Emplo

yer G

roup M

edica

re Pr

escri

ption

Drug

Plan

with

supp

lemen

tal co

verag

e $1

0 / $2

5 / $4

5

Blue

Med

icare

RxSM(P

DP)

2015

Sum

mary

of Be

nefit

s

Blue M

edica

reRxSM

(PDP

)

S28

93_1

421_

0820

14_G

RP

Secti

on I:

Introd

uctio

nIn

trodu

ctio

n to

the

Sum

mar

y of

Ben

efits

for Y

our B

lue

Med

icar

eRx

Plan

– J

anua

ry 1

, 201

5 - D

ecem

ber 3

1, 2

015

Than

k yo

u fo

r you

r int

eres

t in

Blu

e M

edicar

eRx.

Blu

e M

edicar

eRx

includ

es s

tand

ard

Med

icar

e Pa

rt D b

enef

itssu

pple

men

ted

with

cov

erag

e pr

ovid

ed b

y yo

ur fo

rmer

em

ploy

er/u

nion

hea

lth p

lan. B

lue

Med

icar

eRx

is re

ferre

d th

roug

hout

this S

umm

ary

of B

enef

its a

s “p

lan”

or “

this p

lan.”

This p

lan

is o

ffere

d by

Blu

e Cro

ss a

nd B

lue

Shie

ld o

f Mas

sach

uset

ts, Inc

., a M

edicar

e Pr

escr

iptio

n Dru

g Pl

an th

at c

ontra

cts

with

the

Fede

ral g

over

nmen

t.

This S

umm

ary

of B

enef

its te

lls y

ou s

ome

feat

ures

of o

ur p

lan. It

doe

sn’t

list e

very

dru

g we

cove

r, ev

ery

limita

tion, o

rex

clus

ion. T

o ge

t a c

ompl

ete

list o

f our

ben

efits

, ple

ase

call us

and

ask

for t

he “E

viden

ce o

f Cov

erag

e.”

You

hav

e ch

oice

s ab

out h

ow to

get

you

r M

edic

are

pres

crip

tion

drug

ben

efits

·O

ne cho

ice

is to

get

pre

scrip

tion

drug

cov

erag

e th

roug

h a M

edic

are

Pres

crip

tion

Dru

g Pl

an, l

ike

Blu

e M

edic

areR

x(P

DP

). Y

ou are

bei

ng o

ffer

ed th

is p

lan

as p

art o

f you

r for

mer

em

ploy

er’s re

tiree

ben

efits

, but

you

can

cho

ose

topu

rcha

se an

Indi

vidu

al (n

on-g

roup

) Med

icar

e Pr

escr

iptio

n D

rug

Plan

.

·Ano

ther

cho

ice

is to

pur

chas

e yo

ur p

resc

riptio

n dr

ug cov

erag

e th

roug

h an

Indi

vidu

al (n

on-g

roup

) Med

icar

e Adv

anta

gePl

an (l

ike

an H

MO

or P

PO) o

r ano

ther

Med

icar

e he

alth

pla

n th

at o

ffer

s Med

icar

e pr

escr

iptio

n dr

ug cov

erag

e. Y

ou g

etal

l of y

our P

art A

and

Par

t B cov

erag

e, and

pre

scrip

tion

drug

cov

erag

e (P

art D

), th

roug

h th

ese

plan

s.

·N

ote: If

you

enr

oll i

n an

Indi

vidu

al (n

on-g

roup

) pla

n, y

ou m

ay n

ot b

e el

igib

le to

enr

oll i

n yo

ur e

mpl

oyer

’s re

tiree

pla

nin

the

futu

re.

Plea

se con

tact

you

r for

mer

em

ploy

er’s g

roup

adm

inistrat

or fo

r inf

orm

atio

n on

elig

ibili

ty re

quire

men

ts fo

ryo

ur re

tiree

pla

n.

Tip

s fo

r co

mpa

ring

you

r M

edic

are

choi

ces

Thi

s Sum

mar

y of

Ben

efits

boo

klet

giv

es y

ou a su

mm

ary

of w

hat B

lue

Med

icar

eRx

cove

rs and

wha

t you

pay

.

·If

you

wan

t to

com

pare

our

pla

ns w

ith o

ther

Med

icar

e he

alth

pla

ns, a

sk th

e ot

her p

lans

for t

heir

Sum

mar

y of

Ben

efits

boo

klet

s. O

r, us

e th

e M

edic

are

Plan

Fin

der o

n ht

tp://

ww

w.m

edic

are.

gov.

