2017 Group Retiree Medicare Plans

Transcription

1 2017 Group Retiree Medicare Plans Standard Health Maintenance Organization (HMO) Plans Empire BlueCross BlueShield is an HMO and PDP plan with a Medicare contract. Enrollment in Empire BlueCross BlueShield depends on contract renewal. Y0114_17_27233_I_001 03/29/ NYEENMUB_001

2 HMO Plans Help offset your retirees liability expenses by offering one of our Medicare Advantage plans. The Financial Accounting Standards Board (FASB) and Government Accounting Standards Boards (GASB) accounting regulations define the way you book retiree benefit liabilities and can have a dramatic negative impact on your financial statements. Offer your retirees choices. Choose from a number of products based on your location. Offer a health and drug plan or a health-only plan. Offer your retirees coverage that helps them improve the quality of their lives. Our health plans offer preventive care benefits and additional coverage not offered under Medicare. Our Health and Wellness program takes a holistic approach, focusing on helping retirees reach and maintain optimum health. Your retirees can count on our associates to provide timely, accurate answers to their questions. Your retirees have access to tools and health information that can improve their quality of life at every stage. include: - Help with connecting members with their doctor - 24/7 nurse information help line - Savings and discounts through <SpecialOffers SM - SilverSneakers Fitness program 1 nation s leading fitness program designed specifically for active older adults, dedicated to helping seniors reach their health goals - LiveHealth Online See a board-certified doctor on your smartphone, tablet or computer with a Web camera 24 hours a day, 365 days a year. When your doctor isn t readily available, see a doctor online for conditions such as colds, flu, even infections. Retirees can also schedule a future online appointment with a psychologist or social worker, if they need to discuss feelings of depression, stress or anxiousness (mood). Contents Standard Medicare Advantage HMO Plans (Plan 0, Plan 5, Plan 10 High, Plan 10 Low Inpatient... 1 Outpatient... 1 Preventive Care and Screening Tests... 3 Additional... 4 Foreign Travel... 4 Standard Medicare Advantage HMO Plans (Plan 15, Plan 20 High, Plan 20 Low, Plan 25 Inpatient... 5 Outpatient... 5 Preventive Care and Screening Tests... 7 Additional... 8 Foreign Travel... 8 Prescription Drug Plans The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. SilverSneakers is a registered mark of Healthways, Inc. > select employer groups link

3 Medicare Plan 0 Plan 5 Plan 10 High Plan 10 Low Out-of-Pocket Maximum Not applicable $3,000 maximum $3,400 maximum $3,000 maximum $3,400 maximum Inpatient Hospital Medical and Substance Abuse (First 60 days) $1,288 deductible Days Days $322 copay per day $644 copay per day $50 per admission $150 per admission $0 per admission $350 per admission Days 151 and Over Part A benefits exhausted Inpatient Inpatient Psychiatric Hospital Subject to inpatient hospital deductible and copay $50 per admission $150 per admission $0 per admission $350 per admission Inpatient Copayment Maximum Not applicable $150 $450 Not applicable $1,050 Skilled Nursing Facility (100-day limit per benefit period) $0 copay for days 1 20 $161 copay per day for days $50 per admission $100 per admission $0 per admission $250 per admission Home Health Care 0% of the Medicare-approved amount Hospice Care/Respite Care for covered hospice services 5% of the Medicare-approved amount for covered respite care services Outpatient Medicare Part B Annual Deductible $166 deductible Not applicable Not applicable Not applicable Not applicable Primary Care Physician (PCP) Visits Specialist Visits $0 $5 $10 $10 $10 $25 $20 $30 1

4 Medicare Plan 0 Plan 5 Plan 10 High Plan 10 Low Chiropractic Services (Manual manipulation of the spine to correct subluxation) Podiatrist Nonroutine Footcare $10 $20 $20 $20 $10 $25 $20 $30 Podiatrist Routine Footcare (Up to 4 visits ) Not covered PCP: $0 Specialist: $10 PCP: $5 Specialist: $25 PCP: $10 Specialist: $20 PCP: $10 Specialist: $30 Mental Health Outpatient Professional 20%-40% of the Medicare-approved amount $0 $25 $20 $30 Outpatient (continued) Substance Abuse Outpatient Professional Outpatient (Nonemergency) Hospital or Surgical Center Ambulance Services Emergency Room $0 $25 $20 $30 $0 $100 $0 $150 $50 per trip $75 per trip $50 per trip $75 per trip $50, waived if admitted Urgent Care $10, waived if admitted $25, waived if admitted $20, waived if admitted $30, waived if admitted Physical, Occupational and Speech Therapy services $10 $25 $20 $30 Durable Medical Equipment (DME) Prosthetics 20% 20% 20% 20% 20% 20% 20% 20% Diabetic Supplies Glucose Monitors Supplies (Lancets & test strips) 20% 20% 20% 20% $10 per 30-day supply $10 per 30-day supply $10 per 30-day supply $10 per 30-day supply Insulin and Syringes Paid under Part D Paid under Part D Paid under Part D Paid under Part D Paid under Part D 2

