SUMMARY of BENEFITS $10/$25/$60/25% Group MedicareBlue SM Rx (PDP) S5743_073018GFF02_M Final 01
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1 2019 SUMMARY of BENEFITS $10/$25/$60/25% Group MedicareBlue SM Rx (PDP) January 1, 2019 December 31, 2019 S5743_073018GFF02_M Final 01
2 INTRODUCTION This guide is a summary of the prescription drug services covered by Group MedicareBlue Rx (PDP). This booklet includes an overview of our plan and pharmacy network, an easy-to-read chart on the plan s benefits and costs and contact information for customer service. WHAT S INCLUDED IN THIS SUMMARY OF BENEFITS? Benefit chart Frequently asked questions Get help in your language: multi-language interpreter services Here s how to learn more about the plan s benefits and costs: Visit YourMedicareSolutions.com/group Call toll-free, daily, 8 a.m. to 8 p.m., Central and Mountain times. TTY users should call 711.
3 SUMMARY OF BENEFITS Group MedicareBlue Rx $10/$25/$60/25% If you have any questions about the plan s benefits or costs, please contact Group MedicareBlue Rx Customer Service. Prescription drug benefits Initial coverage 30-day supply from a network pharmacy or 31-day supply from a long-term care facility 90-day supply from a network pharmacy or mail order Coverage gap Begins once your total drug costs for the year reach $3,820 Catastrophic coverage During this stage, you pay the following until your total yearly drug costs reach $3,820. 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. Tier Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) Tier Tier 1 (Generic) Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) Tier 4 (Specialty) 30-day supply $10 copay $25 copay $60 copay 25% coinsurance 90-day supply $20 copay $50 copay $120 copay 25% coinsurance You may get 90-day supplies of drugs from retail pharmacies for the same cost as mail order. These pharmacies are called extended day supply pharmacies and are identified in the pharmacy directory. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you must use an out-of-network pharmacy, you will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription. You can ask us to reimburse you for our share of the cost. (Please refer to Chapter 5, Section 2.1 of the Evidence of Coverage for details.) For 2019, during the coverage gap stage, you will pay no more than your usual cost sharing for generic and brand-name drugs. After your yearly out-of-pocket drug costs (including drugs you purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of: 5% of the total cost, or $3.40 copay for generic drugs (including brand drugs treated as generic) and $8.50 copay for all other drugs. 1
4 FREQUENTLY ASKED QUESTIONS Read below to find more information about the plan benefits, eligibility requirements and who to contact for additional questions. WHAT IS GROUP MEDICAREBLUE RX (PDP)? Group MedicareBlue Rx (PDP) is a Prescription Drug Plan that works with your Medicare benefits. This booklet explains what the plan covers and explains what costs you will pay as a member. Not all covered services are listed. To see a complete list of covered services, call and ask for the Evidence of Coverage. Or, visit YourMedicareSolutions.com/group to view the electronic version. CAN I JOIN? You must be entitled to Medicare Part A and/or enrolled in Part B and be identified as an eligible participant by your employer. ARE MY DRUGS COVERED? Check the formulary, also called a drug list, at YourMedicareSolutions.com/group and search for Group Formulary or call customer service. HOW MUCH WILL I NEED TO PAY FOR PRESCRIPTION DRUGS? The amount you pay depends on the tier the drug is on and the benefit stage you have reached. Your costs for each drug tier and benefit stage are shown in the benefit chart in this document. WHICH PHARMACIES CAN I USE? In general, you will need to use the pharmacies in the plan s network to fill your prescriptions. You can find the list of pharmacies for this plan at YourMedicareSolutions.com/ GroupPharmacy. Or call us and we will send you a Pharmacy Directory. WHAT ARE THE DRUG TIERS? Our plan places a drug into one of four tiers. Check the 2019 formulary to find out which tier your drug is on. Tier 1: Generic Drugs This tier is the lowest tier and generally contains the lowest cost generics. Tier 2: Preferred Brand This tier contains preferred brand drugs and some non-preferred generic drugs. Tier 3: Non-Preferred Brand This tier contains non-preferred brand drugs and some non-preferred generic drugs. Tier 4: Specialty This tier contains very high cost brand and generic drugs, which may require special handling and/or close monitoring. WANT TO LEARN MORE ABOUT ORIGINAL MEDICARE? The Medicare & You handbook explains what Original Medicare covers and the costs you may pay. You can view the handbook online at medicare.gov or call MEDICARE ( ) to get a copy. TTY users should call You can call 24 hours a day, seven days a week. 2
5 NOTICE OF RIGHTS NONDISCRIMINATION AND ACCESSIBILITY Group MedicareBlue SM Rx (PDP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Group MedicareBlue Rx does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Group MedicareBlue Rx: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o 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: o Qualified interpreters o Information written in other languages If you need these services, call customer service at , daily, 8:00 a.m. to 8:00 p.m. Central and Mountain times (TTY: 711). If you believe that Group MedicareBlue Rx 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 in writing to: Group MedicareBlue Rx Compliance Officer 1750 Yankee Doodle Road, S120 Eagan, MN You can file a grievance by mail. If you need help filing a grievance, the Group MedicareBlue Rx Compliance Officer is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, through one of the following methods: Electronically through the Office of Civil Rights Complaint Portal By Mail By Phone (TDD) U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC
6 Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). Cushite: XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Chinese: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Laotian: ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Amharic: ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). Karen: ymol.ymo;= erh>uwdraund AusdmtCd<AerRM>Ausdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM. vdriaud; (TTY: 711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Mon-Khmer, Cambodian: របយ តន ស នជ អនកន យ យ ភ ស ខមរ, សវ ជ ន ផនកភ ស ដ យម នគ តឈន ល គ អ ចម នស រ ប ប រ អនក ច រ ទ រស ពទ (TTY: 711) Arabic: (711 ) French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: 711). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). 4
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8 This information is not a complete description of benefits. Call (TTY: 711) for more information. Group MedicareBlue SM Rx (PDP) is a Medicare-approved Part D sponsor. Enrollment in Group MedicareBlue Rx depends on renewal of the plan sponsor s contract with Medicare. Coverage is available to members of an employer or union group and separately issued by one of the following plans: Wellmark Blue Cross and Blue Shield of Iowa,* Blue Cross and Blue Shield of Minnesota,* Blue Cross and Blue Shield of Montana,* Blue Cross and Blue Shield of Nebraska,* Blue Cross Blue Shield of North Dakota,* Wellmark Blue Cross and Blue Shield of South Dakota,* and Blue Cross Blue Shield of Wyoming.* *Independent licensees of the Blue Cross and Blue Shield Association. RAS1071R13 (09/18)
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