Summary of Benefits January 1, 2017 December 31, 2017
|
|
- Rosa Baldwin
- 6 years ago
- Views:
Transcription
1 Pennsylvania Northeastern and West Virginia Pennsylvania BLUE RX PDP Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. This document is available in other formats such as Braille and large print. Service Area Our service area includes: All counties in Pennsylvania and West Virginia. 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. You can see our plan s pharmacy directory at To join Blue Rx PDP Plus or Blue Rx PDP Complete, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Or, call us at (TTY/TDD ), 8:00 a.m. 8:00 p.m., 7 days a week, and we will send you a copy of the pharmacy directory. More About Original Medicare 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 S5593_16_0478 Accepted
2 Blue Rx PDP Blue Rx PDP Plus Blue Rx PDP Complete Premium1 $95.10 $ Deductible $400 $0 Initial Coverage Preferred Retail Standard Retail Preferred Mail Standard Mail Coverage Gap Catastrophic Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and your Part D plan. After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and your Part D plan. Tier 1 (Preferred Generic) $0 Copay $0 Copay Tier 1 (Preferred Generic) $0 Copay $0 Copay Tier 2 (Generic) $2 Copay $6 Copay Tier 2 (Generic) $5 Copay $15 Copay Tier 3 (Preferred Brand) 15% of the cost 15% of the cost Tier 3 (Preferred Brand) $40 Copay $120 Copay Tier 4 (Non-Preferred Brand) 40% of the cost 40% of the cost Tier 4 (Non-Preferred Brand) 35% of the cost 35% of the cost Tier 1 (Preferred Generic) $5 Copay $15 Copay Tier 1 (Preferred Generic) $5 Copay $15 Copay Tier 2 (Generic) $7 Copay $21 Copay Tier 2 (Generic) $10 Copay $30 Copay Tier 3 (Preferred Brand) 25% of the cost 25% of the cost Tier 3 (Preferred Brand) $45 Copay $135 Copay Tier 4 (Non-Preferred Brand) 50% of the cost 50% of the cost Tier 4 (Non-Preferred Brand) 50% of the cost 50% of the cost Tier 1 (Preferred Generic) Not Offered $0 Copay Tier 1 (Preferred Generic) Not Offered $0 Copay Tier 2 (Generic) Not Offered $5 Copay Tier 2 (Generic) Not Offered $12.50 Copay Tier 3 (Preferred Brand) Not Offered 15% of the cost Tier 3 (Preferred Brand) Not Offered $100 Copay Tier 4 (Non-Preferred Brand) Not Offered 40% of the cost Tier 4 (Non-Preferred Brand) Not Offered 35% of the cost Tier 1 (Preferred Generic) Not Offered $12.50 Copay Tier 1 (Preferred Generic) Not Offered $12.50 Copay Tier 2 (Generic) Not Offered $17.50 Copay Tier 2 (Generic) Not Offered $25 Copay Tier 3 (Preferred Brand) Not Offered 25% of the cost Tier 3 (Preferred Brand) Not Offered $ Copay Tier 4 (Non-Preferred Brand) Not Offered 50% of the cost Tier 4 (Non-Preferred Brand) Not Offered 50% of the cost The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan s cost for covered brand-name drugs and 51% of the plan s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics and a $8.25 Copayment for all other drugs. The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan s cost for covered brand-name drugs and 51% of the plan s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. Not everyone will enter the coverage gap. See Additional Table Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $4,950, you pay the greater of: 5% of the cost, or $3.30 Copay for generics and a $8.25 Copayment for all other drugs. If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
3 How to Contact CALL BLUE RX PDP (TTY/TDD ), 8:00 a.m. 8:00 p.m., 7 days a week OR VISIT BLUE RX PDP COMPLETE COVERAGE GAP STANDARD RETAIL COST SHARING Preferred Network Tier 1 (Preferred Generic) All 26% of the cost 26% of the cost Tier 2 (Generic) All 26% of the cost 26% of the cost Standard Network Tier 1 (Preferred Generic) All 31% of the cost 31% of the cost Tier 2 (Generic) All 31% of the cost 31% of the cost STANDARD MAIL ORDER COST SHARING Preferred Network Tier 1 (Preferred Generic) All Not Offered 26% of the cost Tier 2 (Generic) All Not Offered 26% of the cost Standard Network Tier 1 (Preferred Generic) All Not Offered 31% of the cost Tier 2 (Generic) All Not Offered 31% of the cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
4 1You 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. Benefits, premiums and/or co-payments/ co-insurance 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. HM Health Insurance Company is a PDP plan with a Medicare contract. Enrollment is HM Health Insurance Company depends on contract renewal. Highmark Blue Shield and HM Health Insurance Company are independent licensees of the Blue Cross and Blue Shield Association.