5 Medicare Plan 0 Plan 5 Plan 10 High Plan 10 Low Outpatient (continued) Lab and X-rays Chemotherapy Part B Medications Radiation Therapy for covered lab services for covered X-ray services X-rays: $10 Complex X-rays and Diagnostic Tests: $50 X-rays: $25 Complex X-rays and Diagnostic Tests: $75 X-rays: $20 Complex X-rays and Diagnostic Tests: $100 X-rays: $30 Complex X-rays and Diagnostic Tests: $100 20% 20% 20% 20% 20% 20% 20% 20% $10 $25 $20 $30 Blood Member pays for first 3 pints. Over 3 pints 20% coinsurance Annual Wellness Visit Bone Mass Measurement Preventive Care and Screening Tests Colorectal Screening Immunizations (Flu, pneumonia and hepatitis B) Breast Cancer Screening (Mammograms) for covered hepatitis B vaccines, covered flu vaccines and pneumonia vaccines Cervical and Vaginal Cancer Screening for covered Pap services and covered pelvic exam services Prostate Cancer Screening Exam (For men age 50 and older) 3

6 Medicare Plan 0 Plan 5 Plan 10 High Plan 10 Low Additional Routine Hearing Exams (One exam $70 maximum benefit) Not covered Hearing Aids ($500 maximum benefit ) Routine Vision Exams (One exam $50 maximum Not covered benefit) Outpatient* Not covered $50, waived if admitted Foreign Travel Outside USA Emergency Care Urgent Care Inpatient* (60 days per lifetime) Not covered $50 per admission $150 per admission $0 per admission $350 per admission Outpatient* Not covered $10, waived if admitted $25, waived if admitted $20, waived if admitted $30, waived if admitted *Not subject to plan out-of-pocket maximum 4

7 Medicare Plan 15 Plan 20 High Plan 20 Low Plan 25 Plan 30 Out-of-Pocket Maximum Not applicable $3,400 maximum $3,000 maximum $5,000 maximum $6,000 maximum $6,500 maximum Inpatient Hospital Medical and Substance Abuse (First 60 days) $1,288 deductible Days Days $322 copay per day $644 copay per day $550 per admission $0 per admission $200 per day, days 1 5 for each admission $225 per day, days 1 5 for each admission $300 per day, days 1-5 for each admission Days 151 and Over Part A benefits exhausted Inpatient Inpatient Psychiatric Hospital Subject to inpatient hospital deductible and copay $550 per admission $0 per admission Inpatient Copayment Maximum Not applicable $1,650 Not applicable $200 per day, days 1 5 for each admission Subject to plan out-of-pocket maximum $225 per day, days 1 5 for each admission Subject to plan out-of-pocket maximum $300 per day, days 1-5 for each admission Subject to plan out-of-pocket maximum Skilled Nursing Facility (100-day limit per benefit period) Home Health Care $0 copay for days 1 20 $161 copay per day for days $275 per admission $0 per admission $300 per admission $400 per admission $500 per admission $0 Hospice Care/Respite Care for covered hospice services 5% of the Medicare-approved amount for covered respite care services Medicare Part B Annual Deductible $166 deductible Not applicable Not applicable Not applicable Not applicable Not applicable Outpatient Primary Care Physician (PCP) Visits Specialist Visits 20% of the Medicare-approved amount 20% of the Medicare-approved amount $15 $20 $20 $25 $30 $35 $30 $40 $45 $50 5

