January1,2015–December31,2015 Summary ofBenefits Part D 2015 PDP Summary o… ·...

January 1, 2015 – December 31, 2015

Summaryof Benefits

Aetna Medicare Rx Saver (PDP)S5810-042

Aetna Medicare Rx Premier (PDP)S5810-178

Y0001_2015_S5810_042_178_NC Accepted 9/2014

58.06.370.1-NCC

This booklet gives you a summary of what we cover and what you pay. It doesn't list every servicethat we cover or list every limitation or exclusion. To get a complete list of services we cover, call usand ask for the "Evidence of Coverage."

You have choices about how to get yourMedicare prescription drug benefits1 One choice is to get prescription drug coverage

through a Medicare Prescription Drug Plan,like Aetna Medicare Rx Saver (PDP) or AetnaMedicare Rx Premier (PDP).

1 Another choice is to get your prescription drugcoverage through a Medicare Advantage Plan(like an HMO or PPO) or another Medicarehealth plan that offers Medicare prescriptiondrug coverage. You get all of your Part A andPart B coverage, and prescription drugcoverage (Part D), through these plans.

Tips for comparing your Medicare choicesThis Summary of Benefits booklet gives you asummary of what Aetna Medicare Rx Saver(PDP) and Aetna Medicare Rx Premier (PDP)cover and what you pay.

1 If you want to compare our plans with otherMedicare health plans, ask the other plans fortheir Summary of Benefits booklets. Or, usethe Medicare Plan Finder on http://www.medicare.gov.

1 If you want to know more about the coverageand costs of Original Medicare, look in yourcurrent "Medicare & You" handbook. View itonline at http://www.medicare.gov or get acopy by calling 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days aweek. TTY users should call 1-877-486-2048.

Sections in this booklet1 Things to Know About Aetna Medicare Rx

Saver (PDP) and Aetna Medicare Rx Premier(PDP)

1 Monthly Premium, Deductible, and Limits onHow Much You Pay for Covered Services

1 Prescription Drug Benefits

This document is available in other formats suchas Braille and large print.This document may be available in a non-Englishlanguage. For additional information, call us at1-855-338-7030, TTY: 711.

Este documento está disponible en otros formatoscomo Braille y en letra grande.Este documento puede estar disponible en otrosidiomas, aparte del inglés. Para obtenerinformación adicional, llámenos al1-855-338-7030, TTY: 711.

Things to Know About Aetna Medicare Rx Saver(PDP) and Aetna Medicare Rx Premier (PDP)

Hours of Operation1 From October 1 to February 14, you can call

us 7 days a week from 8:00 a.m. to 8:00 p.m.Local time.

1 From February 15 to September 30, you cancall us Monday through Friday from 8:00 a.m.to 8:00 p.m. Local time.

Aetna Medicare Rx Saver (PDP) and AetnaMedicare Rx Premier (PDP) Phone Numbers andWebsite1 If you are a member of one of these plans, call

toll-free 1-877-238-6211, TTY: 711.

Summary of BenefitsJanuary 1, 2015 – December 31, 2015

1 If you are not a member of one of these plans,call toll-free 1-855-338-7030, TTY: 711.

1 Ourwebsite: http://www.aetnamedicare.com

Who can join?To joinAetnaMedicare Rx Saver (PDP), youmustbe entitled toMedicare Part A, and/or be enrolledin Medicare Part B, and live in our service area.

Our service area includes the following: NorthCarolina.

To join Aetna Medicare Rx Premier (PDP), youmust be entitled to Medicare Part A, and/or beenrolled inMedicare Part B, and live in our servicearea.

Which drugs are covered?You can see the complete plan formulary (list ofPart D prescription drugs) and any restrictions onour website (http://www.aetnamedicare.com).Or, call us and we will send you a copy of theformulary.

How will I determine my drug costs?Our plans group each medication into one of five"tiers." You will need to use your formulary tolocatewhat tier your drug is on to determine howmuch it will cost you. The amount you paydepends on the drug's tier and what stage of thebenefit you have reached. Later in this documentwe discuss the benefit stages that occur: InitialCoverage, Coverage Gap, and CatastrophicCoverage.

Which pharmacies can I use?We have a network of pharmacies and you mustgenerally use these pharmacies to fill yourprescriptions for covered Part D drugs.

Some of our network pharmacies have preferredcost-sharing. You may pay less if you use thesepharmacies.

You can see our plans' pharmacy directory at ourwebsite (http://www.aetnapharmacy.com). Or,call us and we will send you a copy of thepharmacy directory.


Aetna Medicare Rx Premier (PDP)Aetna Medicare Rx Saver (PDP)MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOWMUCH YOU PAY FOR COVERED SERVICES

$133.50 per month.$22.40 per month.How much is themonthly premium?

This plan does not have a deductible.$320 per year for Part D prescription drugs.How much is thedeductible?

Plans are offered by AetnaHealth Inc., AetnaHealth of California Inc., and/or Aetna Life Insurance Company (Aetna). AetnaMedicareis a prescription drug plan with a Medicare contract. Enrollment in Aetna Medicare depends on contract renewal.

PRESCRIPTION DRUG BENEFITS

You pay the following until your total yearly drugcosts reach $2,960. Total yearly drug costs are thetotal drug costs paid by both you and our Part D plan.

After you pay your yearly deductible, you pay thefollowing until your total yearly drug costs reach$2,960. Total yearly drug costs are the total drugcosts paid by both you and our Part D plan.