5 Discrimination is Against the Law The Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact the Civil Rights Coordinator. If you believe that the Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Civil Rights Coordinator, P.O. Box 22492, Pittsburgh, PA 15222, Phone: , TTY: 711, Fax: , CivilRightsCoordinator@highmarkhealth.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, the Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at O65_BS_G_P_1Col_12pt_blk_Web
6 O65_BS_G_P_1Col_12pt_blk_Web
7 O65_BS_G_P_1Col_12pt_blk_Web
2018 Community Blue Medicare PPO Summary of Benefits
2018 Community Blue Medicare PPO Summary of Benefits Residents of the following counties: Allegheny, Beaver, Butler, Erie, Greene, Fayette, Washington, Westmoreland, please click here. Residents of the
More informationSummary of Benefits. Community Blue Medicare HMO. Western Pennsylvania. January 1, 2018 December 31, Service Area
Western Pennsylvania Community Blue Medicare HMO Summary of Benefits January 1, 2018 December 31, 2018 Service Area Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong,
More informationSummary of Benefits. Tufts Medicare Preferred PDP PLANS Employer Group Tufts Medicare Preferred PDP3
Tufts Medicare Preferred PDP PLANS 2018 Summary of Benefits Employer Group Tufts Medicare Preferred PDP3 The benefit information provided is a summary of what we cover and that you pay. It does not list
More information(PDP) 2015 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)
(PDP) 2015 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard) Contract S5540, Plans 004 and 002 January 1, 2015 December 31, 2015 Y0079_6779 CMS Accepted 08312014 U5073b,
More information(PDP) 2016 Summary of benefits for our Medicare prescription drug plans (Standard and Enhanced)
(PDP) 2016 Summary of benefits for our Medicare prescription drug plans (Standard and Enhanced) Contract S5540, Plans 002 and 004 January 1, 2016 December 31, 2016 Y0079_7238 CMS Accepted 08312015 U5073g,
More information2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by The Coca-Cola Company () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract
More information2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by Shell () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract January
More informationHealth Options Program
Pennsylvania Public School Employees Retirement System (PSERS) Health Options Program 2017 Annual Notice of Changes You are currently enrolled as a member of the Enhanced, Basic or Value Medicare Rx Option.
More information2018 CareOregon Advantage Star (HMO) Summary of Benefits
2018 Summary of Benefits For Oregon counties: Clackamas, Columbia, Multnomah and Washington H5859_1099_CO_3018v3 CMS ACCEPTED CAREOREGON ADVANTAGE STAR (HMO) (A Medicare Advantage Health Maintenance Organization
More informationPrescription Drug Schedule Humana Medicare Employer Plan
PUB Name: GSB0012 2018 Prescription Drug Schedule Humana Medicare Employer Plan Rx 269 University of Richmond Y0040_GHHK48XEN18 (Pending CMS Approval) Rx 269 Let's talk about Humana Medicare Employer
More informationEnhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible. Blue Shield of California
An independent member of the Blue Shield Association Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) THIS DRUG COVERAGE
More informationSUMMARY OF BENEFITS E0654_19SBSBP
2019 SUMMARY OF BENEFITS JANUARY 1, 2019 DECEMBER 31, 2019 E0654_19SBSBP FI755 TEAMStar MEDICARE PART D PRESCRIPTION DRUG PROGRAM (PDP) (a Medicare Prescription Drug plan (PDP) offered by the International
More informationParticipating Pharmacy 9 Non-Participating Pharmacy 7,8
Rx Spectrum $10/25/40 - $20/50/80 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) Highlight: $0 Calendar Year Pharmacy Deductible $10 Tier 1 / $25 Tier 2
More information2019 Summary of Benefits
2019 Summary of Benefits Jan. 1, 2019 Dec. 31, 2019 888-645-6025 TTY 711 Seven Days a Week, 8 A.M. to 8 P.M.(Oct. 1, 2018, to Mar. 31, 2019) Monday-Friday, 8 A.M. to 8 P.M. (All Other Times) (PDP) (PDP)
More information2019 Summary of Benefits
Connecticut Massachusetts Rhode Island Vermont Blue MedicareRx (PDP) 2019 Summary of Benefits Independent Licensees of the Blue Cross and Blue Shield Association. S2893_1846_M (a Medicare Prescription
More informationSummary of Benefits. Allwell Medicare (HMO) Bexar County, TX H Benefits effective January 1, 2018 H0062_18_2962SB_Accepted
2018 Summary of Benefits Bexar County, TX H0062 -- 001 Benefits effective January 1, 2018 H0062_18_2962SB_Accepted 09102017 This booklet provides you with a summary of what we cover and your cost-sharing.