8 Medicare Plan 15 Plan 20 High Plan 20 Low Plan 25 Plan 30 Chiropractic Services (Manual manipulation of the spine to correct subluxation) Podiatrist Nonroutine Footcare $20 $20 $20 $20 $20 $35 $30 $40 $45 $50 Podiatrist Routine Footcare (Up to 4 visits ) Not covered PCP: $15 Specialist: $35 PCP: $20 Specialist: $30 PCP: $20 Specialist: $40 Not covered Not covered Mental Health Outpatient Professional 20%-4 $35 $30 $40 $40 $40 Outpatient (continued) Substance Abuse Outpatient Professional Outpatient (Nonemergency) Hospital or Surgical Center Ambulance Services Emergency Room $35 $30 $40 $40 $40 $200 $0 $200 $200 $250 $100 per trip $75 per trip $125 per trip $125 per trip $150 per trip $65, waived if admitted $65, waived if admitted $65, waived if admitted $65, waived if admitted $65, waived if admitted Urgent Care $35, waived if admitted $30, waived if admitted $40, waived if admitted $45, waived if admitted $50, waived if admitted Physical, Occupational and Speech Therapy Durable Medical Equipment (DME) Prosthetics $35 $30 $40 $40 $40 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% Diabetic Supplies Glucose Monitors Supplies (Lancets & test strips) 20% 20% 20% 20% 20% $10 per 30-day supply $10 per 30-day supply $10 per 30-day supply $10 per 30-day supply $10 per 30-day supply Insulin and Syringes Paid under Part D Paid under Part D Paid under Part D Paid under Part D Paid under Part D Paid under Part D 6

9 Medicare Plan 15 Plan 20 High Plan 20 Low Plan 25 Plan 30 Lab and X-rays for covered lab services 20% of the Medicare-approved amount for covered X-ray services X-rays: $35 Complex X-rays and Diagnostic Tests: $125 X-rays: $30 Complex X-rays and Diagnostic Tests: $125 X-rays: $40 Complex X-rays and Diagnostic Tests: $125 X-rays: $45 Complex X-rays and Diagnostic Tests: $125 X-rays: $50 Complex X-rays and Diagnostic Tests: $150 Outpatient (continued) Chemotherapy Part B Medications 20% of the Medicare-approved amount 20% of the Medicare-approved amount 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% Radiation Therapy 20% of the Medicare-approved amount $35 $30 $40 $45 $50 Blood Member pays for first 3 pints. Over 3 pints 20% coinsurance $0 Annual Wellness Visit $0 Bone Mass Measurement $0 Preventive Care and Screening Tests Colorectal Screening Immunizations (Flu, pneumonia and hepatitis B) Breast Cancer Screening (Mammograms) 0% of the Medicare-approved amount for covered hepatitis B vaccines, covered flu vaccines and pneumonia vaccines $0 $0 $0 Cervical and Vaginal Cancer Screening for covered Pap services and covered pelvic exam services $0 Prostate Cancer Screening Exam (For men age 50 and older) $0 7

10 Medicare Plan 15 Plan 20 High Plan 20 Low Plan 25 Plan 30 Additional Routine Hearing Exams (One exam $70 maximum benefit) Not covered $0 $0 $0 Not covered Not covered Hearing Aids ($500 maximum benefit ) Routine Vision Exams (One exam $50 maximum Not covered $0 benefit) Foreign Travel Outside USA Emergency Care Urgent Care Outpatient* Inpatient* (60 days per lifetime) Outpatient* Not covered Not covered $550 per admission $0 per admission Not covered $35, waived if admitted $30, waived if admitted $200 per day, days 1 5 for each admission $40, waived if admitted $225 per day, days 1 5 for each admission $45, waived if admitted $300 per day, days 1 5 for each admission $50, waived if admitted *Not subject to plan out-of-pocket maximum 8

