• How our members rate our plan's services and care; • How well our doctors detect illnesses and keep members healthy; • How well our plan helps our members use recommended and safe prescription medications 2 Stars Caution - this plan got low ratings from Medicare for 3 years in a row The number of stars shows how well our plan performs. excellent above average average below average poor UniCare - S5960 CY 2013 Medicare Plan Ratings The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Rating to compare our plan's performance to other plans. Examples of the areas covered by this rating include: For 2013, UniCare received the following overall Plan Rating from Medicare. Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern at 877-541-7382 (toll-free) or 711 (TTY/TDD). Current members please call 800-928-6201 (toll-free) or 711 (TTY/TDD). Y0071_13_16168_U CMS Accepted 33607MUMENUNC
Transcript
• How our members rate our plan's services and care;
• How well our doctors detect illnesses and keep members healthy;
• How well our plan helps our members use recommended and safe prescription medications
Image description. 2 Stars End of image description.
Imagedescription.Caution - this plangot low ratingsfrom Medicare for3 years in a rowEnd of imagedescription.
2 Stars
Caution - this plan got low ratings from Medicare for 3 years in a row
Image description. 5 stars End of image description.
Image description. 4 stars End of image description.
Image description. 3 stars End of image description.
Image description. 2 stars End of image description.
Image description. 1 star End of image description.
The number of stars shows how well our plan performs.
excellent above average average below average poor
UniCare - S5960
CY 2013 Medicare Plan Ratings
The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality andperformance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Ratingto compare our plan's performance to other plans. Examples of the areas covered by this rating include:
For 2013, UniCare received the following overall Plan Rating from Medicare.
Learn more about our plan and how we are different from other plans at www.medicare.gov.
You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00p.m. Eastern at 877-541-7382 (toll-free) or 711 (TTY/TDD).
Current members please call 800-928-6201 (toll-free) or 711 (TTY/TDD).
Y0071_13_16168_U CMS Accepted 33607MUMENUNC
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-928-6201. Someone who speaks English/ Language can help you. This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-928-6201. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果 您需要此翻译服务，请致电 1-800-928-6201。我们的中文工作人员很乐意帮助您。 这是一项免费服 务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如 需翻譯服務，請致電1-800-928-6201。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-928-6201. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-928-6201. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-928-6201 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí.
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-928-6201. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하 고 있습니다. 통역 서비스를 이용하려면 전화 1-800-928-6201 번으로 문의해 주십시오. 한국어를 하 는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-928-6201. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
Arabic:إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا .
سيقوم شخص1-008-829-1026.للحصول على مترجم فوري، ليس عليك سوى االتصال بنا على. ما يتحدث العربية بمساعدتك. هذه خدمة مجانية
Hindi: हमार ेसवासथय या दवा की योजना क ेबार ेमे ंआपक ेिकसी भी पशन क ेजवाब देन ेक ेिलए हमार ेपास मुफत दुभािषया सेवाए ँउपलबध हैं. एक दुभाियषा परापत करन ेक ेिलए, बस हमे ं1-800-928-6201 पर फोन करें. कोई वयिकत जो िहनदी बोलता ह ैआपकी मदद कर सकता है. यह एक मुफत सेवा है.
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-928-6201. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-928-6201. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-928-6201. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-928-6201. Ta usługa jest bezpłatna.
Summary of Benefitsfor MedicareRx Rewards Standard (PDP)
Available in North Carolina
UniCare is a PDP plan with a Medicare contract. Enrollment in UniCare depends on contract renewal.UniCare is the legal entity who has contracted with the Centers for Medicare & Medicaid Services (CMS)to offer the Medicare Prescription Drug plan(s) (PDP) noted. UniCare is the risk-bearing entity licensedunder applicable state law to offer the PDP plan(s) noted. UniCare has retained the services of its relatedcompanies and the authorized brokers/producers to provide administrative services and/or to make thePDP plan(s) available in this region. Coverage is provided by one of the following companies: UniCareLife & Health Insurance Company, UniCare Health Insurance Company of the Midwest (IN & IL only),UniCare Health Plans of the Midwest, Inc. (HMO in IN & IL only). ® Registered mark of WellPoint,Inc.