Initial Coverage

Youmay get your drugs at network retail pharmaciesand mail order pharmacies. Youmay get your drugs at network retail pharmacies

and mail order pharmacies.Preferred Retail Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

Preferred Retail Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

$0$0$0Tier 1

(PreferredGeneric) $0$0$0

Tier 1(PreferredGeneric)$9 copay$6 copay$3 copay

Tier 2 (Non-PreferredGeneric) $9 copay$6 copay$3 copay

Tier 2 (Non-PreferredGeneric)

Summary of BenefitsJanuary 1, 2015 – December 31, 2015

Aetna Medicare Rx Premier (PDP)Aetna Medicare Rx Saver (PDP)

Initial Coverage Three-monthsupply

Two-monthsupply

One-monthsupplyTier

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

$135 copay$90 copay$45 copayTier 3

(PreferredBrand)


(PreferredBrand)

38% of thecost

38% of thecost

38% of thecost

Tier 4 (Non-PreferredBrand)

50% of thecost

50% of thecost

50% of thecost


Not OfferedNot Offered25% of thecost

Tier 5(Specialty

Tier)Not OfferedNot Offered33% of the

cost

Tier 5(Specialty

Tier)

Standard Retail Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier


Three-monthsupply

Two-monthsupply

One-monthsupplyTier


(PreferredGeneric)


(PreferredGeneric)

$15 copay$10 copay$5 copayTier 2 (Non-PreferredGeneric)



(PreferredBrand)


(PreferredBrand)

38% of thecost

38% of thecost

38% of thecost


50% of thecost

50% of thecost

50% of thecost



Initial Coverage Three-monthsupply

Two-monthsupply

One-monthsupplyTier

Three-monthsupply

Two-monthsupply

One-monthsupplyTier


Tier 5(Specialty


cost

Tier 5(Specialty

Tier)

Preferred Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

Preferred Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

$0$0$0Tier 1

(PreferredGeneric)

$0$0$0Tier 1

(PreferredGeneric)




(PreferredBrand)


(PreferredBrand)

38% of thecost

38% of thecost

38% of thecost


50% of thecost

50% of thecost

50% of thecost



Tier 5(Specialty


cost

Tier 5(Specialty

Tier)



Initial Coverage Standard Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier

Standard Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupplyTier


(PreferredGeneric)


(PreferredGeneric)




(PreferredBrand)


(PreferredBrand)

38% of thecost

38% of thecost

38% of thecost


50% of thecost

50% of thecost

50% of thecost



Tier 5(Specialty


cost

Tier 5(Specialty

Tier)

If you reside in a long-term care facility, you pay thesame as at a retail pharmacy.

If you reside in a long-term care facility, you pay thesame as at a retail pharmacy.

Youmay get drugs froman out-of-network pharmacyand pay the same as an in-network pharmacy, butyou will get less of the drug. Youmay get drugs froman out-of-network pharmacy

and pay the same as an in-network pharmacy, butyou will get less of the drug.

Most Medicare drug plans have a coverage gap (alsocalled the "donut hole"). This means that there's a

Most Medicare drug plans have a coverage gap (alsocalled the "donut hole"). This means that there's a

Coverage Gap


Coverage Gap temporary change in what you will pay for yourdrugs. The coverage gap begins after the total yearly

temporary change in what you will pay for yourdrugs. The coverage gap begins after the total yearly

drug cost (includingwhat our plan has paid andwhatyou have paid) reaches $2,960.

drug cost (includingwhat our plan has paid andwhatyou have paid) reaches $2,960.

After you enter the coverage gap, you pay 45% ofthe plan's cost for covered brand name drugs and

After you enter the coverage gap, you pay 45% ofthe plan's cost for covered brand name drugs and

65%of the plan's cost for covered generic drugs until65%of the plan's cost for covered generic drugs untilyour costs total $4,700, which is the end of theyour costs total $4,700, which is the end of thecoverage gap. Not everyone will enter the coveragegap.

coverage gap. Not everyone will enter the coveragegap.

Under this plan, youmay pay even less for the brandand generic drugs on the formulary. Your cost variesby tier. You will need to use your formulary to locateyour drug's tier. See the chart that follows to findout how much it will cost you.

Preferred Retail Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

$0$0$0AllTier 1

(PreferredGeneric)

$135copay$90 copay$45 copaySome

Tier 3(PreferredBrand)



Coverage Gap Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

50%of thecost

50%of thecost

50%of thecostSome

Tier 4(Non-

PreferredBrand)


Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

$12 copay$8 copay$4 copayAllTier 1

(PreferredGeneric)



50%of thecost

50%of thecost

50%of thecostSome

Tier 4(Non-

PreferredBrand)


Coverage Gap Preferred Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

$0$0$0AllTier 1

(PreferredGeneric)



50%of thecost

50%of thecost

50%of thecostSome

Tier 4(Non-

PreferredBrand)

Standard Mail Order Cost-Sharing

Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

$12 copay$8 copay$4 copayAllTier 1

(PreferredGeneric)





Coverage Gap Three-monthsupply

Two-monthsupply

One-monthsupply

DrugsCoveredTier

50%of thecost

50%of thecost

50%of thecostSome

Tier 4(Non-

PreferredBrand)

After your yearly out-of-pocket drug costs (includingdrugs purchased through your retail pharmacy and

After your yearly out-of-pocket drug costs (includingdrugs purchased through your retail pharmacy and

Catastrophic Coverage

throughmail order) reach $4,700, you pay the greaterof:

throughmail order) reach $4,700, you pay the greaterof:

1 5% of the cost, or1 5% of the cost, or1 1$2.65 copay for generic (including brand drugs

treated as generic) and a $6.60 copayment for allother drugs.

$2.65 copay for generic (including brand drugstreated as generic) and a $6.60 copayment for allother drugs.

January1,2015–December31,2015 Summary ofBenefits Part D 2015 PDP Summary o… ·...

Documents

Transcript of January1,2015–December31,2015 Summary ofBenefits Part D 2015 PDP Summary o… ·...