Employer Group
Tufts Medicare Preferred PDP Plus
Summary of Benefits
TufTS MEDicarE PrEfErrED PDP PLaNS
|
2015
Look inside • Plan benefits • Service area listing
SECTION I
INTRODUCTION TO SUMMARY OF BENEFITS
You have choices about how to get your Medicare prescription drug benefits
• One choice is to get your Medicare prescription drug benefits through a Medicare Advantage plan that offers prescription drug coverage.
• Another choice is to get your Medicare prescription drug benefits by joining a Medicare Prescription Drug Plan (such as Tufts Medicare Preferred PDP Plus).
Tips for comparing your prescription drug coverage choices
This Summary of Benefits booklet gives you a summary of what Tufts Medicare Preferred PDP Plus covers and what you pay.
• If you want to compare our plan with other prescription drug plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.
Sections in this booklet
• Things to Know About Tufts Medicare Preferred PDP Plus • Prescription Drug Benefits
This document is available in other formats such as Braille and large print.
This document may be available in a non-English language. For additional information, call us at 1-800-701-9000. Esta información está disponible gratis en otros idiomas. Para obtener información adicional llame nuestro Servicios para Miembros al 1-800-701-9000.
Things to Know About Tufts Medicare Preferred PDP Plus Hours of Operation
• From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. • From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m.
Eastern time.
Tufts Medicare Preferred PDP Plus Phone Numbers and Website
• If you are a member of this plan, call toll-free 1-800-701-9000. • If you are not a member of this plan, call toll-free 1-800-936-1902. • Our website: tuftsmedicarepreferred.org
Who can join?
To join Tufts Medicare Preferred PDP Plus, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live anywhere in the United States, including Puerto Rico.
If you are enrolled in a MA coordinated care (HMO or PPO) plan or a 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 a MA Medical Savings Account (MSA) plan may enroll in a PDP. Enrollees in a 1876 Cost plan my enroll in a PDP.
Which pharmacies can I use?
Tufts Medicare Preferred PDP Plus has a network of pharmacies. If you use the pharmacies that are not in our network, the plan may not pay for your prescriptions.
You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan’s pharmacy directory at our website (tuftsmedicarepreferred.org).
Or, call us and we will send you a copy of the pharmacy directory.
What do we cover?
We cover Part D drugs. Generally, we only cover drugs, vaccines, biological products, and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our formulary.
• You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, tuftsmedicarepreferred.org.
• Or, call us and we will send you a copy of the formulary.
How will I determine my drug costs?
Our plan groups each medication into one of three “tiers.” You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug’s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage.
If you have any questions about this plan’s benefits or costs, please contact Tufts Health Plan or Tufts Medicare Preferred for details.
How much is the monthly premium?
Please see your employer for your premium amount.
PRESCRIPTION DRUG BENEFITS
In 2015, Tufts Health Plan will include Wrap coverage in conjunction with your Part D drug coverage.
Depending on which benefit stage you are in, the Wrap covers a portion of the cost of the drug. This Wrap is additional coverage to your Tufts Medicare Preferred PDP Plan and is offered through Tufts Insurance Company. Please see below for how the Wrap works in the different stages.
Deductible Stage
You begin in this stage when you fill your first prescription of the year. During this stage: • You pay the appropriate copayment based on the tier of drug that you obtain.
• The Wrap will cover up to the Medicare Part D deductible ($320)
You stay in this stage until your year-to-date “total drug costs” (your payments plus any Wrap payments) total $320 (Medicare Part D deductible).
See cost share under the Initial Coverage Stage below.
Initial Coverage
You stay in this stage until your year-to-date total drug costs (your payments plus payments by the Part D and Wrap plans) total $2,960. During this stage:
• You pay the appropriate copayment based on the tier of drug that you obtain.
• The Wrap will pay the balance of the cost after your copayment up to 25% of the cost of the drug. • Tufts Medicare Preferred will pay for 75% of the cost of the drug
You may get your drugs at network retail pharmacies and mail order pharmacies. You pay the following:
Standard Retail Cost-Sharing
Tier One-month supply Two-month supply One-month supply
Tier 1 (Preferred Generic) $10 copay $20 copay $30 copay Tier 2 (Non-Preferred Generic) $20 copay $40 copay $60 copay Tier 3 (Preferred Brand) $35 copay $70 copay $105 copay
Standard Mail Order Cost-Sharing
Tier One-month supply Two-month supply Three-month supply
Tier 1 (Preferred Generic) $7 copay $14 copay $20 copay Tier 2 (Non-Preferred Generic) $13 copay $27 copay $40 copay Tier 3 (Preferred Brand) $23 copay $47 copay $70 copay If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
Coverage Gap
Most Medicare drug plans have a coverage gap (also called the “donut hole”). This means that there’s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2,960.