Introduction to Summary of BenefitsThank you for your interest in MedicareRx Rewards Standard (PDP). Our plan is offered by UniCare Life and HealthInsurance Company which is also called UniCare, a Medicare Prescription Drug Plan that contracts with the Federalgovernment. This Summary of Benefits tells you some features of our plan. It doesn't list every drug we cover, everylimitation, or exclusion. To get a complete list of our benefits, please call MedicareRx Rewards Standard (PDP) andask for the "Evidence of Coverage."
You have choices in your Medicareprescription drug coverageAs a Medicare beneficiary, you can choose from differentMedicare prescription drug coverage options. One optionis to get prescription drug coverage through a MedicarePrescription Drug Plan, like MedicareRx RewardsStandard (PDP). Another option is to get yourprescription drug coverage through a Medicare AdvantagePlan that offers prescription drug coverage. You makethe choice.
How can I compare my options?The charts in this booklet list some important drugbenefits. You can use this Summary of Benefits tocompare the benefits offered by MedicareRx RewardsStandard (PDP) to the benefits offered by other MedicarePrescription Drug Plans or Medicare Advantage Planswith prescription drug coverage.
Where is MedicareRx RewardsStandard (PDP) available?The service area for this plan includes:
North Carolina.
You must live in this area to join this plan.
Who is eligible to join?You can join this plan if you are entitled to MedicarePart A and/or enrolled in Medicare Part B and live in theservice area.
If you are enrolled in an MA coordinated care (HMOor PPO) plan or an MA PFFS plan that includesMedicare prescription drugs, you may not enroll in a
PDP unless you disenroll from the HMO, PPO or MAPFFS plan.
Enrollees in a private Fee-for-Service plan (PFFS) thatdoes not provide Medicare prescription drug coverage,or an MA Medical Savings Account (MSA) plan mayenroll in a PDP. Enrollees in an 1876 Cost plan mayenroll in a PDP.
Where can I get my prescriptions?MedicareRx Rewards Standard (PDP) has formed anetwork of pharmacies. You must use a networkpharmacy to receive plan benefits. We will not pay foryour prescriptions if you use an out-of-networkpharmacy, except in certain cases.
MedicareRx Rewards Standard (PDP) has a list ofpreferred pharmacies. At these pharmacies, you may getyour drugs at a lower co-pay or co-insurance. You maygo to a non-preferred pharmacy, but you may have topay 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 athttp://www.unicare.com/medicare. Our customerservice number is listed at the end of this introduction.
What if my doctor prescribes less thana month's supply?In consultation with your doctor or pharmacist, you mayreceive less than a month's supply of certain drugs. Also,if you live in a long-term care facility, you will receiveless than a month's supply of certain brand and genericdrugs. Dispensing fewer drugs at a time can help reducecost and waste in the Medicare Part D program, whenthis is medically appropriate.
Page 2 – MedicareRx Rewards Standard (PDP)
The amount you pay in these circumstances will dependon whether you are responsible for paying coinsurance(a percentage of the cost of the drug) or a copay (a flatdollar amount for the drug). If you are responsible forcoinsurance for the drug, you will continue to pay theapplicable percentage of the drug cost. If you areresponsible for a copay for the drug, a "daily cost-sharingrate" will be applied. If your doctor decides to continuethe drug after a trial period, you should not pay more fora month's supply than you otherwise would have paid.Contact your plan if you have questions aboutcost-sharing when less than a one-month supply isdispensed.
Does my plan cover Medicare Part Bor Part D drugs?MedicareRx Rewards Standard (PDP) does not coverdrugs that are covered under Medicare Part B asprescribed and dispensed. Generally, we only cover drugs,vaccines, biological products and medical suppliesassociated with the delivery of insulin that are coveredunder the Medicare Prescription Drug Benefit (Part D)and that are on our formulary.
