SM $10 / $25 / $45 MedicareRx Blue - teradyne.com Library/HR/Benefits/2015/2015.3-Blue... · If you...
Transcript of SM $10 / $25 / $45 MedicareRx Blue - teradyne.com Library/HR/Benefits/2015/2015.3-Blue... · If you...
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
1-8
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
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