Life offers you many choices.

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Through It All.

®

Life offers you many choices.

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Blue Cross MedicareRx

SM

Call

1-877-213-2831

8 a.m. - 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies

(for example, voicemail) will be used on weekends and holidays. TTY/TDD: 711

Web

www.mybluepartd.com

Seminars

Find a free seminar near you: www.bcbsil.com/medicare/seminars

Write

Blue Cross MedicareRx • P.O. Box 3897 • Scranton, PA 18505-9947

Medicare

Contact Medicare for more information about Medicare benefits and services, including general information regarding the health, Medicare Advantage Prescription Drug or Part D benefit.

Call

1-800-MEDICARE (1-800-633-4227) • TTY 1-877-486-2048 24 hours a day, 7 days a week

Web

www.medicare.gov

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A

PART

Helps pay for covered doctor’s services and many other medical services and supplies. If you don’t enroll in Part B when you are first eligible for Medicare, you may have to pay a penalty later.

B

PART

Hospital Insurance

Medical Insurance

Where Part D Fits into Medicare

Medicare Supplement Insurance

†

Optional coverage helps to pay for expenses beyond what is covered by Medicare. There are several Medicare Supplement insurance plans, each with different benefits and premiums, so you can choose the plan that works best for your specific needs. Medicare Supplement insurance plans are identified by the separate letters A, B, C, D, F, F-HD, G, K, L, M and N.‡_{The basic benefits of each plan are exactly}

alike for all insurance companies.

C

PART

Helps pay for covered prescription medications. As with Part B, selecting a Part D plan when you are first eligible means you may not have to pay a penalty later.

D

PART

A

PART

B

PART

C

PART

D

PART

Offers medical coverage through a network of providers, such as an HMO or PPO, that is an alternative to Original Medicare (Parts A & B). These plans may or may not cover prescription drugs.

Medicare

Advantage Plans

Prescription

Drug Coverage

*_{Kaiser Family Foundation. Medicare at a Glance Fact Sheet; (2012, November).}

†_{Not connected with or endorsed by the U.S. Government or Federal Medicare Program.} ‡_{Not all of these plans are offered by Blue Cross and Blue Shield of Illinois.}

Medicare is the nation’s largest health insurance program, covering health care services such as hospital stays, skilled nursing and physician services for about 50 million people.*

There are four parts to Medicare. Each provides coverage for different types of health care services. Part D covers prescription drugs.

Helps pay for inpatient hospital care, skilled nursing facility care, home health care and hospice care. While most Americans are enrolled automatically in Medicare Part A, it alone may not cover all of your

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Eligibility and Enrollment

Do you have your Medicare card?

If you’re turning 65 and getting Social Security or Railroad Retirement Board benefits, you will automatically be enrolled in Medicare Part A and Part B. Part A benefits are free for most Americans and begin on the first day of your birthday month. However, because you must pay a premium for Part B coverage, you have the option of turning it down. Medicare will send you a package with your Medicare card and benefit information about 90 days before your birthday.

Enrollment Period

When you are new to Medicare, you should enroll in Part D during your Initial Enrollment Period. This is the seven-month period including:

If you didn’t sign up for Part A and/or Part B when you were first eligible, you can sign up during the General Enrollment Period between January 1 - March 31 each year.

Late Enrollment Penalty

If you don’t enroll in Medicare Parts B and D when you are first eligible, you may have a late enrollment penalty added to your monthly premium.

65th birthday month

3 months prior 3 months after

Initial Enrollment Period

When are you Medicare eligible?

If you answer “yes” to at least one of the following questions, you may be eligible.

•

Are you age 65 or older and have Social Security or Railroad Retirement Board benefits?

•

Are you under age 65 with certain disabilities?

•

Do you have ALS (amyotrophic lateral sclerosis) or, at any age, End-Stage Renal Disease?

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All Part D plans, including Blue Cross MedicareRx, have the phases below. Benefits offered within the plans can vary.

