paying 5% of the total brand cost in the Coverage Gap for all of Emeriti's Rx Plans. This is in addition to the 50% discount that pharmaceutical manufacturers are paying. As you review the Rx Plans, please keep these things in mind: Emeriti s basic Rx Standard Plan is slightly richer than the Medicare standard Part D benefits The Rx Standard Plan uses Aetna's Managed Standard with Select Care Formulary Both the Rx Premium and Plus plans use Aetna's Open I with Select Care Formulary A formulary is a list of Part D prescription drugs covered by the Aetna plan. The drugs on Aetna's Medicare Formularies are selected with the help of a team of doctors and pharmacists. The list must meet requirements set by Medicare. If your drug is not included on Aetna's formularies, you can speak to your doctor about switching to a drug that is on the list. Or your doctor may request a medical exception for the drug to be covered. If you decide to continue taking medications not covered on the formulary without obtaining a medical exception, you will pay the full cost; and these expenses do not count toward the plan s deductible or out-of-pocket limits. An Emeriti-specific formulary guide is available on the Emeriti website at 1There is a fourth Rx plan, the Rx Mid-High Plan, which is closed to new entrants. If you are currently enrolled in that Plan you can stay in it for

4 2015 Part D Prescription Drug Plans - WHAT YOU PAY Exclusions and limitations for the Prescription Drug Plans (PDP): Rx Plan Features Rx Premium Plan Rx Plus Plan Rx Standard Plan5 Formulary Open I with Select Care (4 Tier Plan) Open I with Select Care (4 Tier Plan) Managed Standard with Select Care (3 Tier Plan) Formulary Network Group Standard Group Standard Group Standard Annual Deductible $100 $100 $310 Initial Coverage Period Coinsurance1 Coverage Gap Coinsurance1 Catastrophic Coverage 25% preferred brand 40% non-preferred brand Initial Coverage Period Up to $2,960 in total drug expenses 25% preferred brand 50% non-preferred brand 15% Tier 1 generics 25% higher cost generic and covered brand drugs5 Coverage Gap2 After $2,960 in total drug expenses, but before spending up to $4,700 out-of-pocket (TrOOP) 25% preferred brand2 40% non-preferred brand 45% brand2 Catastrophic Coverage After reaching $4,700 out-of-pocket (TrOOP) $0 You pay greater of 5% or $2.65 generic/$6.60 brand 65% generic 45% brand2 You pay greater of 5% or $2.65 generic/$6.60 brand Step Therapy3 Not required Required for some drugs Required for some drugs 1 Coinsurance is the amount a member pays as a percentage of the negotiated cost for the drug. Coinsurance is applied against the overall cost of the drug, before any discounts or benefits are applied. 2 The Medicare Coverage Gap Discount Program will continue to provide manufacturer discounts on brand name drugs to Part D beneficiaries who reach the Coverage Gap and are not already receiving Extra Help. A 50% discount on the negotiated price of preferred and non-preferred brand drugs (excluding the dispensing fee) will be available from manufacturers that have agreed to provide the discount. 3 Step Therapy is a process where in certain cases one or more clinically equivalent drugs must be tried before the prescribed drug can be covered. If the step therapy drug does not work, Aetna can then cover the requested drug. 4 Aetna requires you or your physician to get prior authorization for certain drugs. This means that you will need to get approval from Aetna before you fill your prescriptions. If you don t get approval, Aetna may not cover the drug. 5 Your cost for generic drugs is usually lower than your cost for brand drugs. However, Aetna in some instances combines higher cost generic drugs on brand tiers. Information is believed to be accurate as of the production date; however, it is subject to change. In the event of a conflict or inconsistency between this material and your insurance plan documents, the terms of the insurance plan documents shall govern. Not all services are covered. Aetna does not provide care or guarantee access to health services. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. See insurance plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. There are three general rules about drugs that Medicare drug plans will not cover under Part D. This PDP plan cannot: cover a drug that would be covered under Medicare Part A or Part B. cover a drug purchased outside the United States and its territories. generally cover drugs prescribed for off label use, unless supported by criteria included in certain reference books (e.g., American Hospital Formulary Service Drug Information, the DRUGDEX Information System and the USPDI). Additionally, certain types of drugs or categories of drugs are not normally covered by a Medicare Prescription Drug Plan. These drugs are not considered Part D drugs and may be referred to as exclusions or non-part D drugs. These drugs include: Drugs used for the treatment of weight loss, weight gain or anorexia; Drugs used for cosmetic purposes or to promote hair growth; Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations; Outpatient drugs where manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale of the drug itself; Drugs used to promote fertility; Drugs used for symptomatic relief of cough and colds; Non-prescription drugs, also called over-the counter (OTC); Drugs used for the treatment of sexual or erectile dysfunction. Health Benefits and Health Insurance plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). Coverage is provided through a Medicare organization or a Medicare prescription drug plan sponsor with a Medicare contract. Benefits, limitations, service areas and premiums are subject to change on January 1 of each year. You must be entitled to Medicare Part A and/or Part B and continue to pay your Part B premium and Part A, where applicable. CMS does not permit an individual to be simultaneously enrolled in a standalone Medicare Prescription Drug plan (PDP) and a separate Medicare medical plan, except in certain limited situations. This would include the group standalone PDP and the Medicare PPO offered through the Emeriti program. If you choose to enroll in the Rx (PDP) plan offered by Emeriti, and you later switch to a Medicare or Medicare Prescription Drug plan offered outside of the Emeriti program, your enrollment in the Rx (PDP) plan would be discontinued. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Members must use network pharmacies to receive plan benefits except in limited, non-routine circumstances when a network pharmacy is not available, including illness while traveling within the United States but outside of the plan s service area where there is no network pharmacy. An additional cost may be incurred for drugs received at an out-of-network pharmacy. If an individual qualifies for extra help with the Medicare prescription drug plan, premium and costs at the pharmacy may be lower. Upon enrollment in the plan, Medicare will tell Aetna how much extra help an individual is getting. An individual can obtain information on whether he/she qualifies by calling Medicare ( ). TTY/TDD users should call ] Health benefits and health insurance plans contain exclusions and limitations. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. A Medicare organization with a Medicare contract. A Medicare approved Part D sponsor. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies. The Aetna companies that offer, underwrite or administer benefits coverage include Aetna Health Inc., Aetna Health of California Inc., and or Aetna Life Insurance Company. Aetna Pharmacy Management refers to an internal business unit of Aetna Health Management, LLC. 6 7

5 Medicare Plans Offer Additional Coverage Disclaimers for the Aetna Medical Plans: Exclusions and Limitations for the Aetna Supplemental Retiree Medical Plan: Exclusions and limitations for the Medicare PPO Plans: Annual eye and hearing exams at no extra cost 1A benefit period lasts from admittance to a hospital or Skilled Nursing Facility (SNF) until 60 days after release. Re-admission within that 60 day period is part of the same benefit period for purposes of the deductible Information is believed to be accurate as of the production date; however, it is subject to change. In the event of a conflict or inconsistency between this material and the insurance plan documents, the terms of the insurance plan documents shall govern. Information is believed to be accurate as of the production date; however, it is subject to change. In the event of a conflict or inconsistency between this material and the insurance plan documents, the terms of the insurance plan documents shall govern. Discounts for eyewear and reimbursements for hearing aids Unlimited coverage for inpatient hospital days Foreign travel emergency medical coverage Silver & Fit Exercise & Healthy Aging Program Access to over 10,000 fitness clubs and exercise centers Engage online and through educational materials Advocacy for health and wellness. A highly skilled Aetna nurse case manager can help you and your family: Understand your doctor s instructions Access services and support you may need Coordinate your care and day limits. Hospital or SNF admissions after the 60 days start a new benefit period, with a new deductible and new day limits. There is no limit to the number of benefit periods in a plan year. You must meet certain requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. 2In the states of New York and Kentucky the name of this group health product is the Aetna Retiree Medical Plans 5 and 6. In the state of Kansas, the name of this group health product is the Aetna Retiree Medical Insurance Plans K and L. In all other states, the name of this group health product is the Aetna Supplemental Retiree Medical Plans K and L. THE AETNA SUPPLEMENTAL RETIREE MEDICAL PLAN/AETNA RETIREE MEDICAL PLAN/AETNA RETIREE MEDICAL INSURANCE PLAN IS NOT A MEDICARE SUPPLEMENT INSURANCE PLAN OR MEDIGAP INSURANCE PLAN. This is an employer group retiree medical plan and may provide benefits that are different from a Medicare Supplement plan. You must meet the eligibility criteria established by your former employer and be enrolled in Medicare Parts A & B to be eligible to enroll in this plan. The Retiree Medical Plan will not provide payment for services, supplies or treatment that are already covered and reimbursed under Original Medicare. The Retiree Medical Plan covers only Medicare-approved charges up to the Medicare allowable amount, unless otherwise noted in the plan documents. Your state may offer you counseling services and advice regarding your health insurance. For more information about Medicare and other insurance, review