11 Empire BlueCross BlueShield Medicare Part D Prescription Drug Plans Offer your retirees a plan that helps them stay healthy and keep their prescription costs affordable. Advances in medical and pharmacy treatments have helped to extend both life expectancy and quality of life. Still, with all the advances, according to the Centers for Medicare & Medicaid Services (CMS), hypertension, high cholesterol, heart disease and diabetes are highly prevalent, and most Medicare beneficiaries have multiple chronic conditions. The effects of multiple chronic conditions on a retiree can be devastating physically, emotionally, socially and financially. (Source: CMS.gov, Chronic Conditions, 2013.) We offer plenty of choices to meet your retirees drug coverage needs. ¾ Choose from a continuum of Medicare Part D formularies. ¾ Choose from one of our standard plans, or work with your account executive to customize a plan for your needs. Coverage that goes beyond paying claims All of our plans are designed to offer benefits above and beyond what retirees can get from Original Medicare. But that s just the beginning. Our mail-order pharmacies offer quality maintenance medications delivered directly to members homes. For added support, our full-service specialty pharmacies connect seniors dealing with chronic, complex conditions with an expansive specialty medication support program that includes patient care advisors, registered nurses and clinical pharmacists. These teams help improve communication between doctors and their patients, and provide an additional level of support not available through a retail pharmacy. To help improve therapy outcomes for Medicare Part D participants who have chronic diseases or conditions, we offer a comprehensive Medicare Part D Medication Therapy Management (MTM) program. MTM programs are central to Medicare prescription drug plans and strongly supported by Centers for Medicare & Medicaid Services (CMS). Our MTM program: ¾ Encourages optimal medication use to help manage conditions, including diabetes and heart disease. ¾ Provides information on clinically recognized dosing, administration techniques, drug interactions and typical side effects. ¾ Identifies retirees with possible adherence issues and works with the retiree and the retiree s physician to address the issues. ¾ Is available to qualified members at no additional cost. retirees can count on from a trusted source Providing health care solutions to America s retiree population isn t new to us we ve been serving retirees under individual plans for 40 years. All of our Customer Service staff serving our Medicare-eligible population is specially trained in handling the unique needs retirees may have. The charts on the following pages provide a high-level overview of the plans you can choose from for your retirees. > select employer groups link Preferred Retail Pharmacy Option Our Preferred Retail Pharmacy option offers group sponsors an opportunity to save costs while preserving a way for retirees to continue to pay the same copays. Most Standard Part D plans are now available with the Preferred Retail Pharmacy option. With this option, retirees pay the standard plan copay when they obtain their prescriptions from a preferred retail network pharmacy. If they choose to use a standard retail network pharmacy, their copay is $5 higher. Preferred retail pharmacies have agreed to provide additional discounts that reduce your cost. Preferred retail pharmacies include: CVS/pharmacy, Food Lion, Giant Eagle Pharmacy, Hannaford, Harris Teeter Supermarkets, Kroger, Shopko, Target, Walmart and their affiliates. Not all pharmacy chains are located in every state, and the list of preferred retail pharmacies can change each January. 9

12 Group Retiree Open Formulary Drug Plans with Extra Covered Drugs Drug Part D Defined Standard Plan 15/30/60 Full Gap*** 10/25/50 Full Gap [All Part D Coverage Phases N/A Select Drugs: $0 Select Drugs: $0] Deductible Phase* $400 $0 $0 Retail Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and true out-of-pocket [TrOOP]) 25% Generics: 51% Brands: 40% Generics: $15 Preferred Brands: $30 Non-Preferred Brands & Non-Formulary Drugs: $60 Generics: $10 Preferred Brands: $25 Non-Preferred Brands & Non-Formulary Drugs: $50 Mail-order Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and TrOOP) 25% Generics: 51% Brands: 40% Generics: $30 Preferred Brands: $60 Non-Preferred Brands & Non-Formulary Drugs:: $120 Generics: $20 Preferred Brands: $50 Non-Preferred Brands & Non-Formulary Drugs: $100 TrOOP Limit* (Member out-of-pocket, plus Coverage Gap Discount) $4,950 $4,950 $4,950 Catastrophic Coverage Phase* (After TrOOP has been met) Generics: $3.30 or 5%, whichever is greater Brands: $8.25 or 5%, whichever is greater Generics: 5% with a minimum of $3.30 and maximum of $15 Brands: 5% with a minimum of $8.25 and maximum of $30 Generics: 5% with a minimum of $3.30 and maximum of $10 Brands: 5% with a minimum of $8.25 and maximum of $25 Retail 30-day supply 30-day supply 30-day supply Supply Amounts Mail-order Extra Covered Drugs** (Medicare-excluded drugs) Cough & cold DESI Vitamins & minerals Lifestyle 90-day supply Generics: 100% of all drug costs Brands: 100% of all drug costs 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies * The Medicare Part D limits can change on an annual basis. These limits are defined by Centers for Medicare & Medicaid Services (CMS). ** Costs for Extra Covered Drugs do not count toward the member s Medicare Part D limits, and these drugs do not qualify for the lower catastrophic coverage copays and coinsurance amounts. *** Not available with Preferred Pharmacy option. Coverage Gap Discount Program: If the member is not receiving help to pay their share of drug costs through the Low-Income Subsidy or PACE programs, the member qualifies for the Medicare Coverage Gap Discount Program. For prescriptions filled in 2017, once the cost paid by the member and this retiree drug plan reaches $3,700, the cost share the member pays will reflect all benefits provided by this retiree drug coverage and the Coverage Gap Discount. The Coverage Gap Discount applies until the cost paid by the member and the Discount reaches $4,950. The Medicare Coverage Gap Discount Program reduces the cost of providing your group-sponsored retiree drug coverage. Drug Manufacturers have agreed to provide a discount on brand drugs which Medicare considers Part D-qualified drugs. These plans cover some brand drugs beyond those covered by Medicare. The discount will not apply to benefits described in the Extra Covered Drugs section of this chart. 10