What is a prescription drug formulary?MedicareRx Rewards Standard (PDP) uses a formulary.A formulary is a list of drugs covered by your plan tomeet patient needs. We may periodically add, remove,or make changes to coverage limitations on certain drugsor change how much you pay for a drug. If we make anyformulary change that limits our members' ability to filltheir prescriptions, we will notify the affected membersbefore the change is made. We will send a formulary toyou and you can see our complete formulary on our Website at http://www.unicare.com/medicare.
If you are currently taking a drug that is not on ourformulary 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 toan alternative drug listed on our formulary with yourphysician's help. Call us to see if you can get a temporarysupply of the drug or for more details about our drugtransition policy.
What should I do if I have otherinsurance in addition to Medicare?If you have a Medigap (Medicare Supplement) policythat includes prescription drug coverage, you mustcontact your Medigap Issuer to let them know that youhave joined a Medicare Prescription Drug Plan. If youdecide to keep your current Medigap supplement policy,your Medigap Issuer will remove the prescription drugcoverage portion of your policy. Call your Medigap Issuerfor details.
If you or your spouse has, or is able to get, employergroup coverage, you should talk to your employer to findout how your benefits will be affected if you joinMedicareRx Rewards Standard (PDP). Get thisinformation before you decide to enroll in this plan.
How can I get extra help with myprescription drug plan costs or getextra help with other Medicare costs?You may be able to get extra help to pay for yourprescription drug premiums and costs as well as get helpwith other Medicare costs. To see if you qualify forgetting extra help, call:
* 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048, 24 hours a day/7 daysa week; and see http://www.medicare.gov 'Programsfor People with Limited Income and Resources' in thepublication Medicare & You.
* The Social Security Administration at 1-800-772-1213between 7 a.m. and 7 p.m., Monday through Friday.TTY/TDD users should call 1-800-325-0778; or
* Your State Medicaid Office.
What are my protections in this plan?All Medicare Prescription Drug Plans agree to stay in theprogram for a full calendar year at a time. Plan benefitsand cost-sharing may change from calendar year tocalendar year. Each year, plans can decide whether tocontinue to participate with the Medicare PrescriptionDrug Program. A plan may continue in their entireservice area (geographic area where the plan acceptsmembers) or choose to continue only in certain areas.Also, Medicare may decide to end a contract with a plan.
Page 3 – MedicareRx Rewards Standard (PDP)
Even if your Medicare Prescription Plan leaves theprogram, you will not lose Medicare coverage. If a plandecides not to continue for an additional calendar year,it must send you a letter at least 90 days before yourcoverage will end. The letter will explain your optionsfor Medicare coverage in your area.
As a member of MedicareRx Rewards Standard (PDP),you have the right to request a coverage determination,which includes the right to request an exception, the rightto file an appeal if we deny coverage for a prescriptiondrug, and the right to file a grievance. You have the rightto request a coverage determination if you want us tocover a Part D drug that you believe should be covered.An exception is a type of coverage determination. Youmay ask us for an exception if you believe you need adrug that is not on our list of covered drugs or believeyou should get a non-preferred drug at a lowerout-of-pocket cost. You can also ask for an exception tocost utilization rules, such as a limit on the quantity ofa drug. If you think you need an exception, you shouldcontact us before you try to fill your prescription at apharmacy. Your doctor must provide a statement tosupport your exception request. If we deny coverage foryour prescription drug(s), you have the right to appealand ask us to review our decision. Finally, you have theright to file a grievance if you have any type of problemwith us or one of our network pharmacies that does notinvolve coverage for a prescription drug. If your problem
involves quality of care, you also have the right to file agrievance with the Quality Improvement Organization(QIO) for your state. Please refer to the Evidence ofCoverage (EOC) for the QIO contact information.
What is a Medication TherapyManagement (MTM) Program?A Medication Therapy Management (MTM) Programis a free service we offer. You may be invited to participatein a program designed for your specific health andpharmacy needs. You may decide not to participate butit is recommended that you take full advantage of thiscovered service if you are selected. Contact MedicareRxRewards Standard (PDP) for more details.
Where can I find information on planratings?The Medicare program rates how well plans perform indifferent categories (for example, detecting and preventingillness, ratings from patients and customer service). Ifyou have access to the web, you can find the Plan Ratingsinformation by using the “Find health & drug plans”web tool on http://www.medicare.gov to compare theplan ratings for Medicare plans in your area. You canalso call us directly to obtain a copy of the Plan Ratingsfor this plan. Our customer service number is listedbelow.
Please call UniCare for more information aboutMedicareRx Rewards Standard (PDP) Visit us at http://www.unicare.com/medicare or, call us:
Customer Service Hours for October 1 – February 14: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern Customer Service Hours for February 15 – September 30: Monday, Tuesday,Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Eastern Current members should call toll-free 1-800-928-6201. (TTY/TDD 711) Prospective members should call toll-free 1-877-541-7382. (TTY/TDD 711)
Page 4 – MedicareRx Rewards Standard (PDP)
Current members should call locally 1-800-928-6201. (TTY/TDD 711) Prospective members should call locally 1-877-541-7382. (TTY/TDD 711) For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visithttp://www.medicare.gov on the web. This document may be available in other formats such as Braille, large print or other alternateformats. This document may be available in a non-English language. For additional information, call customerservice at the phone number listed above. Este documento podría estar disponible en otros formatos como Braille, textos conletras grandes u otros formatos. Este documento podría estar disponible en idiomas distintos del inglés. Comuníquesecon el número de nuestro Servicio de Atención al Cliente, indicado anteriormente,para obtener más información.
Page 5 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
PRESCRIPTION DRUG BENEFITS
Drugs Covered Under Medicare Part DGeneralThis plan uses a formulary. The plan will sendyou the formulary. You can also see the
Most drugs are not covered under OriginalMedicare. You can add prescription drugcoverage to Original Medicare by joining aMedicare Prescription Drug Plan, or you can
OutpatientPrescription Drugs
formulary at http://www.unicare.com/medicare on the web.
get all your Medicare coverage, includingprescription drug coverage, by joining aMedicare Advantage Plan or a Medicare CostPlan that offers prescription drug coverage.
Different out-of-pocket costs may apply forpeople who
have limited incomes,live in long term care facilities, orhave access to Indian/Tribal/Urban (IndianHealth Service) providers.
$47.90 monthly premium
Most people will pay their Part D premium.However, some people will pay a higherpremium because of their yearly income (over$85,000 for singles, $170,000 for marriedcouples). For more information about Part Dpremiums based on income, call Medicare at1-800-MEDICARE (1-800-633-4227). TTYusers should call 1-877-486-2048. You mayalso call Social Security at 1-800-772-1213.TTY users should call 1-800-325-0778.
The plan offers national in-networkprescription coverage (i.e., this would include50 states and the District of Columbia). Thismeans that you will pay the same cost-sharingamount for your prescription drugs if you getthem at an in-network pharmacy outside ofthe plan's service area (for instance when youtravel).
If you have any questions about this plan's benefits or costs, please contactUniCare for details
Section II:
Summary of Benefits
Page 6 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Total yearly drug costs are the total drug costspaid by both you and a Part D plan.
The plan may require you to first try one drugto treat your condition before it will coveranother drug for that condition.
Some drugs have quantity limits.
Your provider must get prior authorizationfrom MedicareRx Rewards Standard (PDP)for certain drugs.
You must go to certain pharmacies for a verylimited number of drugs, due to specialhandling, provider coordination, or patienteducation requirements that cannot be metby most pharmacies in your network. Thesedrugs are listed on the plan's website,formulary, printed materials, as well as on theMedicare Prescription Drug Plan Finder onMedicare.gov.
If the actual cost of a drug is less than thenormal cost-sharing amount for that drug,you will pay the actual cost, not the highercost-sharing amount.
If you request a formulary exception for a drugand MedicareRx Rewards Standard (PDP)approves the exception, you will pay Tier 4:Non-Preferred Brand cost sharing for thatdrug.
In-Network$310 deductible on all drugs except Tier 1:Preferred Generic drugs.
Initial CoverageAfter you pay your yearly deductible, you paythe following until total yearly drug costsreach $2,850:
Retail PharmacyContact your plan if you have questions aboutcost-sharing or billing when less than aone-month supply is dispensed.
