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2 Hindi: Y0071_13_15045_U_015 CMS Accepted 30879MUSMLMUB_015

3 Thank you... for your interest in our prescription drug plans (PDPs). You deserve a prescription drug plan you can count on. One that gives you access to the medicines you need and to a pharmacy you know and rely on. With this in mind, here are the benefits our PDPs offer: Coverage for all formulary generic and brand-name drugs during the coverage gap, some generic drugs at a low copay Monthly premiums as low as $ Access to more than 54,000 network pharmacies across the country A choice of plans, with different premiums and formularies, to meet your benefit needs:, Plus (PDP), Gold (PDP) Have questions? Let s talk. To reach a licensed insurance agent, call: TTY/TDD 711, 8 a.m. to 8 p.m., seven days a week. Customer Service: TTY/TDD: 711, 8 a.m. to 8 p.m., seven days a week, October 1, 2012, to February 14, 2013; 8 a.m. to 8 p.m., Monday Friday, except holidays, February 15 to September 30, You must continue to pay your Medicare Part B premium. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year. Limitations, copayments and restrictions may apply. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Y0071_13_14988_R_001 CMS Approved 28187MUSENMUB_001 S CA us at Steve@SteveShorr.com 28187MUSENMUB 2012 Sales to get Brochure an OFFICIAL Blue PDP clean BK 03 unmarked 12 copy of this brochure or click link below if it's available online

4 Some good terms to know Before you move on, here are some of the common words you ll find in this booklet: -name drugs These are drugs that are developed by a company who holds the rights to sell them. When the rights expire, other drug companies can make their own version of the drugs (see generic drugs below). Coinsurance The percentage of cost you may have to pay for covered services or prescription drugs after you pay any plan deductibles. Copayment/copay The specific dollar amount you may have to pay for covered services or prescription drugs after you pay any plan deductibles. Deductible The amount you must pay for health care or prescriptions, before Original Medicare or other insurance begins to pay. Formulary This is a list of all the drugs your plan covers. The list tells you what tier your drug is in and if there are any requirements or limits for coverage. drugs s are simply copies of brand-name drugs. -name and generic drugs have the same active ingredients, strength and dose. The Food and Drug Administration requires that generic drugs meet the same standards for purity, quality, safety and strength. Premium The payment you make on a regular basis, usually monthly, to Medicare, an insurance company, or a health care plan for medical, hospital or prescription drug coverage. Prescription drug plan Offered by private insurers approved by Medicare to help pay for many brand-name and generic prescribed drugs. In this booklet, a prescription drug plan is also referred to as a PDP or Medicare Part D. A-2

5 Predict your drug costs with our prescription drug plans You ll find our prescription drug coverage helps pay for many brand-name and generic prescribed drugs. This will help you better predict and control your costs at the pharmacy. Take a look at the chart below for an overview of what you can expect to pay for a 30-day supply of your covered prescriptions at a network retail pharmacy. 1 Standard Plus Gold Premium: $41.30 Premium: $76.80 Premium: $ Deductible: $325 2 Deductible: $0 Deductible: $0 Initial Coverage Tier 1 Drugs: $2 copay $2 copay $2 copay begins after Preferred you pay your Tier 2 Drugs: $6 copay $7 copay $7 copay deductible (if you have one). In this stage, you will pay Tier 3 Drugs: $39 copay $45 copay $45 copay your copays or Preferred coinsurance. Tier 4 Drugs: $85 copay $90 copay $90 copay Tier 5 Drugs: 25% coinsurance $95 copay $95 copay Injectable Tier 6 Drugs: 25% coinsurance 33% coinsurance 33% coinsurance Specialty Coverage Gap begins after you and your plan have spent $2,970. While in the gap, what you pay for each drug will depend on the coverage your plan offers in the gap, any Extra Help you receive or if there are any discounts or assistance programs available for your drugs. Catastrophic Coverage begins after you have spent $4,750. In this stage, you will pay a small copay or coinsurance for your covered drugs for the remainder of the year. 1 Copays or coinsurance may be different for an extended days supply and at long-term care and mail-order pharmacies. 2 This plan includes a deductible. You will pay the full cost of your covered prescriptions up to this amount at the beginning of each year. Please review your Summary of Benefits carefully before you enroll. For additional plan details, please check the Summary of Benefits later in this booklet.