the Guide to Health Insurance for People with Medicare published by the federal government and available at Aetna Supplemental Plans L and K are not available in MD and Florida. Therefore, Emeriti will offer Aetna Group Medicare Supplement Insurance (GMS) Plans A and L to retirees living in Florida. NOTE: In the states of New York and Kentucky the name of this group health product is the Aetna Retiree Medical Plans 5 and 6. In the state of Kansas, the name of this group health product is the Aetna Retiree Medical Insurance Plans K and L. In all other states, the name of this group health product is the Aetna Supplemental Retiree Medical Plans K and L (hereinafter collectively referred to as Retiree Medical Plan ). The Retiree Medical Plan is offered, underwritten or administered by Aetna Life Insurance Company (Aetna) and its affiliates. State mandates may apply. CHCS Services, Inc. is currently the third party administrator (TPA) for the Retiree Medical Plan. This material is for informational purposes only. Not all health services are covered. See insurance plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Providers are independent contractors and are not agents of Aetna. Aetna does not provide care or guarantee access to health services. Members must use a health care provider that is eligible to receive reimbursement under Medicare in order to receive benefits under this plan, except as otherwise noted in the insurance plan documents. THE AETNA SUPPLEMENTAL RETIREE MEDICAL PLAN/AETNA RETIREE MEDICAL PLAN/AETNA RETIREE MEDICAL INSURANCE PLAN IS NOT A MEDICARE SUPPLEMENT INSURANCE PLAN OR MEDIGAP INSURANCE PLAN. This is an employer group retiree medical plan and may provide benefits that are different from a Medicare Supplement plan. You must meet the eligibility criteria established by your former employer and be enrolled in Medicare Parts A & B to be eligible to enroll in this plan. The Retiree Medical Plan will not provide payment for services, supplies or treatment that are already covered and reimbursed under Original Medicare. The Retiree Medical Plan covers only Medicare-approved charges up to the Medicare allowable amount, unless otherwise noted in the plan documents. Your state may offer you counseling services and advice regarding your health insurance. For more information about Medicare and other insurance, review the Guide to Health Insurance for People with Medicare published by the federal government and available at Please refer to the insurance plan documents (Evidence of Coverage) for a complete listing of benefits, exclusions and limitations. The following is a partial listing of exclusions and limitations under the Plan (PPO): Services that are not medically necessary or not covered under the Original Medicare Program unless otherwise noted Plastic or cosmetic surgery unless medically necessary Custodial care Experimental procedures or treatments beyond Original Medicare limits Routine foot care that is not medically necessary Outpatient Prescription Drugs except those covered under Medicare Part B The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan. A Medicare organization with a Medicare contract. A Medicare approved Part D sponsor. Benefits, formulary, pharmacy network, premium and/or components/co-insurance may change on January 1, Plans are offered by Aetna Health Inc., Aetna Health of California Inc., and/or Aetna Life Insurance Company (Aetna). Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change each year. Discount Programs provide access to discounted prices and are not insured benefits. While this material is believed to be accurate as of the print date, it is subject to change. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. You must be entitled to Medicare Part A and continue to pay your Part B premium and Part A, if applicable. Higher costs may apply for out-ofnetwork services. Precertification, or prior approval of coverage, is requested for certain services. Providers must be licensed and eligible to receive payment under the federal Medicare program, and agree to accept the PPO plan. 3Medicare determines frequency and payment for preventive services, including routine gynecological e xams and pap smears, mammo grams, PSA/DRE tests, colorectal cancer screening, eye exams and hearing The Aetna Supplemental Retiree Medical Plan offering is pending state filing and approval in some states. The state product filing process is complicated by the unique variations in state requirements, and some states may have lengthy product approval timelines. Therefore, we do not and cannot guarantee that any state will approve this product on a specific date. exams. Also routine colonoscopy; routine sigmoidoscopy; bone density test and other screenings including for those at high risk. Not all services are covered every year. Refer to the Medicare and You handbook or Medicare.gov for coverage limitations and frequencies. Discount programs provide access to discounted prices and are NOT insured benefits. The member is responsible for the full cost of the discounted services. Health information programs provide general health information and are not a substitute for diagnosis or treatment by a physician or other health care professional. Discount programs provide access to discounted prices and are not insured benefits. 8 9

6 2015POST65NATPCC