OutpatientPrescription Drugs(continued)
Page 7 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
You can get drugs from a preferred andnon-preferred pharmacy the following way(s):
Tier 1: Preferred Generic$1 copay for a one-month (30-day) supplyof drugs in this tier from a preferredpharmacy$2 copay for a two-month (60-day) supplyof drugs in this tier from a preferredpharmacy$3 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$9 copay for a one-month (30-day) supplyof drugs in this tier from a non-preferredpharmacy$18 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$27 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy
Tier 2: Non-Preferred Generic$4 copay for a one-month (30-day) supplyof drugs in this tier from a preferredpharmacy$8 copay for a two-month (60-day) supplyof drugs in this tier from a preferredpharmacy$12 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$12 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$24 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$36 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy
OutpatientPrescription Drugs(continued)
Page 8 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Tier 3: Preferred Brand$38 copay for a one-month (30-day)supply of drugs in this tier from a preferredpharmacy$76 copay for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy$114 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$43 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$86 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$129 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy
Tier 4: Non-Preferred Brand$89 copay for a one-month (30-day)supply of drugs in this tier from a preferredpharmacy$178 copay for a two-month (60-day)supply of drugs in this tier from a preferredpharmacy$267 copay for a three-month (90-day)supply of drugs in this tier from a preferredpharmacy$94 copay for a one-month (30-day)supply of drugs in this tier from anon-preferred pharmacy$188 copay for a two-month (60-day)supply of drugs in this tier from anon-preferred pharmacy$282 copay for a three-month (90-day)supply of drugs in this tier from anon-preferred pharmacy
OutpatientPrescription Drugs(continued)
Page 9 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Tier 5: Injectable Drugs25% coinsurance for a one-month(30-day) supply of drugs in this tier froma preferred pharmacy25% coinsurance for a two-month(60-day) supply of drugs in this tier froma preferred pharmacy25% coinsurance for a three-month(90-day) supply of drugs in this tier froma preferred pharmacy25% coinsurance for a one-month(30-day) supply of drugs in this tier froma non-preferred pharmacy25% coinsurance for a two-month(60-day) supply of drugs in this tier froma non-preferred pharmacy25% coinsurance for a three-month(90-day) supply of drugs in this tier froma non-preferred pharmacy
Tier 6: Specialty Tier25% coinsurance for a one-month(30-day) supply of drugs in this tier froma preferred pharmacy25% coinsurance for a one-month(30-day) supply of drugs in this tier froma non-preferred pharmacy
Long-Term Care PharmacyLong term care pharmacies must dispensebrand name drugs in amounts less than a 14days supply at a time. They may also dispenseless than a month's supply of generic drugs ata time. Contact your plan if you havequestions about cost-sharing or billing whenless than a one-month supply is dispensed.
You can get drugs the following way(s):
Tier 1: Preferred Generic$9 copay for a one-month (34-day) supplyof drugs in this tier
OutpatientPrescription Drugs(continued)
Page 10 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Tier 2: Non-Preferred Generic$12 copay for a one-month (34-day)supply of drugs in this tier
Tier 3: Preferred Brand$43 copay for a one-month (34-day)supply of drugs in this tier
Tier 4: Non-Preferred Brand$94 copay for a one-month (34-day)supply of drugs in this tier
Tier 5: Injectable Drugs25% coinsurance for a one-month(34-day) supply of drugs in this tier
Tier 6: Specialty Tier25% coinsurance for a one-month(34-day) supply of drugs in this tier
Mail OrderContact your plan if you have questions aboutcost-sharing or billing when less than aone-month supply is dispensed.