6 Is a prescription drug plan right for you? A prescription drug plan works with the following types of hospital and medical coverage: Original Medicare + Prescription Drug + + Original Medicare provides coverage for basic hospital (Part A) and medical expenses (Part B). Part D is offered by private insurers, and it helps pay for many prescription drugs. Original Medicare + Medicare Supplement + Prescription Drug Original Medicare provides coverage for basic hospital (Part A) and medical expenses (Part B). Medicare Supplement plans, offered by private insurers, can help pay your share of the expenses, such as deductibles and coinsurance, that Original Medicare does not fully cover. Part D is offered by private insurers, and it helps pay for many prescription drugs. If you haven t made a decision about your medical coverage, we suggest that you speak with your broker or sales representative. He or she can tell you more about your options. Note: When you sign up for Part D coverage, you automatically will be disenrolled (dropped) from any other Part D plan you are currently in, such as Medicare Advantage or another Part D plan. Just remember, you can only join or leave a plan at certain times during the year. A-4

7 When can you enroll? Initial enrollment period 7 months surrounding your Medicare eligibility: This is the 3 months before you turn 65, the month when you turn 65, and the 3 months after. st nd rd st nd rd 3 months before 3 months after Annual election period October 15 to December 7, The period you can enroll in or change your Medicare Advantage (MA) or Medicare Advantage prescription drug plan. This is also the period you can enroll in, change or disenroll from a Part D plan. You may also switch to Original Medicare. New coverage will begin January 1, Medicare Advantage disenrollment period January 1 to February 14, You may disenroll from your MA plan. During this time, you will be enrolled in Original Medicare and will have the option of choosing a stand-alone Part D plan. Special enrollment period (SEP) A common SEP applies if you are covered under an employer s or union s plan and will retire after 65. In this case, you can enroll with no penalty during the three months before your Part B takes effect. Other examples include: if you qualify for Medicare s Extra Help for Part D (see the Extra Help section later in this booklet), if you qualify for both Medicaid and Medicare, or if you have moved outside of the plan s service area. A-5

8 Some common questions about prescription drug plans While the benefits of having a PDP are pretty clear, some of the terms and details relating to these plans can be a little confusing. So here is some information that will help answer common questions: How do I find out if my drugs are covered? Typically, only drugs listed on the formulary are covered. Your plan will mail a formulary to you after you enroll and annually when it s time to renew your policy. From time to time, your plan may change the drugs on the formulary. If this should happen, we will let you know in writing by mail at least 60 days before the change takes place. What is a formulary? A formulary is a list of all the drugs your plan covers. The list tells you: Which drugs require prior authorization from your plan before you fill the prescription. What are formulary tiers? Every drug on the formulary is in a costsharing tier. What you pay for your prescription depends, in part, on which tier your drug is in. For example, Tier 1 usually includes preferred generic drugs with the lowest copay. As the tier number increases, the drugs in that tier generally cost you more than drugs in the lower-numbered tiers. See the Summary of Benefits later in this booklet for details on the tiers your plan has, including the copay or coinsurance amount for each tier. Need a full list of covered drugs or to find a pharmacy? Go to Or you may call us at our toll-free Customer Service number. We can tell you if your drugs are covered or help you find a pharmacy. If there is a quantity limit on the frequency, amount or dosage of certain drugs. If there are any requirements, such as trying other drugs first, called step therapy. The cost-sharing tier a drug is in. A-6

9 Some common questions... (continued) What is the coverage gap and how do you plan for it? The coverage gap is the coverage stage with the highest out-of-pocket costs for you. Understanding the coverage stages can help you plan for the coverage gap. How the coverage stages work: The initial coverage stage begins after you pay your deductible (if you have one). In this stage, you will pay your copays or coinsurance. If you and your plan, together, spend a certain amount on covered drugs, you will enter the coverage gap stage. What you pay will depend on the coverage your plan offers in the gap, as well as any Extra Help you receive, or assistance programs and discounts available for your drugs. When a certain amount has been spent on your covered drugs, you will leave the coverage gap. Then you will enter the catastrophic coverage stage. You will pay a small copay or coinsurance for your covered drugs for the remainder of the year. The Summary of Benefits later in this booklet lists the copay or coinsurance amounts for each coverage stage. Also, your plan will send an Explanation of Benefits (EOB) letter to you each month that you fill a prescription. The EOB will show which coverage stage you re in and how close you are to entering the next one. What factors affect what I pay? While coverage and costs differ with each Medicare drug plan, all plans offer at least Medicare s set standard level of coverage. Factors that can affect the cost of your drug plan are: Premiums and deductibles Your decision to use a network or out-of-network pharmacy If your drugs are on your plan s formulary What formulary tier your drugs are in Which coverage stage you are in If you get Medicare s Extra Help to pay for some of your Part D costs What can I do to help reduce my costs? Go generic. The Food and Drug Administration (FDA) requires generic drugs to meet the same safety and quality standards as brand-name drugs, but generics often cost less. Take covered drugs. Look your prescription up on the formulary to see if it is covered by your plan and has any requirements (such as prior authorization) before your plan will cover it. There may be other drug options that will work for you. And they may even cost less. Ask your doctor. A-7

10 Be in the know before you enroll in a prescription drug plan Eligibility To join a prescription drug plan: You must be entitled to Medicare Part A or enrolled in Medicare Part B (or you have both Parts A and B) and continue to pay your Medicare Part B premium. Your coverage can begin as soon as your effective date. You must live in the same service area of the drug plan you want to join. You cannot be enrolled in another Medicare prescription drug plan or a Medicare Advantage plan (HMO, PPO) at the same time. You can be enrolled if you are a member of a Medicare private-feefor-service (PFFS) plan or are enrolled in an 1876 Cost Plan (which does not include Part D coverage). Delayed enrollment may result in a late penalty It s wise to enroll in a PDP when you re first eligible for Medicare. If you wait to get Part D, you may end up paying a late enrollment penalty. When you join one of our PDPs, we will tell you if you owe a penalty and what your premium will be. The penalty fee becomes part of your premium as long as you are enrolled in a PDP, and it may even increase every year. At the same time, your Medicare Part B premium must continue to be paid either by you, Medicaid or another third party. Please note that if you cancel or don t renew your Part D coverage, and go 63 days or more without coverage, you will pay the late enrollment penalty when you do enroll again. However, you may not have to pay the late enrollment penalty if you receive Extra Help, or if you can provide proof of other creditable prescription drug coverage (for example, from an employer or union). A-8

11 Be in the know before you enroll... (continued) When you need Extra Help 1 If you qualify for Medicare s Extra Help and are enrolled in a Part D plan, Medicare can help by paying a percentage of your costs. If you qualify, you will get the following: Help paying for your drug plan s monthly premium, yearly deductible, coinsurance and copays for covered prescription drugs No coverage gap No late enrollment penalty Extra Help qualifications You will qualify for Extra Help if you have one of these: Both Medicare and Medicaid Help from Medicaid paying your Medicare Part B premium Both Medicare and Supplemental Security Income (SSI) To find out more about getting Extra Help, you can either call: The Social Security Office at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users can call Medicare at MEDICARE ( ), 24 hours a day/7 days a week. TTY/TDD users can call Your State Medicaid Office. Sign up options Once you ve decided on a PDP and are ready to sign up, you will need information from your Medicare card to fill out your enrollment form at the end of this booklet. Your sales representative or agent can help you and accept a copy for your enrollment. You can also mail the top copy of each page to the address listed on the first page of the application. Or sign up online at: Monthly premium payment options If your plan has a premium, you can choose your payment option. Simply choose your desired plan payment option on the enrollment application: Option 1: By check. If you choose to pay your premium directly to us, you will get a bill each month. Option 2: By automatic withdrawal. 2 Option 3: Taken out of your monthly Social Security check. 2 1 You can t get Medicare coverage gap discounts on brand-name drugs if you receive Extra Help. 2 This payment option may take up to three months to set up. A-9

12 How to reach us Clip this page out and place it in a handy location. Anthem s licensed insurance agent TTY/TDD line a.m. to 8 p.m., seven days a week Customer Service TTY/TDD line a.m. to 8 p.m., seven days a week, October 1, 2012, to February 14, a.m. to 8 p.m., Monday Friday, February 15 to September 30, 2013 Visit us online... Find your covered drugs Find a Pharmacy Plan ratings... Plan performance Star Ratings are assessed each year and may change from one year to the next. For more information on our Medicare plan ratings information, go to A stand-alone prescription drug plan with a Medicare contract. The person who is discussing plan options with you is either employed by or contracted with Anthem Life and Health Insurance Company. The person may be compensated based on your enrollment in a plan. Anthem Life and Health Insurance Company (Anthem) has contracted with the Centers for Medicare and Medicaid Services (CMS) to offer the Medicare prescription drug plans (PDPs) noted above or herein. Anthem is the state-licensed, risk-bearing entity offering these plans. Anthem has retained the services of its related companies and authorized agents/brokers/producers to provide administrative services and/or to make the PDPs available in this region. Anthem Life and Health Insurance Company is an independent licensee of the Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The name and symbol are registered marks of the Association. A-10

13 Blue - S5596 CY 2013 Medicare Plan Ratings The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Plan Ratings help you know how good a job our plan is doing. You can use this Plan Rating to compare our plan's performance to other plans. Examples of the areas covered by this rating include: How our members rate our plan's services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications For 2013, Blue received the following overall Plan Rating from Medicare. Image description. 3 Stars End of image description. 3 Stars The number of stars shows how well our plan performs. Image description. 5 stars End of image description. excellent Image description. 4 stars End of image description. above average Image description. 3 stars End of image description. average Image description. 2 stars End of image description. below average Image description. 1 star End of image description. poor Learn more about our plan and how we are different from other plans at You may also contact us Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern at (toll-free) or 711 (TTY/TDD). Current members please call (toll-free) or 711 (TTY/TDD). Y0071_13_16165_U CMS Accepted 33601MUMENMUB

14 Summary of Benefits : Introduction to Summary of Benefits : Summary of Benefits

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16 Summary of Benefits for Standard SM (PDP), Plus SM (PDP), and Gold SM (PDP) Available in California A stand-alone prescription drug plan with a Medicare contract. Anthem Life and Health Insurance Company (Anthem) has contracted with the Centers for Medicare & Medicaid Services (CMS) to offer the Medicare Prescription Drug Plans (PDPs) noted above or herein Anthem is the state-licensed, risk-bearing entity offering these plans. Anthem has retained the services of its related companies and authorized agents/brokers/producers to provide administrative services and/or to make the PDPs available in this region. Anthem Life and Health Insurance Company is an independent licensee of the Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The name and symbol are registered marks of the Association. Y0071_13_15447_U_001 CMS Accepted 31788MUSENMUB_001 S5596_033_034_035_CA_PDP

17 Section I: Introduction to Summary of Benefits Thank you for your interest in, Plus (PDP), and Blue Cross. Our plans are offered by Anthem Life and Health Insurance Company/, a Medicare Prescription Drug Plan that contracts with the Federal government. This Summary of Benefits tells you some features of our plan. It doesn't list every drug we cover, every limitation, or exclusion. To get a complete list of our benefits, please call, Plus (PDP), and and ask for the "Evidence of Coverage". You Have Choices In Your Medicare Prescription Drug Coverage As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through a Medicare Prescription Drug Plan, like, Plus (PDP), and. Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice. How Can I Compare My Options? The charts in this booklet list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by, Plus (PDP), and to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage. There is more than one plan listed in this Summary of Benefits. If you are enrolled in one plan and wish to switch to another plan, you may do so only during certain times of the year. Please call Customer Service for more information. Who Is Eligible to Join? You can join these plans if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. If you are enrolled in an MA coordinated care (HMO or PPO) plan or an MA PFFS plan that includes Medicare prescription drugs, you may not enroll in a PDP unless you disenroll from the HMO, PPO or MA PFFS plan. Enrollees in a private fee-for-service plan (PFFS) that does not provide Medicare prescription drug coverage, or an MA Medical Savings Account (MSA) plan may enroll in a PDP. Enrollees in an 1876 Cost plan may enroll in a PDP. Where Are, Plus (PDP), and Available? The service area for these plans includes: California. You must live in this area to join these plans. Where Can I Get My Prescriptions?, Plus (PDP), and Gold(PDP) have formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Page 2, Plus (PDP), and

18 The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or visit us at Our customer service number is listed at the end of this introduction. Does My Plan Cover Medicare Part B or Part D Drugs?, Plus (PDP), and Gold(PDP) do not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies associated with the delivery of insulin that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary. What Should I Do If I Have Other Insurance in Addition to Medicare? If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined a Medicare Prescription Drug Plan. If you decide to keep your current Medigap supplement policy, your Medigap Issuer will remove the prescription drug coverage portion of your policy. Call your Medigap Issuer for details. If you or your spouse has, or is able to get, employer group coverage, you should talk to your employer to find out how your benefits will be affected if you join Blue Cross, Plus (PDP), and Gold(PDP). Get this information before you decide to enroll in these plans. What Is a Prescription Drug Formulary?, Plus (PDP), and Gold(PDP) use a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members' ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician's help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How Can I Get Extra Help With My Prescription Drug Plan Costs or Get Extra Help With Other Medicare Costs? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: * MEDICARE ( ). TTY/TDD users should call , 24 hours a day/7 days a week and see 'Programs for People with Limited Income and Resources' in the publication Medicare & You. * The Social Security Administration at between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call or * Your State Medicaid Office. What Are My Protections In These Plans? All Medicare Prescription Drug Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to Page 3, Plus (PDP), and

19 calendar year. Each year, plans can decide whether to continue to participate with the Medicare Prescription Drug Program. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Prescription Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of, Plus (PDP), and, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. What Is a Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact, Plus (PDP), and for more details. Where Can I Find Information On Plan Ratings? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for these plans. Our customer service number is listed below. Please call for more information about, Plus (PDP), and Blue Cross Visit us at or, call us: Customer Service Hours for October 1 February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Pacific Page 4, Plus (PDP), and

20 Customer Service Hours for February 15 September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Pacific Current members should call toll-free TTY/TDD 711 Prospective members should call toll-free TTY/TDD 711 Current members should call locally TTY/TDD 711 Prospective members should call locally TTY/TDD 711 For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-english language. For additional information, call customer service at the phone number listed above. Este documento podría estar disponible en otros formatos como Braille, textos con letras grandes u otros formatos. Este documento podría estar disponible en idiomas distintos del inglés. Comuníquese con el número de nuestro Servicio de Atención al Cliente, indicado anteriormente, para obtener más información. Page 5, Plus (PDP), and