How Medicare Part D Works

Annual Deductible

You pay

this amount for your prescriptions before Blue Cross MedicareRx begins to pay.

Initial Coverage

You pay

a copay or coinsurance for each eligible prescription filled.

Blue Cross MedicareRx pays

the rest until total costs reach $2,850 (the total costs you and Blue Cross MedicareRx have paid together, excluding premiums).

Coverage Gap

You pay

your prescription drug costs until you reach $4,550 in year-to-date True Out-Of-Pocket (TrOOP) costs (payments including deductibles, copays, coinsurance). During this time, you may be eligible for a discount on brand name drugs and a 28% discount on generic drugs at the time of purchase.

Catastrophic Coverage

You pay

$2.55 copay for generics, $6.35 copay or 5% coinsurance (whichever is greater) for other drugs, and 5% coinsurance for specialty drugs after $4,550 in TrOOP costs are reached.

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Basic Plan

Value Plan

Plus Plan

Monthly

Premium* $23 $37.50 $97.70

Annual Deductible

Amount you pay before Blue Cross MedicareRx begins to pay

$310 for

All Tiers Tiers 3, 4 & 5 only$275 for $0

Initial Coverage Period Copays

(30-day supply) Annual drug costs up to $2,850

Preferred Pharmacy/Non-Preferred Pharmacy

Ti er 1 - Preferred Generic Drugs $1/$6 Ti er 2 - Non-Preferred Generic Drugs $2/$8 Ti er 3 - Preferred Brand Drugs $39/$45 Ti er 4 - Non-Preferred Brand Drugs $85/$95 Ti er 5 - Specialty Drugs 25% Ti er 1 - Preferred Generic Drugs $0/$5 Ti er 2 - Non-Preferred Generic Drugs $2/$7 Ti er 3 - Preferred Brand Drugs $39/$44 Ti er 4 - Non-Preferred Brand Drugs $85/$95 Ti er 5 - Specialty Drugs 25% Ti er 1 - Preferred Generic Drugs $0/$5 Ti er 2 - Non-Preferred Generic Drugs $2/$7 Ti er 3 - Preferred Brand Drugs $33/$40 Ti er 4 - Non-Preferred Brand Drugs $80/$95 Ti er 5 - Specialty Drugs 33% Gap Coverage

Annual drug costs exceeding $2,850 (up to a total of $4,550 out-of-pocket costs)

You will receive a discount on Brand Name Drugs and pay only 72% of the costs of Generic Drugs.

$0/$5 copay for Preferred Generic Drugs

$2/$7 copay for Non-Preferred Generic Drugs Member will receive a discount on Brand Name Drugs.

After the Gap Copays

After your total out-of-pocket costs exceed $4,550

You pay whichever is greater:

Tier 1 - Preferred Generic Drugs: $2.55 copay or 5% coinsurance for your drug Tier 2 - Non-Preferred Generic Drugs: $2.55 copay or 5% coinsurance for your drug Tier 3 - Preferred Brand Drugs: $6.35 copay or 5% coinsurance for your drug Tier 4 - Non-Preferred Brand Drugs: $6.35 copay or 5% coinsurance for your drug Tier 5 - Specialty Drugs: 5% coinsurance for your drug

Your 2014 Blue Cross MedicareRx Plan Options

* You must continue to pay your Medicare Part B premium.

The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.

Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1 of each year.

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List all your prescription drugs in one place as you consider your choices.

Prescription Drug List

My Prescription Drug List Instructions

Write the names of your prescription drugs.

Look for them on the Comprehensive Formulary at www.mybluepartd.com/rxlist/il and check the Tiers in which they are listed.

Add the drugs you buy at a Preferred Pharmacy in the tan boxes for Tiers 1 – 4. (A Preferred Pharmacy allows you a larger discount on copays.)

Add the drugs you buy at a Non-Preferred Pharmacy in the teal boxes for Tiers 1 – 4. Add your Specialty drugs under Tier 5. Make a note of their cost.