More informationSummary of Benefits. Allwell Medicare (HMO) Palm Beach, Manatee, Marion and Seminole Counties, Florida H
2018 Summary of Benefits Palm Beach, Manatee, Marion and Seminole Counties, Florida H9276-003 Benefits effective January 1, 2018 H9276_18_2860SB_A Accepted 09172017 This booklet provides you with a summary
More informationHumana Medicare Employer Plan
GHHHWTDEN_18_NMRHCA Humana Medicare Employer Plan Plans that go the extra mile MILE Humana Medicare Advantage At Humana, we help you understand the many aspects of Medicare and try to make your options
More informationSYMPHONIX RITE AID VALUE RX (PDP)
SYMPHONIX RITE AID VALUE RX (PDP) and SYMPHONIX RITE AID PREMIER RX (PDP) (a Medicare Prescription Drug plan (PDP) offered by SYMPHONIX HEALTH INSURANCE, INC. with a Medicare contract) Summary of Benefits
More information2018 Summary of Benefits
2018 Summary of Benefits Benton, Crawford, Sebastian, Washington Counties, AR H9630--001 Benefits effective January 1, 2018 H9630_18_2913SB Accepted 09302017 This booklet provides you with a summary of
More information2018 Summary of Benefits
2018 Summary of Benefits Hamilton, Howard, and Marion counties, Indiana H3499--001 Benefits effective January 1, 2018 H3499_18_3257SB_A Accepted 09172017 This booklet provides you with a summary of what
More informationSummary of Benefits. Allwell Medicare (HMO) Duval, Lake, Pinellas, Polk and Volusia Counties, Florida H H9276_18_2858SB _A Accepted
2018 Summary of Benefits Duval, Lake, Pinellas, Polk and Volusia Counties, Florida H9276-001 Benefits effective January 1, 2018 H9276_18_2858SB _A Accepted 09172017 This booklet provides you with a summary
More informationSummary of Benefits. Allwell Medicare (HMO) Cameron and Hidalgo counties, TX H
2018 Summary of Benefits Allwell Medicare (HMO) Cameron and Hidalgo counties, TX H0062 -- 003 Benefits effective January 1, 2018 H0062_18_2965SB_Accepted 09102017 This booklet provides you with a summary
More information2018 Summary of Benefits
2018 Summary of Benefits Allwell Medicare Select (HMO) Benton, Washington counties, AR H9630--003 Benefits effective January 1, 2018 H9630_18_2915SB Accepted 09302017 This booklet provides you with a summary
More informationSummary of Benefits. Allwell Medicare Premier (HMO) Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H
2018 Summary of Benefits Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H9276-002 Benefits effective January 1, 2018 H9276_18_2859SB_B_Accepted 10032017 This booklet provides you
More informationEffective January 1 December 31, Summary of Benefits. Blue Shield Rx Plus (PDP) Blue Shield Rx Enhanced (PDP) blueshieldca.com/findamedicareplan
Effective January 1 December 31, 2018 Summary of Benefits Blue Shield Rx Plus (PDP) Blue Shield Rx Enhanced (PDP) blueshieldca.com/findamedicareplan S2468_17_217A_003_004 Accepted 08252017 We all have
More informationSummary Of Benefits January 1, December 31, 2019
Summary Of Benefits January 1, 2019 - December 31, 2019 Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the
More informationSummary of Benefits. Community Blue Medicare Plus PPO. Northeastern Pennsylvania. January 1, 2018 December 31, Service Area
Northeastern Pennsylvania Community Blue Medicare Plus PPO Summary of Benefits January 1, 2018 December 31, 2018 Service Area Our service area includes the following counties in Pennsylvania: Clinton,
More information2019 Allwell Medicare (HMO) H2915: 003 Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset,
2019 Allwell Medicare (HMO) H2915: 003 Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland Counties, PA H2915_19_8120SB_003_M
More information2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA
2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA H2915_19_8121SB_005_M Accepted 09072018 This booklet
More informationAnnual Notice of Changes for 2018
Brand New Day Classic Choice for Medi-Medi (HMO) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Classic Choice for Medi-Medi. Next year, there will
More information2018 Summary of Benefits
2018 Summary of Benefits Ascension, East Baton Rouge, Livingston, West Baton Rouge, and Tangipahoa Parishes, LA H5117--001 Benefits effective January 1, 2018 H5117_18_2922SB Accepted 09302017 This booklet
