Medicare Part D Prescription Drug Plan The value you expect with exclusive Costco savings... in a plan that s easy to use and understand That s the Aetna Medicare Rx Costco Plus Plan (PDP) Enroll at www.aetnamedicare.com/costco Other pharmacies are available in our network
Costco has teamed up with Aetna to offer a Medicare Part D Prescription Drug Plan With over 40 years of experience serving people eligible for Medicare, Aetna knows what you re looking for when it comes to your Medicare Prescription Drug Plan. You want it to be affordable. You want it to include the prescription drugs that matter to you most. And you want it to be easy to understand and easy to use. And with over 30 years of experience in delivering value, Costco knows how to offer exclusive features and savings that its members expect. Get the most value with special cost savings when you fill your prescriptions at one of Costco s hundreds of U.S. pharmacies.* In addition, you ll also have access to Aetna s pharmacy network with more than 60,000 pharmacies nationwide. Copays are higher when you fill your prescriptions at other Aetna network pharmacies. * Costco Warehouse membership not required.
Aetna Medicare Rx Costco Plus Plan (PDP) Medicare Prescription Drug Coverage Initial Coverage Limit Amount you pay for covered prescriptions until costs for you and the plan reach $2,840: Special savings when you fill your Costs at other Aetna Medicare Rx Mail order prescriptions at a Costco pharmacy* network pharmacies delivery** 1 Month Supply 3 Month Supply 1 Month Supply 3 Month Supply 3 Month Supply Tier 1 Preferred generic (most plan generics are on this tier) $2 copay $5 copay $4 copay $12 copay $12 copay Tier 2 Non preferred generic $20 copay $50 copay $25 copay $75 copay $60 copay Tier 3 Preferred brand $25 copay $62.50 copay $30 copay $90 copay $75 copay Tier 4 Non preferred brand $60 copay $150 copay $65 copay $195 copay $180 copay Tier 5 Specialty 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance 25% coinsurance Enhanced Benefit The plan includes supplemental benefit coverage for Tier 1 generic benzodiazepines and barbiturates, prescription drugs not covered by Medicare Part D (NOTE: These non Part D drugs do not count toward satisfying your deductible, initial coverage limit, or true out of pocket expenses) Coverage Gap Amount you pay after your initial coverage limit and until your true out-of-pocket expenses reach $4,550: Coverage continues for Tier 1 generic benzodiazepines and barbiturates at the same copays shown above For all other covered drugs, you receive a discount on brand name drugs and pay only 93% of the costs of generic drugs Catastrophic Coverage Amount you pay after your true out-of-pocket expenses reach $4,550: The greater of $2.50 copay for generic prescription drugs (including brand drugs treated as generic), $6.30 copay for all other covered prescription drugs OR 5% coinsurance The Aetna Medicare Rx Costco Plus Plan (PDP) is available to residents of Alaska, Arizona, California, Colorado, Florida, Hawaii, Idaho, Illinois, Michigan, Nevada, New Mexico, New York, Ohio, Oregon, Utah, Virginia, and Washington. * Fill your prescriptions at any U.S. Costco pharmacy location for preferred pharmacy savings. Costco Warehouse membership is not required. ** Prescription mail order costs are for preferred providers of service, Costco Mail Order Pharmacy or Aetna Rx Home Delivery. Costs may be more for non preferred providers. Enroll at www.aetnamedicare.com/costco Monthly plan premiums vary by region. Please refer to the plan s Summary of Benefits for the monthly plan premium in your service area.
The Aetna Medicare Rx Costco Plus plan gives you the following benefits $0 deductible start saving right away More than 90% of covered generics are available at the lowest copay Coverage for most Medicare approved Part D prescription drugs Mail order delivery service for your convenience Enhanced coverage for generic benzodiazepines and barbiturates prescription drugs not covered by Medicare Part D and offers special cost savings on your prescription drugs at Costco pharmacies. Other pharmacies are available in our network Learn more about the Aetna Medicare Rx Costco Plus Plan (PDP) benefits, costs, and covered drugs, and enroll by: Visiting our website at www.aetnamedicare.com/costco Or calling our toll-free number 1-888-260-7630 (TTY/TDD 1-888-760-4748), 8 am to 8 pm, 7 days a week. Medicare beneficiaries may enroll in the Aetna Medicare Rx Costco Plus Plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov or by calling Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies (Aetna). The benefit information provided herein is a brief summary, not a comprehensive 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 January 1, 2012. You must be entitled to Medicare Part A or B and continue to pay your Part B premium and Part A, if applicable. Medicare beneficiaries may enroll in a plan only during specific times of the year. To obtain additional information, please contact Aetna Medicare at 1 800 213 4599 (TTY/TDD 1 888 760 4748), from 8 am to 8 pm, 7 days a week. In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non routine circumstances. Pharmacy clinical programs such as prior authorization, step therapy, and quantity limits may apply to your prescription drug coverage. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1 800 MEDICARE (1 800 633 4227) (TTY users should call 1 877 486 2048), 24 hours a day, 7 days a week; the Social Security Office at 1 800 772 1213 between 7 am and 7 pm, Monday through Friday (TTY users should call 1 800 325 0778); or your Medicaid office. This material is for informational purposes only. Not all health services are covered. See plan documents for a complete description of benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by location and are subject to change. Aetna receives rebates from drug manufacturers that may be taken into account in determining Aetna s Preferred Drug List. Rebates do not reduce the amount a member pays the pharmacy for covered prescriptions. Providers are independent contractors and are not agents of Aetna. Provider participation may change without notice. Aetna does not provide care or guarantee access to health services. Translation of this material into another language may be available. For assistance, please call Member Services at: 1 800 213 4599 (TTY/TDD 1 888 760 4748. Puede estar disponible la traducción de este material en otro idioma. Para ayuda, por favor llame a Servicios al Miembro al: 1 800 213 4599 (TTY/TDD: 1 888 760 4748). A Medicare approved Part D sponsor 2010 Aetna Inc. S5810_D_PE_MM_00723 CMS Approved 08/11/2010