• For generic drugs on Tier 1 or Tier 2, you pay the Tier 1 or Tier 2 copayment. The Wrap will pay the balance of the cost of the generic drug until you move into the Catastrophic Stage.
• For brand name drugs on Tier 2 or Tier 3, you pay the Tier 2 or Tier 3 copayment. Until you move into the Catastrophic Stage, the Wrap will pay the balance of the cost of the brand name drug after your copayment and the 50% manufacturer’s discount.
• Both copayments and the 50% manufacturer’s discount on brand name drugs will count towards your out-of-pocket costs.
After you enter the coverage gap, you pay the following until your costs total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap.
Standard Retail Cost-Sharing
Tier One-month supply Two-month supply One-month supply
Tier 1 (Preferred Generic) $10 copay $20 copay $30 copay Tier 2 (Non-Preferred Generic) $20 copay $40 copay $60 copay Tier 3 (Preferred Brand) $35 copay $70 copay $105 copay
Standard Mail Order Cost-Sharing
Tier One-month supply Two-month supply Three-month supply
Tier 1 (Preferred Generic) $7 copay $14 copay $20 copay Tier 2 (Non-Preferred Generic) $13 copay $27 copay $40 copay Tier 3 (Preferred Brand) $23 copay $47 copay $70 copay
Catastrophic Stage
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay:
• $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. • The Wrap will pay the balance of the cost after your copayment up to 5% of the cost of the drug
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-701-9000. Someone who speaks English can help you.
This is a free service.
Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-701-9000. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。如果您需要
此翻译服务, 请致电 1-800-701-9000. 我们的中文工作人员很乐意帮助您。这是一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯
服務, 請致電 1-800-701-9000. 我們講中文的人員將樂意為您提供幫助。這是一項免費服務.
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-701-9000. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d’interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d’assurance-médicaments. Pour accéder au service d’interprétation, il vous suffit de nous appeler au 1-800-701-9000. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
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German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-701-9000. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있
습니다. 통역 서비스를 이용하려면 전화1-800-701-9000번으로 문의해 주십시오. 한국어를 하는 담당자 가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-701-9000. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: إننا نقدم خدمات المترجم الفوري المجانية للإجابة عن أي أسئلة تتعلق بالصحة أو جدول الأدوية لدينا. للحصول على مترجم فوري، ليس عليك سوى الاتصال بنا على1-800-701-9000. سيقوم شخص ما يتحدث العربية بمساعدتك. هذه خدمة مجانية. Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-800-701-9000 पर फोन करें. कोई व्यक्ति जो हिन्दी बोलता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-701-9000. Un nostro incaricato che parla Italianovi fornirà l’assistenza necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-701-9000. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-701-9000. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-701-9000. Ta usługa jest bezpłatna.
Japanese:当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために、無料の通訳
サービスがありますございます。通訳をご用命になるには、1-800-701-9000にお電話ください。日本 語を話す人 者 が支援いたします。これは無料のサービスです。
Tufts Health Plan Medicare Preferred is a PDP plan with a Medicare contract. Enrollment in Tufts Health Plan Medicare Preferred depends on contract renewal.
This information is available for free in other languages. Please call our Customer Relations number at 1-800-701-9000 or, for TTY users, 1-800-208-9562, Monday - Friday 8:00 a.m. - 8:00 p.m. (from Oct. 1 - Feb. 14 representatives are available 7 days a week, 8:00 a.m. - 8:00 p.m.). After hours and on holidays, please leave a message and a representative will return your call on the next business day. Esta información está disponible gratuitamente en otros idiomas. Sírvase llamar a nuestro número de Servicio al Cliente al 1-800-701-9000 o, para usuarios con problemas auditivos (TTY), al 1-800-208-9562, de lunes a viernes, desde las 8:00 a.m. hasta las 8:00 p.m. (desde el 1 de octubre hasta el 14 de febrero hay representantes disponibles los 7 días de la semana, desde las 8:00 a.m. hasta las 8:00 p.m.). Después del horario de atención y en días feriados, por favor deje un mensaje y un representante le devolverá su llamada el día laborable siguiente.
QuESTioNS?
call 1-800-936-1902
//
TTY 1-888-899-8977
Representatives are available Monday – Friday, 8 a.m. – 8 p.m. (From October 1 – February 14, representatives are available 7 days a week, 8 a.m. – 8 p.m.). After hours and on holidays, please leave a message and a representative will return your call on the next business day.