More information2019 Allwell Medicare (HMO) H7173: 002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties, GA
2019 Allwell Medicare (HMO) H7173: 002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties, GA H7173_19_8074SB_002_M Accepted 09072018 This booklet provides you with a summary of what
More informationSummary of Benefits. Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H
2018 Summary of Benefits Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H0351 -- 049-001 Benefits effective January 1, 2018 H0351_18_3205SB_B_ Accepted 10142017 This booklet provides you
More informationAnnual Notice of Changes for 2018
Brand New Day Classic Care Drug Savings (HMO) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Classic Care. Next year, there will be some changes to
More information2019 Allwell Medicare (HMO) H Kane County, IL
2019 Allwell Medicare (HMO) H1475 -- 002 Kane County, IL H1475_19_7967SB_002_M Accepted 09282018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It does
More informationSummary of Benefits. Allwell Medicare Premier (HMO) Pinal County, Arizona H
2018 Summary of Benefits Allwell Medicare Premier (HMO) Pinal County, Arizona H0351 -- 043-004 Benefits effective January 1, 2018 H0351_18_3060SB_A_ Accepted 10142017 This booklet provides you with a summary
More informationCarePartners of Connecticut HMO Plans Buyer s Guide. Includes a chart comparing all HMO plan options
CarePartners of Connecticut HMO Plans 2019 Buyer s Guide Includes a chart comparing all HMO plan options Service Area: to join a CarePartners of Connecticut plan, you must live in our service area: Hartford,
More information2018 Summary of Benefits
2018 Summary of Benefits Barry, Christian, Greene, Jasper, Lawrence, and Newton Counties, MO H1664--001 Benefits effective January 1, 2018 H1664_18_2916SB Accepted 09302017 This booklet provides you with
More informationAnnual Notice of Changes for 2018
Brand New Day Harmony Choice for Medi-Medi (HMO SNP) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Harmony - Dual Access. Next year, there will be
More information2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX
2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX H0062_19_7952SB_002_M_Accepted 09072018 This booklet provides you with a summary of what we cover
More informationSummary of Benefits. Regence Medicare Script TM. Enhanced (PDP) Basic (PDP) Medicare Prescription Drug Plan for Utah
2013 Summary of Benefits Medicare Prescription Drug Plan for Utah Regence Medicare Script TM Enhanced (PDP) Regence Medicare Script TM Basic (PDP) Regence BlueCross BlueShield of Utah is an Independent
More informationCoverage Through Employer/Union name Grp# Last Name: First Name: Middle Initial: 9 F
PO Box 9178 Watertown, MA 02472 2019 Employer Group HMO Election Form Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille). DATE STAMP Please
More information2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA
2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA H0562_19_7914SB_112_M_Accepted 09072018 1 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities.
More informationsummary of benefits Blue Shield of California Medicare Rx Plan (PDP)
summary of benefits Blue Shield of California Medicare Rx Plan (PDP) An employer-sponsored Medicare Prescription Drug Plan for City and County of San Francisco retirees, spouses and eligible dependents
More informationPharmacy Benefits Member Guide
Commercial Pharmacy Benefits Member Guide Optimizing your pharmacy benefits for a healthier you Carol Kim, Health Net We focus on getting you the health information you need, when you need it. Understanding
More informationFarm Bureau Select Rx 2017 Summary of Benefits January 1, December 31, 2017
P.O. Box 266380 Weston, FL 33326 Farm Bureau Select Rx 2017 Summary of Benefits January 1, 2017 - December 31, 2017 Thank you for your interest in Farm Bureau Select Rx, Our plan is offered by Members
More information2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N
2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N McLarenHealthPlan.com/MedicareSupplement Call us toll-free (888) 327-0671, Monday - Friday from 8 a.m. 6 p.m.
More informationMedicare Made Simple. A guide to your health plan options
Medicare Made Simple A guide to your health plan options Introduction When you re eligible for Medicare, understanding and comparing all of your health plan options can be confusing. This guide describes
More informationSummary of Benefits. January 1, 2015 December 31, First Health Part D Premier Plus (PDP) S
January 1, 2015 December 31, 2015 Summary of Benefits S5768-167 S5768-131 80.06.370.1-NC Y0022_2015_S5768_167_131_NC Accepted 9/2014 Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives
More information2018 Summary of Benefits
2018 Summary of Benefits Abbeville, Allendale, Bamberg, Barnwell, Chester, Chesterfield, Clarendon, Dillon, Edgefield, Florence, Georgetown, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg,
More informationLVAIC-Muhlenberg College: Lehigh Valley Flex Blue PPO Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkblueshield.com or by calling 1-800-345-3806.
More informationFarm Bureau Essential Rx 2018 Summary of Benefits January 1, December 31, 2018
Farm Bureau Health Plans P.O. Box 266380 Weston, FL 33326 Farm Bureau Essential Rx 2018 Summary of Benefits January 1, 2018 - December 31, 2018 Thank you for your interest in Farm Bureau Essential Rx.
More information2019 Health Net Gold Select (HMO) H0562: Riverside and San Bernardino Counties, CA
2019 Health Net Gold Select (HMO) H0562:101-002 Riverside and San Bernardino Counties, CA H0562_19_7860SB_101_002_M_Accepted 09072018 1 This booklet provides you with a summary of what we cover and your
More informationWPAHS: Community Blue EPO Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at Highmarkbcbs.com or by calling 1-800-472-1506. Important
More informationINTRODUCTION TO SUMMARY OF BENEFITS
INTRODUCTION TO This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services
More information(PDP) 2014 Summary of benefits for our Medicare prescription drug plans (Enhanced and Standard)
(PDP) 2014 Summary of benefits for our prescription drug plans (Enhanced and Standard) Contract S5540, Plans 004 and 002 January 1, 2014 December 31, 2014 U5073c, 8/13 Y0079_6249 CMS Accepted 09112013
More informationPlan Comparison Chart. Includes medical and prescription drug (Rx) benefit information
Medicare Advantage (HMO) Plans 2019 Plan Comparison Chart Includes medical and prescription drug () benefit information Plan Comparison Chart HMO Saver or Basic plans may be a good fit if you: Are relatively
More informationSPECIAL ENROLLMENT PERIOD FORM
SPECIAL ENROLLMENT PERIOD FORM A Special Enrollment Period (SEP) is defined as a period during which you and your family have a right to sign up for new or make changes to existing health insurance coverage.
More information<Logo> 2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO
2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO H1664_19_7896SB_004_M_Accepted 09082018 This booklet provides you
More informationPlease contact Sharp Health Plan if you need information in another language or format (Braille).
2019 Sharp Direct Advantage SM Basic (HMO) & Sharp Direct Advantage SM Premium (HMO) Enrollment Form Completing your enrollment is your first step to becoming a Sharp Direct Advantage Medicare member.
More informationSummary of Benefits. My RxBLUE (PDP). Medicare prescription drug plan from the Cross and Shield 10MX0010 R1/11 S5937_091010AMFU
2011 Summary of Benefits 2011 My RxBLUE (PDP). Medicare prescription drug plan from the Cross and Shield 10MX0010 R1/11 S5937_091010AMFU Summary of Benefits for RxBLUE (PDP) January 1, 2011 December 31,
More information2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Vitality Health Plan of California (HMO) County and County H1426 001/002/003 H1426_19_078_MK_ENG_M H1426 001/002/003 Vitality Health Plan of California January 1, 2019 December
More information2010 Summary of Benefits S5601
P.O. Box 280200, Nashville, TN 37228 Contact SilverScript Insurance Company for more information about our plans NOTE: Please contact us if you have questions or concerns about our plans. representatives
More information2019 Health Net Ruby (HMO) H Lane County, OR
2019 Health Net Ruby (HMO) H6815-003-003 Lane County, OR H6815_19_8067SB_003_003_M Accepted 09072018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It
More information2011 Summary of Benefits
2011 Summary of Benefits (PDP) and January 1, 2011 December 31, 2011 BlueCross BlueShield of South Carolina contracts with the federal government. Contract # s5953 (PDP) s5953_pdp2011sb cms approved 08312010
More informationIndividual Enrollment Form
Please contact Peach State Health Plan if you need information in another language or format (Braille). To enroll in Peach State Health Plan, please provide the following information: Please check which
More information2018 Summary of Benefits
January 1 December 31, 2018 2018 Summary of Benefits Kaiser Permanente Medicare Advantage (HMO) for Federal Members High, Standard, and High Deductible Health Plan Options MA0001579-51-17 About this Summary
More information2019 Health Net Violet 2 (PPO) H Marion and Polk Counties, OR
2019 Health Net Violet 2 (PPO) H5439-014-003 Marion and Polk Counties, OR H5439_19_8049SB_014_003_M Accepted 09072018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities.