Use your My Prescription Drug List to complete the Pick A Plan worksheet on pages 8 - 9. The totals are not final costs, but are only estimates of what you could spend annually in each plan. Or, use our online Plan Selector tool at www.mybluepartd.com/selectplan/il.

My Prescription Drug List

Name of Prescription Drug/Dose

Tier 1 Preferred Generics Tier 2 Non-Preferred Generics Tier 3 Preferred Brand Tier 4 Non-Preferred Brand Tier 5 Specialty

Preferred Pharmacy: Use the number of drugs under Tiers 1 - 4 to complete the

tan boxes on the Pick A Plan worksheet.

Non-Preferred Pharmacy: Use the number of drugs under Tiers 1 - 4 to complete the

teal boxes on the Pick A Plan worksheet.

Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 1 Tier 2 Tier 3 Tier 4

Warfarin

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Annual Deductible Annual Premium Cost

A

Estimated Monthly Drug Costs*

Using your Drug List totals from page 7, write the number of prescription drugs you will fill at a PreferredPharmacy in the tan boxes and the number of prescription drugs you will fill at a Non-Preferred Pharmacyin the teal boxes. Multiply the number in each tan box and each

teal box by the copay amount listed next to it. Write the total in the green boxes.

Multiply the cost of Tier 5 drugs in the gray

box by 25% coinsurance and write the total amount in the green box.

* Assumes a 30-day eligible prescription at an in-network pharmacy and that out-of-pocket costs have not reached $2,850 (coverage gap). Many factors can affect your

calculations. This worksheet is not intended to reflect all costs.

B

Estimated Monthly Drug Cost boxes together and write total in the Add the pink boxgreen .

C

Estimated Annual Drug Cost

Multiply the pink box by 12. This is what 12 months of your prescription drugs may cost. Write the total in the blue box.

D

Estimated Total Annual Costs

Add the blue box with the numbers entered in Line D. This is your estimated total cost for one year in the plan.

Basic Plan

$23 x 12 =

Monthly Premium Months Number of Tier 1 drugs used Number of Tier 2 drugs used Number of Tier 3 drugs used Number of Tier 4 drugs used

Total cost of Tier 5 drugs used

Add drug costs from green boxes

x 12 months =

Annual Deductible: Annual Premium: Estimated Annual Drug Cost (Line C):

Estimated Total:

Pick A Plan Worksheet

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Basic Plan

$23 x 12 =

Monthly Premium Months Number of Tier 1 drugs used Number of Tier 2 drugs used Number of Tier 3 drugs used Number of Tier 4 drugs used

Total cost of Tier 5 drugs used

Add drug costs from green boxes

x 12 months =

Estimated Total:

Value Plan

Plus Plan

$37.50 x 12 =

Monthly Premium Months $97.70 x 12 =Monthly Premium Months Number of Tier 1 drugs used Number of Tier 1 drugs used Number of Tier 2 drugs used Number of Tier 2 drugs used Number of Tier 3 drugs used Number of Tier 3 drugs used Number of Tier 4 drugs used Number of Tier 4 drugs used

Total cost of Tier 5 drugs used Total cost of Tier 5 drugs used

Add drug costs from green boxes Add drug costs from green boxes

x 12 months =

Estimated Total:

x $5.00 copay = x $5.00 copay = x $44.00 copay = x $40.00 copay = x $7.00 copay = x $7.00 copay = x $95.00 copay = x $95.00 copay = x $0.00 copay = x $0.00 copay = x $39.00 copay = x $33.00 copay = x $2.00 copay = x $2.00 copay = x $85.00 copay = x $80.00 copay =

+

=

+

=

x 25% coinsurance = x 33% coinsurance = $450 $1,172.40 $450 $1,172.40

$275 for Tiers 3, 4 & 5 only $0

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Formulary and Pharmacy Facts

Blue Cross MedicareRx Formulary

•

You can save money by switching to a generic. Ask your doctor/pharmacist if this is an option for you.