13 Group Retiree Open Formulary Drug Plans with Extra Covered Drugs Drug Part D Defined Standard Plan 10/20/40 Full Gap 5/25/40 Full Gap [All Part D Coverage Phases N/A Select Drugs: $0 Select Drugs: $0] Deductible Phase* $400 $0 $0 Retail Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and true out-of-pocket [TrOOP]) 25% Generics: 51% Brands: 40% Generics: $10 Preferred Brands: $20 Non-Preferred Brands & Non-Formulary Drugs: $40 Generics: $5 Preferred Brands: $25 Non-Preferred Brands & Non-Formulary Drugs: $40 Mail-order Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and TrOOP) 25% Generics: 51% Brands: 40% Generics: $20 Preferred Brands: $40 Non-Preferred Brands & Non-Formulary Drugs:: $80 Generics: $5 Preferred Brands: $50 Non-Preferred Brands & Non-Formulary Drugs: $80 TrOOP Limit* (Member out-of-pocket, plus Coverage Gap Discount) $4,950 $4,950 $4,950 Catastrophic Coverage Phase* (After TrOOP has been met) Generics: $3.30 or 5%, whichever is greater Brands: $8.25 or 5%, whichever is greater Generics: 5% with a minimum of $3.30 and maximum of $10 Brands: 5% with a minimum of $8.25 and maximum of $20 Generics: 5% with a minimum of $3.30 and maximum of $5 Brands: 5% with a minimum of $8.25 and maximum of $25 Retail 30-day supply 30-day supply 30-day supply Supply Amounts Mail-order Extra Covered Drugs** (Medicare-excluded drugs) Cough & cold DESI Vitamins & minerals Lifestyle 90-day supply Generics: 100% of all drug costs Brands: 100% of all drug costs 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies * The Medicare Part D limits can change on an annual basis. These limits are defined by Centers for Medicare & Medicaid Services (CMS). ** Costs for Extra Covered Drugs do not count toward the member s Medicare Part D limits, and these drugs do not qualify for the lower catastrophic coverage copays and coinsurance amounts. Coverage Gap Discount Program: If the member is not receiving help to pay their share of drug costs through the Low-Income Subsidy or PACE programs, the member qualifies for the Medicare Coverage Gap Discount Program. For prescriptions filled in 2017, once the cost paid by the member and this retiree drug plan reaches $3,700, the cost share the member pays will reflect all benefits provided by this retiree drug coverage and the Coverage Gap Discount. The Coverage Gap Discount applies until the cost paid by the member and the Discount reaches $4,950. The Medicare Coverage Gap Discount Program reduces the cost of providing your group-sponsored retiree drug coverage. Drug Manufacturers have agreed to provide a discount on brand drugs which Medicare considers Part D-qualified drugs. These plans cover some brand drugs beyond those covered by Medicare. The discount will not apply to benefits described in the Extra Covered Drugs section of this chart. 11