More informationMedicareBlue Rx a stand-alone prescription drug plan
MedicareBlue Rx a stand-alone prescription drug plan 2018 Step-by-step enrollment guide MedicareBlue SM Rx (PDP) S5743_090716_B04_RE CMS Approved 09/07/2017 Thank you for considering MedicareBlue Rx to
More informationHealth Options Program Option Selection Period FAQs
Health Options Program Option Selection Period FAQs The Health Options Program Q What is a Qualifying Event? A A Qualifying Event is what makes you eligible for enrollment in the Health Options Program.
More informationMedicare Made Simple. A guide to your health plan options
Medicare Made Simple A guide to your health plan options Introduction When you re eligible for Medicare, comparing all of your health plan options can be confusing. The truth is, it doesn t have to be.
More informationSummary of Benefits for Blue MedicareRx Standard SM (PDP), Blue MedicareRx Plus SM (PDP) and Blue MedicareRx Premier SM (PDP)
Summary of Benefits for Standard SM (PDP), Plus SM (PDP) and Premier SM (PDP) Available in Colorado A -approved Part D sponsor. Anthem Insurance Companies, Inc. (AICI) has contracted with the Centers for
More informationAlternate Phone Number: ( ) Address: Sex: 9 M ( ) 9 F. Permanent Residence Address (P.O. Box is not allowed): City: State: Zip Code:
PO Box 9178 Watertown, MA 02472 2018 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
More information2018 Individual Enrollment Request Form
2018 Individual Enrollment Request Form If you have questions, please contact AgeWell New York at: 1-866-586-8044 or TTY 1-800-662-1220 Fax Enrollment form to 1-855-895-0784 Please contact AgeWell New
More informationMA BENEFIT COMPARISON PLAN OPTIONS FOR MA-SMGP-COMP-1216
MA BENEFIT COMPARISON PLAN OPTIONS FOR -MA-SMGP-COMP-1216 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Copay Plans HMO Value Platinum - $0/$0 0/ $7000 5 5 CIF 0 $200 $40 $70
More information9 HMO Basic Rx $23.00 per month 9 HMO Value Rx $54.00 per month 9 HMO Prime Rx $79.00 per month 9 HMO Prime Rx Plus $99.
PO Box 9178 Watertown, MA 02472 2019 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
More informationNOTIFICATION FROM EMPLOYEE BENEFITS
NOTIFICATION FROM EMPLOYEE BENEFITS The Open Enrollment period will commence on November 1, 2017 and end on November 21, 2017. All changes made during this period will be effective January 1, 2018. If
More informationTufts Medicare Preferred Supplement. IMportant information. PO Box 9178 Watertown, MA 02472
Tufts Medicare Preferred Supplement 2018 Enrollment Application PO Box 9178 Watertown, MA 02472 IMportant information Please read the Important Information section, fill out the application on page 1,
More informationGROUP SUBMISSION STATUS
q New Business Current Client or Group No(s) q Product Changes: Add Change* Renew As Is Cancel Medical q q q q Vision q q q q Dental q q q q *Include enrollment forms to report changes, if not signed up
More informationPlease check which plan you want to enroll in: If you live in Litchfield, Hartford, New Haven, New London, Tolland, or Windham Counties: Sex: 9 M ( )
PO Box 9178 Watertown, MA 02472 2019 CarePartners of Connecticut (HMo) INDIVIDUAL ENROLLMENT FORM Please contact CarePartners of Connecticut if you need information in another language or format (Braille).