•

Save time and money by using our convenient mail-order service.

•

View the most current formulary at www.mybluepartd.com/rxlist/il.

Blue Cross MedicareRx Pharmacies

•

Blue Cross MedicareRx has pharmacies nationwide, giving you peace of mind while traveling.

•

For you to receive benefits, Blue Cross MedicareRx network pharmacies or mail-order service must be used, except in an emergency.

•

Blue Cross MedicareRx PreferredPharmacies and their affiliates include:

Thousands of prescription drugs are in our formulary. Thousands of pharmacies are in our network.

– CVS

– Good Neighbor

– Sam’s Club

– SUPERVALU

– Walmart

Other network pharmacies are available in our network. Visit www.mybluepartd.com/pharmacies/il for a current network pharmacy listing.

See

page 11

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More Choices and More Savings

Choose Generics

If your prescription is for a preferred or non-preferred brand drug, talk to your doctor or pharmacist about switching to a generic. This example shows how switching could save you money.

Choose a

Preferred Pharmacy

When you fill your prescription at a Preferred Pharmacy, you may purchase a 90-day supply of an eligible generic or brand prescription drug and pay only two and a half months of copays instead of three. Here’s an example of the possible savings.

Save with Generics at a Preferred Pharmacy

Drug Tier 30-Day Supply Annually

**Estimated* Savings**

Compared to Tier 4

Tier 1:

Preferred Generic Drug $1 copay $12 copay You save $1,008 Tier 2:

Non-Preferred Generic Drug $2 copay $24 copay You save $996 Tier 3:

Preferred Brand Drug $39 copay $468 copay You save $552 Tier 4:

Non-Preferred Brand Drug $85 copay $1,020 copay $0

Visit www.mybluepartd.com/rxlist/il to view the Comprehensive Formulary.

Visit www.mybluepartd.com/pharmacies/il to view the pharmacies in our network.

* For illustrative purposes only, using the Basic Plan and Preferred Pharmacy. Copay amounts are per prescription and assume member has not reached $2,850 in annual drug costs.

Save at the Pharmacy

Drug Tier Preferred Pharmacy 30-Day Supply Preferred Pharmacy 90-Day Supply Non-Preferred Pharmacy 90-Day Supply

Estimated*

Savings

Tier 1:

Preferred Generic Drug $1 copay $2.50 copay $18 copay $15.50 Tier 3:

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Should you stay with your plan or switch?

If you’ve decided to switch plans, it’s time to enroll. Use this chart to confirm your decision.

Your plan may still meet your needs if

any of these is true:

Consider switching to another plan if

any of these is true:

I don’t currently take any prescription drugs.

I use the same prescription drugs as last year, and they are still on my plan’s formulary. My costs (premiums, deductible, copays), while different, are still within my budget.

I need more coverage. I need a lower-cost plan.

My current plan may not cover my prescription drugs next year.

If your current plan still meets your needs, you don’t need to do anything.

Select a plan to meet your current needs and see page 13 for enrollment options.

Have these items handy:

Your red, white and blue Medicare card

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Enroll in Blue Cross MedicareRx

Choose one of these easy ways to enroll.

Call

Our product specialist will walk you through enrolling in Blue Cross MedicareRx.

Call:

1-877-213-2831 TTY/TDD 711

Attend a free seminar.

www.bcbsil.com/ medicare/seminars

Meet with a local agent.

www.bcbsil.com/ medicareagents

Mail

Fill out the enclosed enrollment form. To avoid processing delays, check that you:

Select the plan (Basic, Value or Plus) you want.

Copy your Medicare number exactly as printed on your Medicare ID card. Sign the form. Mail the white copy in the postage-paid envelope. The blue copy is for your records.