·If

you

wan

t to

know

mor

e ab

out t

he cov

erag

e an

d co

sts o

f Orig

inal

Med

icar

e, lo

ok in

you

r cur

rent

"Med

icar

e &

You

" han

dboo

k. V

iew

it o

nlin

e at

http:

//ww

w.m

edic

are.

gov

or g

et a cop

y by

cal

ling

1-80

0-M

ED

ICAR

E(1

-800

-633

-422

7), 2

4 ho

urs a

day

, 7 d

ays a

wee

k. T

TY

user

s sho

uld

call

1-87

7-48

6-20

48.

1

This d

ocum

ent i

s av

aila

ble

in o

ther

form

ats

such

as

Bra

ille a

nd la

rge

prin

t. Th

is d

ocum

ent m

ay b

e av

aila

ble

in a

non

-Eng

lish

lang

uage

. For

add

ition

al in

form

atio

n, c

all u

s at

1-8

88-5

43-4

917,

24

hour

s a

day,

7 da

ys a

wee

k. T

TY/T

DD u

sers

sho

uld

call 1-

866-

236-

1069

.

Thing

s to K

now

Abou

t Blue

Med

icareR

x

Hours

of Op

eration

You

can

call

us 2

4 ho

urs a

day

, 7 d

ay a w

eek.

Blu

e M

edic

areR

x P

hone

Num

bers

and

Web

site

Plea

se cal

l Blu

e M

edic

areR

x fo

r mor

e in

form

atio

n ab

out o

ur p

lan.

Cur

rent

mem

bers

sho

uld

call

toll-

free

1-8

88-5

43-4

917.

(TT

Y/T

DD

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66-2

36-1

069)

Pro

spec

tive

Mem

bers

, ple

ase

cont

act y

our b

enef

its adm

inistrat

or.

Visit

us at h

ttp:

//gro

ups.

rxm

edic

arep

lans

.com

Who c

an jo

in?Yo

u ca

n jo

in th

is p

lan

if yo

u ar

e en

title

d to

Med

icar

e Pa

rt A

and

/or e

nrol

led

in M

edic

are

Part B

and

live

in th

e se

rvic

e ar

ea w

hich

incl

udes

the

Uni

ted

Stat

es and

its t

errit

orie

s (ex

clud

ing

the

Virg

in Is

land

s).

If y

ou are

enr

olle

d in

a M

A coo

rdin

ated

car

e (H

MO

or P

PO) p

lan

or a M

A p

rivat

e fe

e-fo

r-se

rvic

e (M

A P

FFS)

pla

n th

at in

clud

es M

edic

are

pres

crip

tion

drug

s, yo

u m

ay n

ot e

nrol

l in

a pr

escr

iptio

n dr

ug p

lan

(PD

P) u

nles

s you

disen

roll

from

the

HM

O, P

PO o

r MA P

FFS

plan

.

Enr

olle

es in

a p

rivat

e fe

e-fo

r-se

rvic

e (P

FFS)

pla

n th

at d

oes n

ot p

rovi

de M

edic

are

pres

crip

tion

drug

cov

erag

e or

a M

A M

edic

al S

avin

gsAcc

ount

(MSA

) pla

n m

ay e

nrol

l in

a PD

P. E

nrol

lees

in an

1876

Cos

t pla

n m

ay e

nrol

l in

a PD

P. P

leas

e co

ntac

t you

r ben

efits

adm

inistrat

or fo

rm

ore

info

rmat

ion.

2

3

Which

drug

s are

covered

?Yo

u ca

n se

e th

e co

mpl

ete

plan

form

ular

y (li

st o

f Par

t D p

resc

riptio

n dr

ugs)

and

any

rest

rictio

ns o

n ou

r Web

site

(http:

//gro

ups.r

xmed

icar

epla

ns.com

). O

r, ca

ll us

and

we

will

send

you

a cop

y of

the

form

ular

y.

How

will I

deter

mine

my d

rug co

sts?

Our

pla

n gr

oups

eac

h m

edic

atio

n in

to o

ne o

f 3 “

tiers

.” Y

ou w

ill n

eed

to u

se y

our f

orm

ular

y to

loca

te w

hat t

ier y

our d

rug

is o

n to

det

erm

ine

how

muc

h it

will

cos

t you

. The

am

ount

you

pay

dep

ends

on

the

drug

's tie

r and

wha

t sta

ge o

f the

ben

efit

you

have

reac

hed.

Lat

er in

this

docu

men

t we

disc

uss t

he b

enef

it st

ages

that

occ

ur: I

nitia

l Cov

erag

e, C

over

age

Gap

, and

Cat

astrop

hic C

over

age.

Which

pharm

acies

can I

use?

We

have

a n

etw

ork

of p

harm

acie

s and

you

mus

t gen

eral

ly u

se th

ese

phar

mac

ies t

o fil

l you

r pre

scrip

tions

for c

over

ed P

art D

dru

gs.

You

can

see

our p

lan’

s pha

rmac

y di

rect

ory

at o

ur W

eb si

te (h

ttp:

//gro

ups.r

xmed

icar

epla

ns.com

). O

r, ca

ll us

and

we

will

send

you

a cop

y of

the

phar

mac

y di

rect

ory.

If you ha

ve any q

uestio

ns about th

is plan

’s benefits or

costs,

please

conta

ct Blu

e Medica

reRx for

details.

Secti

on II:

Summ

ary of

Ben

efits

Pre

scrip

tion

Dru

g B

enef

its

The

ben

efits

des

crib

ed b

elow

are

offer

ed b

y Blu

e M

edic

areR

x, a st

anda

rd M

edic

are

Part D

pla

n su

pple

men

ted

with

ben

efits

prov

ided

by

your

form

er e

mpl

oyer

.

Initi

al C

over

age

You

pay t

he fo

llowin

g unt

il yo

ur to

tal y

early d

rug c

osts

reac

h $2

,960

1 :Sta

ndar

d R

etai

l Cos

t-Sha

ring

One

-mon

th s

uppl

yT

wo-

mon

th s

uppl

yT

hree

-mon

th s

uppl

y2

Tie

r 1

Gen

eric

Dru

gs$1

0$2

0$3

0

Tie

r 2

Pre

ferr

ed B

rand

Dru

gs$2

5$5

0$7

5

Tie

r 3

Non

-Pre

ferr

ed B

rand

Dru

gs$4

5$9

0$1

35

Specia

lty d

rugs

are

lim

ited

to a

one

-mon

th su

pply p

er fi

ll.

Mai

l Ord

er C

ost-Sha

ring

One

-mon

th s

uppl

yT

wo-

mon

th s

uppl

yT

hree

-mon

th s

uppl

y

Tie

r 1

Gen

eric

Dru

gs$1

0$2

0$2

0

Tie

r 2

Pre

ferr

ed B

rand

Dru

gs$2

5$5

0$5

0

Tie

r 3

Non

-Pre

ferr

ed B

rand

Dru

gs$4

5$9

0$9

0

Specia

lty d

rugs

are

lim

ited

to a

one

-mon

th su

pply p

er fi

ll.

Cov

erag

e G

apA

fter

you

r to

tal y

earl

y dr

ug c

osts

rea

ch $

2,96

0, y

our f

orm

er e

mpl

oyer

prov

ides

supp

lem

enta

l cov

erag

e th

at w

ill k

eep

your

cop

aym

ents

and

/or

coin

sura

nce

as o

utlin

ed abo

ve.

Your

cop

aym

ents

and

/or c

oins

uran

ce w

ill n

ot cha

nge

until

you

qua

lify

for

Cat

astrop

hic C

over

age.

Cat

astr

ophi

c C

over

age

After

your

year

ly out

-of-p

ocke

t dru

g cos

ts re

ach $4

,700

, you

pay

:G

ener

ic D

rugs

(inc

ludi

ng b

rand

dru

gs tr

eate

d as

gen

eric

)$2

.65

All

othe

r D

rugs

$6.6

0

1 All

cove

red

drug

s are

on

the

Blu

e M

edic

areR

x gr

oup

form

ular

y/dr

ug li

st.

2 Ava

ilabl

e at

reta

il ph

arm

acie

s tha

t hav

e ag

reed

to allo

w m

embe

rs to

fill

90-d

ay su

pplie

s of t

heir

pres

crip

tions

.

4

Gen

eral

Inf

orm

atio

n

In so

me

case

s, th

e pl

an re

quire

s you

to fi

rst t

ry o

ne d

rug

to tr

eat y

our m

edic

al con

ditio

n be

fore

they

will

cov

er ano

ther

dru

g fo

r tha

tco

nditi

on.

Cer

tain

pre

scrip

tion

drug

s will

hav

e m

axim

um q

uant

ity li

mits

.

Your

pro

vide

r mus

t get

prio

r aut

horiz

atio

n from

Blu

e M

edic

areR

x fo

r cer

tain

pre

scrip

tion

drug

s.

Cov

ered

Par

t D d

rugs

are

ava

ilabl

e at

out

-of-ne

twor

k ph

arm

acie

s in

spec

ial c

ircum

stan

ces,

incl

udin

g ill

ness

whi

le tr

avel

ing

outs

ide

of th

epl

an's

serv

ice

area

whe

re th

ere

is n

o ne

twor

k ph

arm

acy.

You

r cop

aym

ent a

nd/o

r coi

nsur

ance

at o

ut-o

f-ne

twor

k ph

arm

acie

s is t

he sa

me

as at

netw

ork

phar

mac

ies a

nd d

epen

ds o

n w

heth

er y

ou p

urch

ase

a G

ener

ic, P

refe

rred

Bra

nd, S

peci

alty

or N

on-P

refe

rred

Bra

nd d

rug.

How

ever

, if

you

go to

an

out-of

-net

wor

k ph

arm

acy,

you

are

resp

onsibl

e fo

r the

diff

eren

ce b

etw

een

the

amou

nt cha

rged

at t

he o

ut-o

f-ne

twor

k ph

arm

acy

and

wha

t you

r pla

n w

ould

hav

e pa

id at a

net

wor

k ph

arm

acy.

Med

icar

e co

nsid

ers d

rugs

whi

ch cos

t mor

e th

an $

600

for a

one

mon

th su

pply

to b

e Sp

ecia

lty d

rugs

.

Med

icar

e C

over

age

Gap

Dis

coun

t Pro

gram

The

Med

icar

e C

over

age

Gap

Disco

unt P

rogr

am p

rovi

des m

anuf

actu

rer d

isco

unts

on

bran

d na

me

drug

s to

Part D

enr

olle

es w

ho h

ave

reac

hed

year

-to-

date

“to

tal d

rug

cost

s” o

f $2,

960

and

are

not a

lread

y re

ceiv

ing

“Ext

ra H

elp.

”

If y

ou h

ave

reac

hed

year

-to-

date

“to

tal d

rug

cost

s” o

f $2,

960,

you

r for

mer

em

ploy

er p

rovi

des s

uppl

emen

tal c

over

age

that

will

kee

p yo

urco

paym

ents

and

/or c

oins

uran

ce in

the

Cov

erag

e G

ap th

e sa

me

as w

hat y

ou p

ay in

the

Initi

al C

over

age

Lev

el. B

oth

the

amou

nt y

ou p

ay and

the

amou

nt d

isco

unte

d by

the

man

ufac

ture

r cou

nt to

war

d yo

ur o

ut-o

f-po

cket

cos

ts and

mov

e yo

u th

roug

h th

e C

over

age

Gap

. The

am

ount

disc

ount

ed b

y th

e m

anuf

actu

rer w

ill cou

nt to

war

d yo

ur o

ut-o

f-po

cket

cos

ts as i

f you

had

pai

d th

is am

ount

. You

r Exp

lana

tion

of B

enef

its(E

OB) w

ill sh

ow any

disco

unte

d am

ount

pro

vide

d.

Onc

e yo

ur o

ut-o

f-po

cket

cos

ts re

ach

$4,7

00, y

ou w

ill m

ove

to th

e C

atas

trop

hic ph

ase

and

the

Med

icar

e C

over

age

Gap

Disco

unt P

rogr

amw

ill n

o lo

nger

be

appl

icab

le.

If y

ou h

ave

any

ques

tions

abo

ut th

e av

aila

bilit

y of

disco

unts

for t

he d

rugs

you

are

taki

ng o

r abo

ut th

e M

edic

are

Cov

erag

e G

ap D

isco

unt

Prog

ram

in g

ener

al, p

leas

e co

ntac

t Cus

tom

er C

are.

5

S28

93_1

473

Acc

epte

d 08

2420

14

Mul

ti-la

ngua

ge In

terp

rete

r Se

rvic

es

Eng

lish:

We

have

free

inte

rpre

ter s

ervi

ces

to a

nsw

er a

ny q

uest

ions

you

may

hav

e ab

out o

ur h

ealth

or d

rug

plan

. To

get a

n in

terp

rete

r,ju

st c

all u

s at

1-8

88-5

43-4

917.

Som

eone

who

spe

aks

Eng

lish/

Lang

uage

can

hel

p yo

u. T

his

is a

free

ser

vice

.

Spa

nish

: Ten

emos

ser

vici

os d

e in

térp

rete

sin

cos

to a

lgun

o p

ara

resp

onde

r cua

lqui

er p

regu

nta

que

pued

a te

ner s

obre

nue

stro

pla

n de

salu

d o

med

icam

ento

s. P

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habl

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on u

n in

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rete

, por

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en q

ue h

able

esp

añol

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odrá

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dar.

Est

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icio

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num

ang

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ons

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ịch

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oser

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os.

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ean:

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1-88

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6S28

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Acc

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