21 If you have any questions about these plans' benefits or costs, please contact for details. Section II: Summary of Benefits Benefit Original Medicare Plus (PDP) Gold (PDP) Prescription Drug Benefits Outpatient Prescription Drugs Most drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. Drugs Covered Under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at ca/medicare on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/ Urban (Indian Health Service) providers. $41.30 monthly premium Most people will pay their Part D premium. However, some people will pay Drugs Covered Under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at ca/medicare on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/ Urban (Indian Health Service) providers. $76.80 monthly premium Most people will pay their Part D premium. However, some people will pay Drugs Covered Under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at ca/medicare on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/ Urban (Indian Health Service) providers. $ monthly premium Most people will pay their Part D premium. However, some people will pay Page 6, Plus (PDP), and

22 Benefit Original Medicare a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. Plus (PDP) a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. Gold (PDP) a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part D premiums based on income, call Medicare at MEDICARE ( ). TTY users should call You may also call Social Security at TTY users should call The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and a Part D plan. Page 7, Plus (PDP), and

23 Benefit Original Medicare The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Standard (PDP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual Plus (PDP) The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Plus (PDP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual Gold (PDP) The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from Gold (PDP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual Page 8, Plus (PDP), and

24 Benefit Original Medicare Plus (PDP) Gold (PDP) cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Cross approves the exception, you will pay Tier 4: cost sharing for that drug. cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Cross Plus (PDP) approves the exception, you will pay Tier 4: cost sharing for that drug. cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and Blue Cross Gold (PDP) approves the exception, you will pay Tier 4: cost sharing for that drug. In-Network $325 annual deductible. In-Network $0 deductible. In-Network $0 deductible. Initial Coverage After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,970: Initial Coverage You pay the following until total yearly drug costs reach $2,970: Initial Coverage You pay the following until total yearly drug costs reach $2,970: Retail Pharmacy Tier 1: Preferred $2 copay for a $4 copay for a $6 copay for a Retail Pharmacy Tier 1: Preferred $2 copay for a $4 copay for a $6 copay for a Retail Pharmacy Tier 1: Preferred $2 copay for a $4 copay for a $6 copay for a Page 9, Plus (PDP), and

25 Benefit Original Medicare Tier 2: $6 copay for a $12 copay for a $18 copay for a Tier 3: Preferred $39 copay for a $78 copay for a $117 copay for a Tier 4: $85 copay for a $170 copay for a Plus (PDP) Tier 2: $7 copay for a $14 copay for a $21 copay for a Tier 3: Preferred $45 copay for a $90 copay for a $135 copay for a Tier 4: $90 copay for a $180 copay for a Gold (PDP) Tier 2: $7 copay for a $14 copay for a $21 copay for a Tier 3: Preferred $45 copay for a $90 copay for a $135 copay for a Tier 4: $90 copay for a $180 copay for a Page 10, Plus (PDP), and

26 Benefit Original Medicare $255 copay for a Tier 5: Injectable Drugs 25% coinsurance for a 25% coinsurance for a 25% coinsurance for a Tier 6: Specialty Tier 25% coinsurance for a Long-Term Care Pharmacy Tier 1: Preferred $2 copay for a (34-day) supply of Tier 2: Plus (PDP) $270 copay for a Tier 5: Injectable Drugs $95 copay for a $190 copay for a $285 copay for a Tier 6: Specialty Tier 33% coinsurance for a Long-Term Care Pharmacy Tier 1: Preferred $2 copay for a (34-day) supply of Tier 2: Gold (PDP) $270 copay for a Tier 5: Injectable Drugs $95 copay for a $190 copay for a $285 copay for a Tier 6: Specialty Tier 33% coinsurance for a Long-Term Care Pharmacy Tier 1: Preferred $2 copay for a (34-day) supply of Tier 2: Page 11, Plus (PDP), and