You can get drugs the following way(s):
Tier 1: Preferred Generic$1 copay for a one-month (30-day) supplyof drugs in this tier$2 copay for a two-month (60-day) supplyof drugs in this tier$2 copay for a three-month (90-day)supply of drugs in this tier
Tier 2: Non-Preferred Generic$4 copay for a one-month (30-day) supplyof drugs in this tier$8 copay for a two-month (60-day) supplyof drugs in this tier$8 copay for a three-month (90-day)supply of drugs in this tier
OutpatientPrescription Drugs(continued)
Page 11 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Tier 3: Preferred Brand$38 copay for a one-month (30-day)supply of drugs in this tier$114 copay for a two-month (60-day)supply of drugs in this tier$114 copay for a three-month (90-day)supply of drugs in this tier
Tier 4: Non-Preferred Brand$89 copay for a one-month (30-day)supply of drugs in this tier$267 copay for a two-month (60-day)supply of drugs in this tier$267 copay for a three-month (90-day)supply of drugs in this tier
Tier 5: Injectable Drugs25% coinsurance for a one-month(30-day) supply of drugs in this tier25% coinsurance for a two-month(60-day) supply of drugs in this tier25% coinsurance for a three-month(90-day) supply of drugs in this tier
Tier 6: Specialty Tier25% coinsurance for a one-month(30-day) supply of drugs in this tier
Coverage GapAfter your total yearly drug costs reach$2,850, you receive limited coverage by theplan on certain drugs. You will also receive adiscount on brand name drugs and generallypay no more than 47.5% for the plan's costsfor brand drugs and 72% of the plan's costsfor generic drugs until your yearlyout-of-pocket drug costs reach $4,550.
Catastrophic CoverageAfter your yearly out-of-pocket drug costsreach $4,550, you pay the greater of:
5% coinsurance, or
OutpatientPrescription Drugs(continued)
Page 12 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
$2.55 copay for generic (including branddrugs treated as generic) and a $6.35 copayfor all other drugs.
Out-of-NetworkPlan drugs may be covered in specialcircumstances, for instance, illness whiletraveling outside of the plan's service areawhere there is no network pharmacy. You mayhave to pay more than your normalcost-sharing amount if you get your drugs atan out-of-network pharmacy. In addition, youwill likely have to pay the pharmacy's fullcharge for the drug and submitdocumentation to receive reimbursement fromMedicareRx Rewards Standard (PDP).
You can get out-of-network drugs thefollowing way:
Out-of-Network Initial CoverageAfter you pay your yearly deductible, you willbe reimbursed up to the plan's cost of the drugminus the following for drugs purchasedout-of-network until your total yearly drugcosts reach $2,850:
Tier 1: Preferred Generic$9 copay for a one-month (30-day) supplyof drugs in this tier
Tier 2: Non-Preferred Generic$12 copay for a one-month (30-day)supply of drugs in this tier
Tier 3: Preferred Brand$43 copay for a one-month (30-day)supply of drugs in this tier
Tier 4: Non-Preferred Brand$94 copay for a one-month (30-day)supply of drugs in this tier
OutpatientPrescription Drugs(continued)
Page 13 – MedicareRx Rewards Standard (PDP)
MedicareRx Rewards Standard(PDP)
Original MedicareBenefit
Tier 5: Injectable Drugs25% coinsurance for a one-month(30-day) supply of drugs in this tier
Tier 6: Specialty Tier25% coinsurance for a one-month(30-day) supply of drugs in this tier
You will not be reimbursed for the differencebetween the Out-of-Network Pharmacycharge and the plan's In-Network allowableamount.
Out-of-Network Coverage GapYou will be reimbursed up to 28% of the planallowable cost for generic drugs purchasedout-of-network until total yearly out-of-pocketdrug costs reach $4,550. Please note that theplan allowable cost may be less than theout-of-network pharmacy price paid for yourdrug(s).
You will be reimbursed up to 52.5% of theplan allowable cost for brand name drugspurchased out-of-network until your totalyearly out-of-pocket drug costs reach $4,550.Please note that the plan allowable cost maybe less than the out-of-network pharmacyprice paid for your drug(s).
Out-of-Network Catastrophic CoverageAfter your yearly out-of-pocket drug costsreach $4,550, you will be reimbursed fordrugs purchased out-of-network up to theplan's cost of the drug minus your cost share,which is the greater of:
5% coinsurance, or$2.55 copay for generic (including branddrugs treated as generic) and a $6.35 copayfor all other drugs.
You will not be reimbursed for the differencebetween the Out-of-Network Pharmacy
