For Alabamians who want an affordable, stand-alone Medicare Part D Prescription Drug Plan Plan Highlights. S1030_MKT3_BRO_17 Accepted

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1 For Alabamians who want an affordable, stand-alone Medicare Part D Prescription Drug Plan Plan Highlights S1030_MKT3_BRO_17 Accepted

2 Medicare Part D is a government benefit that helps cover your costs for prescription drugs. You must enroll in a private insurance plan like BlueRx (PDP) to receive Part D benefits. There are four stages (or phases) of coverage: STAGE 1 Deductible Phase The deductible is the amount you pay before plan benefits begin. STAGE 2 Initial Coverage Phase You pay a share of the cost for each prescription after you reach the deductible, until the total Rx spending reaches $3,700 in STAGE 3 Coverage Gap Phase Most plans have a coverage gap or donut hole that starts after you and the plan reach the Initial Coverage Limit. In the gap, you pay 51% of generic drug costs and 40% of brand-name drug costs. STAGE 4 Catastrophic Coverage Phase Once your out-of-pocket spending reaches the limit ($4,950 in 2017), you pay a small amount for the rest of the year (your plan pays the rest). See how your two BlueRx plan options work on the enclosed chart.

3 Here s what you can expect to pay for prescriptions with BlueRx: BlueRx Option I BlueRx Option II Monthly Plan Premium* $69.70 $ Deductible Phase What you spend for prescriptions before BlueRx benefits begin. Deductible $330 $0 (NO deductible) Initial Coverage Phase What you pay for prescriptions after you reach the deductible (if any), until TOTAL prescription spending (by you and BlueRx) reaches $3,700. Preferred Cost-Sharing Pharmacy Copays/Coinsurance Tier 1 Preferred Generic $5 $2 Tier 2 Non-Preferred Generic $10 $8 Tier 3 Preferred Brand $37 $37 Tier 4 Non-Preferred Brand 40% 40% Tier 5 Specialty Tier 26% 33% Standard Cost-Sharing Pharmacy Copays/Coinsurance Tier 1 Preferred Generic $15 $12 Tier 2 Non-Preferred Generic $20 $18 Tier 3 Preferred Brand $47 $47 Tier 4 Non-Preferred Brand 50% 50% Tier 5 Specialty Tier 26% 33% Coverage Gap Phase Once the TOTAL prescription annual spending exceeds $3,700 and YOUR spending is below $4,950, you pay 51% of generic drug costs and 40% of brand-name drug costs. Catastrophic Coverage Phase Once YOUR out-of-pocket spending on prescriptions reaches $4,950, you pay the greater of $3.30 for generic drugs and $8.25 for brand-name drugs OR 5% coinsurance per prescription for the rest of the year. BlueRx pays the rest. *You must continue to pay your Medicare Part B premium. Some BlueRx (PDP) covered drugs may be subject to prior authorization, step therapy or have quantity limits.

4 HerHere e BlueRx (PDP) is prescription drug coverage that can be paired with a C Plus Medicare Select plan or purchased as a stand-alone plan. BlueRx covers the medications people with Medicare use most often: Like all Part D plans, BlueRx has a list of covered drugs (formulary) generic, brand-name and specialty prescription drugs. Covered drugs are assigned to one of five tiers, which determines the amount you pay (your copay). Choose from two BlueRx plan options: BlueRx Option I BlueRx Option II Covers all Medicare-approved Covers all Medicare-approved prescription drugs, prescription drugs. plus an expanded formulary that includes more Has a lower monthly premium with brand-name drugs. a $330 deductible in 2017 that There is no deductible. You pay as little as $2 per must be met before benefits begin. prescription from the start. Nationwide pharmacy network: With BlueRx, you ll have access to more than 63,000 pharmacies nationwide, including major national chains like Walgreens and Walmart. Enjoy preferred cost-sharing with BlueRx: In addition to a nationwide network of pharmacies, both BlueRx options offer preferred cost- sharing benefits. Preferred cost sharing means you have lower copays if you get your prescriptions filled at selected pharmacies more than 850 here in Alabama. Not only will you pay less for your 30-day supply of medication, but you can get a 90-day supply of your prescription drugs with just two times the copay (instead of three). It s like getting 30 days for FREE. Mail-order pharmacy service is available: You can save both time and money by having your prescriptions delivered right to your door and you get free shipping, too! Our mail-order suppliers can fill a 90-day prescription for your routine medications, and you pay only the copay for a 60-day supply. You may qualify for extra help to pay for BlueRx. People with limited income and resources may qualify for extra help to lower their prescription drug costs. If you qualify, your monthly plan premium will be lower, your copays will be lower, and you will have no coverage gap. Many people are eligible for these savings and don t realize it. To see if you qualify for extra help, you can call: Medicare MEDICARE ( ) TTY users: hours a day, 7 days a week Social Security Administration TTY users: a.m. to 7 p.m., Monday - Friday Alabama Medicaid Agency TTY users: medicaid.alabama.gov Or you can contact the Alabama State Health Insurance Assistance Program (SHIP). This organization provides education and counseling on low-income assistance programs for people with Medicare. Call toll free AGE-LINE ( ). TTY: BlueRx gives you the peace of mind, convenience and value that you expect from Blue Cross and Blue Shield of Alabama. Whichever BlueRx option you choose, you ll rest easy knowing you have the coverage you need at a price you can afford, with access to our nationwide network of more than 63,000 pharmacies.

5 You can enroll in BlueRx (PDP) if you are both: An Alabama resident Entitled to Medicare Part A and/or enrolled in Part B A BlueRx plan can be purchased as a stand-alone plan, which you would need with Original Medicare. Or, it can be paired with a C Plus Medicare Select plan. If you have questions about our plans or need help enrolling: Call toll-free: (TTY 711), 8 a.m. to 8 p.m., 7 days a week.* Or visit us online at: * From February 15 to September 30, on weekends and holidays, you may be required to leave a message. Calls will be returned the next business day. BlueRx (PDP) is a Medicare-approved Part D plan. Enrollment in BlueRx (PDP) depends on contract renewal. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. To the extent of any discrepancy between this document and your Evidence of Coverage/Contract Booklet, your Evidence of Coverage/Contract Booklet takes priority. Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. BlueRx s pharmacy network offers limited access to pharmacies with preferred cost sharing in Alabama. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred cost sharing, please call (TTY 711) or consult the online pharmacy directory at Members may enroll in BlueRx only during specific times of the year. For more information about enrollment periods, call toll free (TTY 711), 8 a.m. to 8 p.m., 7 days a week. You may be enrolled in only one Part D plan at a time. Medicare beneficiaries who are enrolled in a MA PFFS plan that includes Medicare prescription drugs or any MA coordinated care (HMO or PPO) plan will be automatically disenrolled from the HMO, PPO or MA PFFS plan if they enroll in a PDP. Medicare beneficiaries enrolled in a Private Fee-for-Service plan (PFFS) that does not include Medicare prescription drug coverage, a MA Medical Savings Account (MSA) plan or an 1876 Cost plan may enroll in a PDP and will not be automatically disenrolled from the PFFS, MSA or an 1876 Cost plan. Medicare beneficiaries may also enroll in BlueRx through the CMS Medicare Online Enrollment Center located at Blue Cross and Blue Shield of Alabama is an Independent Licensee of the Blue Cross and Blue Shield Association. 6770(10/16)BRxBR