27 Benefit Original Medicare $6 copay for a (34-day) supply of Tier 3: Preferred $39 copay for a (34-day) supply of Tier 4: $85 copay for a (34-day) supply of Tier 5: Injectable Drugs 25% coinsurance for a (34-day) supply of Tier 6: Specialty Tier 25% coinsurance for a (34-day) supply of Please note that brand drugs must be dispensed incrementally in long-term care facilities. drugs may be dispensed incrementally. Contact your plan Plus (PDP) $7 copay for a (34-day) supply of Tier 3: Preferred $45 copay for a (34-day) supply of Tier 4: $90 copay for a (34-day) supply of Tier 5: Injectable Drugs $95 copay for a (34-day) supply of Tier 6: Specialty Tier 33% coinsurance for a (34-day) supply of Please note that brand drugs must be dispensed incrementally in long-term care facilities. drugs may be dispensed incrementally. Contact your plan Gold (PDP) $7 copay for a (34-day) supply of Tier 3: Preferred $45 copay for a (34-day) supply of Tier 4: $90 copay for a (34-day) supply of Tier 5: Injectable Drugs $95 copay for a (34-day) supply of Tier 6: Specialty Tier 33% coinsurance for a (34-day) supply of Please note that brand drugs must be dispensed incrementally in long-term care facilities. drugs may be dispensed incrementally. Contact your plan Page 12, Plus (PDP), and

28 Benefit Original Medicare Plus (PDP) Gold (PDP) about cost-sharing billing/collection when less than a supply is dispensed. about cost-sharing billing/collection when less than a supply is dispensed. about cost-sharing billing/collection when less than a supply is dispensed. Mail Order Mail Order Tier 1: Preferred $2 copay for a $3 copay for a $3 copay for a Tier 2: $6 copay for a $9 copay for a $9 copay for a Tier 3: Preferred Tier 1: Preferred $2 copay for a $3 copay for a $3 copay for a Tier 2: $7 copay for a $10.50 copay for a $10.50 copay for a Tier 3: Preferred Mail Order Tier 1: Preferred $2 copay for a $3 copay for a $3 copay for a Tier 2: $7 copay for a $10.50 copay for a $10.50 copay for a Tier 3: Preferred Page 13, Plus (PDP), and

29 Benefit Original Medicare $39 copay for a $97.50 copay for a $97.50 copay for a Tier 4: $85 copay for a $ copay for a $ copay for a Tier 5: Injectable Drugs 25% coinsurance for a 25% coinsurance for a Plus (PDP) $45 copay for a $ copay for a $ copay for a Tier 4: $90 copay for a $225 copay for a $225 copay for a Tier 5: Injectable Drugs $95 copay for a $ copay for a Gold (PDP) $45 copay for a $ copay for a $ copay for a Tier 4: $90 copay for a $225 copay for a $225 copay for a Tier 5: Injectable Drugs $95 copay for a $ copay for a Page 14, Plus (PDP), and

30 Benefit Original Medicare 25% coinsurance for a Tier 6: Specialty Tier 25% coinsurance for a Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 79% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750. Plus (PDP) $ copay for a Tier 6: Specialty Tier 33% coinsurance for a Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 79% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750. Additional Coverage Gap The plan covers few formulary generics (less than 10% of formulary generic drugs) through the coverage gap. The plan offers additional coverage in the gap for the following tiers. Gold (PDP) $ copay for a Tier 6: Specialty Tier 33% coinsurance for a Coverage Gap After your total yearly drug costs reach $2,970, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 47.5% for the plan's costs for brand drugs and 79% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,750. Additional Coverage Gap The plan covers many formulary generics (65% - 99% of formulary generic drugs), some formulary brands (10% - 64% of formulary brand drugs) through the coverage gap. Page 15, Plus (PDP), and

31 Benefit Original Medicare Plus (PDP) Gold (PDP) You pay the following: The plan offers additional coverage in the gap for the following tiers. You pay the following: Retail Pharmacy Tier 1: Preferred $7 copay for a all drugs covered $14 copay for a all drugs covered $21 copay for a all drugs covered Retail Pharmacy Tier 1: Preferred $7 copay for a all drugs covered $14 copay for a all drugs covered $21 copay for a all drugs covered Tier 2: $7 copay for a all drugs covered $14 copay for a all drugs covered Page 16, Plus (PDP), and

32 Benefit Original Medicare Plus (PDP) Long-Term Care Pharmacy Tier 1: Preferred $7 copay for a (34-day) supply of all drugs covered Please note that brand drugs must be dispensed incrementally in long-term care facilities. drugs may be dispensed incrementally. Gold (PDP) $21 copay for a all drugs covered Tier 3: Preferred 69% coinsurance for a select drugs covered 69% coinsurance for a select drugs covered 69% coinsurance for a select drugs covered Long-Term Care Pharmacy Tier 1: Preferred $7 copay for a (34-day) supply of all drugs covered Page 17, Plus (PDP), and

33 Benefit Original Medicare Plus (PDP) Gold (PDP) Contact your plan about cost-sharing billing/collection when less than a supply is dispensed. Tier 2: $7 copay for a (34-day) supply of all drugs covered Tier 3: Preferred 69% coinsurance for a (34-day) supply of select drugs covered Please note that brand drugs must be dispensed incrementally in long-term care facilities. drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a supply is dispensed. Page 18, Plus (PDP), and

34 Benefit Original Medicare Plus (PDP) Gold (PDP) Mail Order Mail Order Tier 1: Preferred Tier 1: Preferred $7 copay for a $7 copay for a all drugs covered all drugs covered $10.50 copay for $10.50 copay for a a all drugs covered all drugs covered $10.50 copay for $10.50 copay for a a all drugs covered all drugs covered Tier 2: $7 copay for a all drugs covered $10.50 copay for a all drugs covered $10.50 copay for a all drugs covered Tier 3: Preferred Page 19, Plus (PDP), and

35 Benefit Original Medicare Plus (PDP) Gold (PDP) 69% coinsurance for a select drugs covered 69% coinsurance for a select drugs in this tier 69% coinsurance for a select drugs covered Please contact the plan for a complete list of drugs covered through the gap. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay the greater of: 5% coinsurance, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay the greater of: 5% coinsurance, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay the greater of: 5% coinsurance, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area Page 20, Plus (PDP), and

36 Benefit Original Medicare where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Standard (PDP). Initial Coverage After you pay your yearly deductible, you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2,970: Tier 1: Preferred $2 copay for a Plus (PDP) where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Plus (PDP). Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,970: Tier 1: Preferred $2 copay for a Gold (PDP) where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Gold (PDP). Initial Coverage You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,970: Tier 1: Preferred $2 copay for a Page 21, Plus (PDP), and

37 Benefit Original Medicare Tier 2: $6 copay for a Tier 3: Preferred $39 copay for a Tier 4: $85 copay for a Tier 5: Injectable Drugs 25% coinsurance for a Tier 6: Specialty Tier 25% coinsurance for a You will not be reimbursed for the difference between the Pharmacy charge and Plus (PDP) Tier 2: $7 copay for a Tier 3: Preferred $45 copay for a Tier 4: $90 copay for a Tier 5: Injectable Drugs $95 copay for a Tier 6: Specialty Tier 33% coinsurance for a You will not be reimbursed for the difference between the Pharmacy charge and Gold (PDP) Tier 2: $7 copay for a Tier 3: Preferred $45 copay for a Tier 4: $90 copay for a Tier 5: Injectable Drugs $95 copay for a Tier 6: Specialty Tier 33% coinsurance for a You will not be reimbursed for the difference between the Pharmacy charge and Page 22, Plus (PDP), and

38 Benefit Original Medicare Plus (PDP) Gold (PDP) the plan's In-Network allowable amount. the plan's In-Network allowable amount. the plan's In-Network allowable amount. Coverage Gap You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Coverage Gap You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Coverage Gap You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4,750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). Page 23, Plus (PDP), and