Web

Our secure online form has simple, step-by-step instructions that make enrollment easy. Go to:

www.mybluepartd. com/enroll/il

Medicare beneficiaries may also enroll in Blue Cross MedicareRx through the CMS Medicare Online Enrollment

Center located at

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Welcome Kit

About two weeks after you get your ID card, you’ll receive your Welcome Kit. It will include your Evidence of Coverage along with everything you’ll need to know about being a member of Blue Cross MedicareRx.

After you enroll

Look for these communications.

Acknowledgement Letter

We will send you a letter within 10 days of receiving your enrollment form. If you enrolled with an agent or broker, you’ll get a phone call to confirm your enrollment and to answer any questions you may have.

Confirmation Letter/ID Card

After your enrollment has been approved, we’ll send you a confirmation letter. It will include your Blue Cross MedicareRx ID card and the date your coverage will be effective.

LifeTimes offers news you can use

Watch your mailbox for LifeTimes, our quarterly newsletter filled with information and articles you’re sure to enjoy, or view it online at www.bcbsil.com/lifetimes.

Blue Access for Members

SM

_(BAM)

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Important Information

Limitations and Exclusions

There are items and services not covered by Blue Cross MedicareRx. These are called limitations and exclusions. A full list can be found in the Evidence of Coverage. Here is a limited list. Blue Cross MedicareRx cannot cover a drug purchased outside the U.S. and its territories. Blue Cross MedicareRx does not cover:

• Over-the-counter (OTC) drugs • Drugs when used to aid fertility

• Drugs when used to ease signs of cough or cold • Drugs when used for cosmetic purposes or to aid hair

growth

• Vitamins and mineral products ordered by a doctor, except vitamins for pregnant women and fluoride preparations

• Drugs when used for the care of sexual or erectile dysfunction, such as Viagra, Cialis, Levitra, and Caverject

• Drugs when used for care of anorexia, weight loss, or weight gain

• Outpatient drugs for which the manufacturer calls for tests or monitoring services to be bought only from the drug maker as a term of sale

• Barbiturates and Benzodiazepines (starting January 1, 2013 a limited number of these products will be covered for specific indications)

Quantity limits, step therapy, and prior authorization may apply. Look in the online Comprehensive Formulary for more information.

What are my protections under

Blue Cross MedicareRx?

Blue Cross MedicareRx agrees to stay in the

program for a full year at a time. Each year, the plan decides whether to carry on for another year. Even if Blue Cross MedicareRx leaves the program, you will not lose Medicare coverage.

Grievances and Appeals

If you have a problem with our plan, there are two formal processes in place to address your issue: appeal and grievance. An appeal is something you do if you disagree with a decision to deny a request for prescription drugs or payment for services or drugs you already received. You may also make an appeal if you disagree with a decision to stop services that you are receiving. For example, you may ask for an appeal if our plan doesn’t pay for a drug, item, or service you think you should be able to receive. A grievance is a type of complaint you make about us or one of our network pharmacies, including a complaint concerning the quality of your care. This type of complaint does not involve coverage or payment disputes. For more information, please call us.

PLEASE NOTE:

This information is available for free in other languages. Please contact our Customer Service number at 1-877-213-2831 for additional

information. (TTY/TDD users should call 711). We are open between 8 a.m. and 8 p.m., local time, 7 days a week. If you are calling from February 15 through September 30, alternate technologies (for example, voicemail) will be used on the weekends and holidays. TTY/TDD: 711.

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Use our online selection tool or call us.

Web

Our secure online selection tool has simple, step-by-step instructions that make it easy: www.mybluepartd.com

Seminars

Find an educational seminar near you: www.bcbsil .com/medicare/seminars

Call

Our product specialist will walk you through your options: 1-877-213-2831 • TTY/TDD 711

Make the right choice for your peace of mind.

Medicare Supplement Insurance Plan Notice:

Medicare Supplement insurance plans are offered by Blue Cross and Blue Shield of Illinois, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association.

Medicare Part D Plan Notice: