2015 Summary of Benefits

Transcription

1 P.O. Box 52424, Phoenix, AZ Summary of Benefits sponsored by Shell (a Medicare Prescription Drug Plan (PDP) offered by SilverScript Insurance Company with a Medicare contract) January 1, 2015 December 31, 2015 Y0080_52001_SB_CLT_2015_9439_2429_801

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3 SECTION 1 Introduction to Summary of Benefits You have choices about how to get your Medicare prescription drug benefits One choice is to get prescription drug coverage through a Medicare Prescription Drug Plan, like sponsored by Shell. Another choice is to get your prescription drug coverage through a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans. Please note: This prescription coverage is offered in conjunction with your medical coverage. If you choose a Medicare prescription drug plan other than sponsored by Shell, you will need to seek medical coverage at your own expense. Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call To get a complete list of our benefits, please call and ask for the Evidence of Coverage. Sections in this booklet Things to Know About Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at , 24 hours a day, 7 days a week. TTY users should call Este documento está disponible en otros formatos tales como Braille y en letras grandes. Este documento podría estar disponible en un idioma distinto al inglés. Para obtener información adicional, llámenos al , las 24 horas del día, los 7 días de la semana. Los usuarios de teléfono de texto (TTY) deben llamar al Things to Know About Hours of Operation You can call us 24 hours a day, 7 days a week. Local time. Phone Numbers If you are a member of this plan, call toll-free TTY users should call If you are not a member of this plan, call toll-free TTY users should call

4 Who can join? To join, you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, and live in our service area. Our service area includes the following: is available in the United States and its territories. Which drugs are covered? To see the complete plan formulary (list of Part D prescription drugs) and any restrictions call Customer Care and we will send you a copy of the formulary. Shell has elected to cover certain drugs not covered under Medicare Part D as described and dispensed as part of an additional benefit. These are not subject to the appeals and exceptions process. Please contact Customer Care for any questions regarding your additional benefit. How will I determine my drug costs? Our plan groups each medication into one of four tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur:, Coverage Gap, and Catastrophic Coverage. Please note: Your employer provides additional coverage that may differ in structure from the primary benefit and also cover additional medications. There may be instances where your cost share may be more or less when it is paid by the additional coverage. If you are unsure about the cost share on the additional coverage or which drugs may or may not be covered, please call Customer Care to verify drug coverage. Which pharmacies can I use? We have a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. If you use an out-of-network pharmacy, we will reimburse you your total cost minus your cost share amount for the drug. You must submit a paper claim in order to be reimbursed. You may be able to save on your maintenance medications by changing your 30-day refills to 90-day supplies at Preferred Pharmacies. If you re currently taking any long-term medicines, you can continue to fill your 30-day refills. However, you may save by changing your 30-day refills to lower-cost 90-day supplies. Filling one 90-day at a preferred pharmacy can sometimes cost you less than three 30-day refills of the same prescription. Choose from two 90-day refill options for the same low price. Option 1: Refill at any CVS/pharmacy. Fill your 90-day at any CVS/pharmacy location and pick up your medicines at your convenience. Option 2: Refill with CVS Caremark Mail Service Pharmacy. Have a 90-day of your long term medicines shipped to your home. To see our plan's pharmacy directory call Customer Care and we will send you a copy. If you have any questions about this plan s benefits or costs, please contact SilverScript for details.

5 Section II Summary of Benefits Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Please contact your former employer group, union, or trust for more information about the premium for this plan. This plan does not have a deductible. Prescription Drug Benefits You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Retail Cost-Sharing (cont.) Tier Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) Up to a 34-day Up to a 68-day Up to a 90-day $5.00 copay $10.00 copay $10.00 copay $50.00 copay $ copay $90.00 copay $70.00 copay $ copay $ copay Applicable Brand / Generic Co-Pay copay Applicable Brand / Generic Co-Pay copay Applicable Brand / Generic Co-Pay copay

6 Standard Retail Cost-Sharing (cont.) Tier Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) Up to a 34-day Up to a 68-day Up to a 90-day $5.00 copay $10.00 copay $15.00 copay $50.00 copay $ copay $ copay $70.00 copay $ copay $ copay Applicable Brand/Generic Co-pay copay Applicable Brand/Generic Co-pay copay Applicable Brand/Generic Co-pay copay Mail Order Cost-Sharing (cont.) Tier Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) Up to a 34-day Up to a 68-day Up to a 90-day $10.00 copay $10.00 copay $10.00 copay $90.00 copay $90.00 copay $90.00 copay $ copay $ copay $ copay of the total cost N/A N/A Long Term Care (LTC) Cost-Sharing (cont.) Tier Up to a 31-day Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) $5.00 copay $50.00 copay $70.00 copay Applicable Brand/Generic Co-pay copay

7 Coverage Gap Your former employer, union, or trust will provide additional coverage that will keep your copays/coinsurance consistent through the Coverage Gap, therefore you will see no change in copays until you qualify for Catastrophic Coverage. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost, or $2.65 copay for generic (including brand drugs treated as generic) (no greater than $5 for up to a 30-day ) and a $6.60 copayment for all other drugs (no greater than $60 for up to 30-day ). This information is available for free in other languages. Please call our Customer Care number at (TTY: ), 24 hours a day, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Servicio al Miembro, al (teléfono de texto (TTY): ), las 24 horas del día, los 7 días de la semana. You must continue to pay your Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on 01/01/2016. is a Prescription Drug Plan. This plan is offered by SilverScript Insurance Company, which has a Medicare contract. Enrollment depends on contract renewal.

8 P.O. Box 52424, Phoenix, AZ Important Plan Information Información Importante Sobre el Plan