More informationAPPLICATION FOR NEW 2018 INDIVIDUAL/FAMILY PLAN HEALTH INSURANCE
APPLICATION FOR NEW 2018 INDIVIDUAL/FAMILY PLAN HEALTH INSURANCE This Application is for coverage during the calendar year 2018. PLEASE COMPLETE STEPS 1 6. If you are an insurance agent/producer, please
More informationMedicare Advantage HMO plans
2018 Medicare Advantage HMO plans Promise Rx (HMO-POS) Surety Rx (HMO-POS) Medicare coverage that works with and for you Y0117_MC-778-2822-C-10-17 approved Why choose a plan from Security Health Plan?
More information2019 Health Net Violet 1 (PPO) H5439: 011 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County,
2019 Health Net Violet 1 (PPO) H5439: 011 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County, WA H5439_19_8026SB_011_M Accepted 09072018 This booklet
More informationSummary of Benefits. Express Scripts Medicare. Value Choice S5660 & S5983. January 1, 2016 December 31, 2016
Express Scripts Medicare Value Choice (a Medicare prescription drug plan (PDP) offered by Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located
More informationFor Alabamians who want an affordable, stand-alone Medicare Part D Prescription Drug Plan Plan Highlights. S1030_MKT3_BRO_17 Accepted
For Alabamians who want an affordable, stand-alone Medicare Part D Prescription Drug Plan. 2017 Plan Highlights S1030_MKT3_BRO_17 Accepted Medicare Part D is a government benefit that helps cover your
More information2019 Short Enrollment Request
Page 1 of 7 Medicare Advantage HMO South Region 2019 Short Enrollment Request FOR OFFICE USE ONLY Member ID no. Effective date of coverage Election period individual is enrolling in: AEP SEP ICEP IEP OEPI
More informationAnnual Notice of Changes for 2018
VNSNY CHOICE Preferred (HMO SNP) offered by VNSNY CHOICE Medicare Annual Notice of Changes for 2018 You are currently enrolled as a member of VNSNY CHOICE Preferred. Next year, there will be some changes
More informationGranite Alliance Insurance Company (PDP) 2017 Annual Notice of Pharmacy Benefit Changes For DMBA Members
Granite Alliance Insurance Company (PDP) 2017 Annual Notice of Pharmacy Benefit Changes For DMBA Members You are currently enrolled as a member of DMBA s Medicare Prescription Drug Plan (PDP) through Granite
More informationREQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA 95741
More informationANNUAL NOTICE OF CHANGES FOR 2018
Cigna HealthSpring Rx Secure (PDP) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2018 You are currently enrolled as a member of Cigna HealthSpring Rx Secure (PDP). Next year, there will be
More informationHighmark Blue Cross Blue Shield: my Priority Blue Flex HMO 1700GQ Coverage Period: 01/01/ /31/2017
Coverage for: Individual/Family Plan Type: HMO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbs.com
More informationBlueMedicare Premier Rx (PDP) offered by Florida Blue
BlueMedicare Premier Rx (PDP) offered by Florida Blue Annual Notice of Changes for 2018 You are currently enrolled as a member of BlueMedicare Rx-Option 1 (PDP). Next year, there will be some changes to
More information2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA
2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA H0562_19_7815SB_045_M_Accepted 09072018 1 This booklet provides you with a summary of what we
More informationSummary of Benefits. Allwell Dual Medicare (HMO SNP)
2018 Summary of Benefits Allwell Dual Medicare (HMO SNP) Abbeville, Allendale, Bamberg, Barnwell, Beaufort, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield,
More informationHighmark Blue Cross Blue Shield: my Priority Blue Flex HMO 1000G Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.highmarkbcbs.com or by calling 1-888-510-1084. Important
More informationSummary Of Benefits. January 1, December 31, Blue Shield Promise TotalDual Plan (HMO SNP)
Summary Of Benefits Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the Blue Shield Association January 1,
More information2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs
2018 Plan Year Monthly Plan for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug
More informationSummary of Benefits. Aetna Medicare Rx Costco Plus Plan (PDP) S5810. California. January 1, 2010 to December 31, 2010
January 1, 2010 to December 31, 2010 Summary of Benefits Aetna Medicare Rx S5810 California S5810_D_PE_SB_90712 (08/2009) Visit us www.aetnamedicare.com 1 Summary of Benefits: Aetna Medicare Rx Section
More informationYou have from October 15 until December 7 to make changes to your Medicare coverage for next year.
Farm Bureau Essential Rx (PDP) offered by Farm Bureau Health Plans Annual Notice of Changes for 2019 You are currently enrolled as a member of Farm Bureau Essential Rx. Next year, there will be some changes
More information