14 Group Retiree Comprehensive Closed Formulary Drug Plans with Extra Covered Drugs Drug Part D Defined Standard Plan 15/45/80 Full Gap*** 10/30/60 Full Gap 5/10/20 Full Gap [All Part D Coverage Phases N/A Select Drugs: $0 Select Drugs: $0 Select Drugs: $0] Deductible Phase* $400 $0 $0 $0 Retail Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and TrOOP) 25% Generics: 51% Brands: 40% Generics: $15 Preferred Brands: $45 Non-Preferred Brands: $80 Generics: $10 Preferred Brands: $30 Non-Preferred Brands: $60 Generics: $5 Preferred Brands: $10 Non-Preferred Brands: $20 Mail-order Pharmacy Initial Coverage Phase* (After deductible, up to $3,700 in drug costs) Gap Coverage Phase (Coverage between the member s Initial Coverage limit and TrOOP) 25% Generics: 51% Brands: 40% Generics: $30 Preferred Brands: $90 Non-Preferred Brands: $160 Generics: $20 Preferred Brands: $60 Non-Preferred Brands: $120 Generics: $10 Preferred Brands: $20 Non-Preferred Brands: $40 True Out-Of-Pocket (TrOOP) Limit* (Member out-of-pocket, plus Coverage Gap Discount) $4,950 $4,950 $4,950 $4,950 Catastrophic Coverage Phase* (After TrOOP has been met) Generics: $3.30 or 5%, whichever is greater Brands: $8.25 or 5%, whichever is greater Generics: 5% with minimum of $3.30 and maximum of $15 Brands: 5% with minimum of $8.25 and maximum of $45 Generics: 5% with minimum of $3.30 and maximum of $10 Brands: 5% with minimum of $8.25 and maximum of $30 Generics: 5% with minimum of $3.30 and maximum of $5 Brands: 5% with minimum of $8.25 and maximum of $10 Retail 30-day supply 30-day supply 30-day supply 30-day supply Supply Amounts Mail-order Extra Covered Drugs** (Medicare-excluded drugs) Cough & cold DESI Vitamins & minerals Lifestyle 90-day supply Generics: 100% of all drug costs Brands: 100% of all drug costs 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies 90-day supply except for Specialty Drugs which are limited to a 30-day supply and member pays a 30-day retail copay Generics: Retail and Mail-order copay applies Brands: Retail and Mail-order copay applies * The Medicare Part D limits can change on an annual basis. These limits are defined by Centers for Medicare & Medicaid Services (CMS). ** Costs for Extra Covered Drugs do not count toward the member s Medicare Part D limits, and these drugs do not qualify for the lower catastrophic coverage copays and coinsurance amounts. *** Not available with Preferred Pharmacy option. Coverage Gap Discount Program: If the member is not receiving help to pay their share of drug costs through the Low-Income Subsidy or PACE programs, the member qualifies for the Medicare Coverage Gap Discount Program. For prescriptions filled in 2017, once the cost paid by the member and this retiree drug plan reaches $3,700, the cost share the member pays will reflect all benefits provided by this retiree drug coverage and the Coverage Gap Discount. The Coverage Gap Discount applies until the cost paid by the member and the Discount reaches $4,950. The Medicare Coverage Gap Discount Program reduces the cost of providing your group-sponsored retiree drug coverage. Drug Manufacturers have agreed to provide a discount on brand drugs which Medicare considers Part D-qualified drugs. These plans cover some brand drugs beyond those covered by Medicare. The discount will not apply to benefits described in the Extra Covered Drugs section of this chart. 12

15 Notes that Apply to All Standard Part D Plans 1) If a member purchases drugs at any retail or mail-order pharmacy that is not listed in our participating pharmacy directory, the member will be responsible for all amounts over our negotiated cost. 2) Extra Covered Drug benefits are non-medicare supplemental benefits. The costs for these drugs do not count toward the Medicare Part D limits (initial coverage limit and TrOOP). 3) Vaccines may be obtained and administered from the pharmacy or doctor s office. One copay will be applied for the purchase and administration of a vaccine, even if billed separately. Members will be liable for any provider charges over our negotiated administration allowance. 4) Medicare limits (initial coverage limit, TrOOP and catastrophic copays) change each calendar year. The limits shown apply to 2017 benefits. 5) The Group Medicare plans shown in this brochure include Medicare Part D drug benefits and non-medicare supplemental drug benefits. CMS approves the Medicare Part D benefits and for insured coverage, the non-medicare supplemental benefits are approved by your state insurance department. Members only need to use one ID card to access all benefits at a network retail or mail-order pharmacy. Medicare parameters for January 1, 2017, as of April This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply., premiums and/or copayments/coinsurance may change upon renewal or on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. Services provided by Empire HealthChoice HMO, Inc., licensee of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans.