Prime Solution Retiree Plan
(Blue Cross Blue Shield with separate pharmacy coverage through Group
MedicareBlue Rx)
Freedom HealthPartners Retiree National
Choice*
Seniorsfor
Plan Type Medicare Cost Plan with Prescription Drug Coverage
Medicare Cost Plan with Prescription Drug Coverage
Medicare Advantage Plan with Prescription Drug Coverage
How Plan works with Medicare and Medicare Assignment
Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses. Medica pays Medicare coinsurance and deductible. Medica pays primary for Medicare Part B provider expenses.
You are encouraged to use Medica network providers, but you do not
assign your Medicare benefits to Medica.
You are allowed to use your Medicare benefits outside of the Medica network.
Medicare pays primary for Part A inpatient hospital, skilled nursing facility, and home health care expenses.
HealthPartners pays Medicare coinsurance and deductible.
HealthPartners pays primary for Medicare Part B provider expenses.
You are encouraged to use HealthPartners network providers, but you do not assign your Medicare benefits to HealthPartners.
You are allowed to use your Medicare benefits outside of the HealthPartners network.
* See Page 15 for how this plan works with Medicare.
UCare administers benefits and claims payment of Medicare Parts A and B, as well as the additional benefits included in the plan, such as Prescription Drug coverage (Part D) and preventive care.
Bills for health care services are sent directly to UCare by providers (not to Medicare) and are processed in the UCare Claims Department.
You cannot use your Medicare benefits outside of the UCare network
Medicare Part B You must enroll in Medicare Part B.
Premiums are paid by reducing your Social Security payment.
You must enroll in Medicare Part B.
Premiums are paid by reducing your Social Security payment.
You must enroll in Medicare Part B.
Premiums are paid by reducing your Social Security payment.
You must enroll in Medicare Part B.
Premiums are paid by reducing your Social Security payment.
Medicare Part D You are automatically enrolled in Medicare Part D through the plan. Premiums paid to plan cover the cost of Medicare Part D.
You are automatically enrolled in Medicare Part D through the plan. Premiums paid to plan cover the cost of Medicare Part D.
You are automatically enrolled in Medicare Part D through the plan. Premiums paid to plan cover the cost of Medicare Part D.
You are automatically enrolled in Medicare Part D through the plan. Premiums paid to plan cover the cost of Medicare Part D.
Coordinates with Medicare and includes Medicare prescription drug program
U of M Retiree Plan pays after applying U of M Retiree Plan inpatient deductible and coinsurance.
You pay Medicare Part B annual deductible.
You are encouraged to use BCBS network providers, but you do not assign your Medicare benefits to Blue Cross. You are allowed to use your U of M Retiree Plan benefits outside of the BCBS network.
Office Visit $15 copay No copay $15 copay $15 copay
Emergency
Services 100% worldwide coverage; $50
copay if not admitted
100% after Medicare Part B annual deductible
($162 for 2011; amount may change for 2012)
100%, $50 copay if
not admitted 100% worldwide coverage; $50 copay
if not admitted
Ambulance 100% 100% after Medicare
Part B annual deductible ($162 for 2011; amount
may change for 2012)
100% 100%
Urgent Care
Office Visit 100% after $15
copay 100% after Medicare Part B annual deductible
($162 for 2011; amount may change for 2012)
100% after $15
copay 100% after $20
copay
Hospital
Skilled Nursing Facilities
Mental Health
Chemical Dependency
100%
100% after 3-day hospitalization for up to 100 days per
benefit period
100% up to 365-day lifetime limit
100%
Plan pays 80% of first
$2,900 of total allowed amount following the $100 annual inpatient deductible;
100% thereafter through end of calendar year. Your out- of-pocket expense is limited
to $680 per year, including
$100 annual inpatient deductible.
Same as above
Same as above
Same as above
100%
100% after 3-day hospitalization for up to 100 days per
benefit period
100% up to 190-day lifetime limit
100%
100%
100% for up to 100 days per benefit
period (3-day hospital stay not
required) 100% up to 190-day
lifetime limit
100%
Inpatient
Outpatient
Preventive Care 100% 100% 100% 100%
Physician 100% after $15
copay 100% after Medicare Part B annual
deductible ($162 for 2011; amount
may change for 2012)
100% after $15
copay 100% after $15 copay (no copay for routine visits)
Eye and Hearing
Exams (routine) 100% after $15
copay 100% of allowed
amount 100% 100%; $75 annual
allowance toward lenses and frames
Outpatient/
Surgery 100% 100% after Medicare
Part B annual deductible ($162 for 2011; amount
may change for 2012)
100% 100%
Outpatient
Mental Health 100% after $15
copay 100% after Medicare Part B annual
deductible ($162 for 2011; amount
may change for 2012)
100% after $15 copay; $7.50 copay
for group therapy
100% after $15 copay
Outpatient Chemical Dependency
Chiropractic Care
Physical and Occupational Therapy
100% after $15 copay
100% after $15 copay
100% after $15 copay
100% after Medicare Part B annual
deductible ($162 for 2011; amount
may change for 2012) 100% after Medicare
Part B annual deductible ($162 for 2011; amount
may change for 2012)
100% after Medicare Part B annual
deductible ($162 for 2011; amount may change for 2012)
100% after $15 copay
100%
100%
100% after $15 copay
100% for Medicare- approved services at UCare-affiliated
chiropractor 100% after $15
copay Prime Solution Retiree Plan
(Blue Cross Blue Shield with separate pharmacy coverage through Group
MedicareBlue Rx)
Freedom HealthPartners Retiree National
Choice
Seniorsfor
Health Care Services
Speech and Language Therapy
100% after $15
copay 100% after Medicare Part B annual
deductible ($162 for 2011; amount
may change for 2012)
100% after $15
copay 100% after $15
copay
Home Health
Care 100% of Medicare-
approved amount for medically necessary
skilled care
100% of Medicare- approved amount for
medically necessary skilled care
100% of Medicare- approved amount for medically necessary
skilled care
100% of Medicare- approved amount for
medically necessary skilled care
Generic Drugs -
Retail Pharmacy $10 copay
for 31-day supply $10 copay
for 31-day supply $10 copay
for 30-day supply Up to a $10 copay for 34-day supply
Formulary Brand Drugs - Retail Pharmacy
$30 copay
for 31-day supply $30 copay for Preferred Brand and
Specialty Drugs for 31-day supply
$30 copay
for 30-day supply $30 copay for 34-day supply
Non-Preferred Formulary Brand Drugs - Retail Pharmacy
$30 copay for 31-day
supply $50 copay for
Non-Preferred Brand drugs
$30 copay for 30-day
supply $30 copay
for 34-day supply
Supplemental Covered under 25% coinsurance Covered under Covered under
Drug Benefit above copays above copays above copays
Drugs Purchased 3-month supply 3-month supply 3-month supply 3-month supply by Mail Order available for 2 available for 2 available for 2 (102 day) available copays through copays through copays through for 2 copays through mail order mail order or if using mail order mail order and at
Preferred Extended participating
Pharmacy (PXT) within pharmacies
Group MedicareBlue
RX Pharmacy network
Non-Formulary Not applicable Prior authorization Not applicable Not applicable required
Prescription
Drugs
Note: Separate card provided for pharmacy
coverage through MedicareBlue Rx
Catastrophic Pharmacy 30-day supply
If total prescription drug out-of-pocket expenses exceed
$4,700 per year, member cost will be the lesser of:
• drug cost or
• $10 copay for generic drugs and
• $30 copay for brand/non-preferred brand/specialty
drugs
If total prescription drug out-of-pocket expenses including drug manufacturer discounts exceed $4,700 per year, member cost will be the greater of:
• 5% of drug cost or
• $2.60 copay for generic drugs and
• $6.50 copay for brand/formulary drugs
If total prescription drug out-of-pocket expenses exceed
$4,700 per year, member cost will be the lesser of:
• drug cost or
• $10 copay for generic drugs and
• $30 copay for brand/non-preferred brand/specialty drugs
If total prescription drug out-of-pocket expenses exceed
$4,700 per year, member cost will be the lesser of:
• drug cost or
• $10 copay for generic drugs and
• $30 copay for brand/non-preferred brand/specialty drugs
Prosthetics, Durable Medical Equipment, Hearing Aids
100%, $500 for
hearing aids 100%,
80% for hearing aids every 3 years
90%, including diabetic supplies;
80% for hearing aids every 3 years
100% prosthetics and diabetic supplies;
80% durable medical equipment; $500 every 36 months for
hearing aids
Travel Coverage/
Extended Absence
May be out of service area for up
to 9 consecutive months; benefits must be activated by calling Member
Services
No limitations May be out of service area for up to 9 consecutive months;
benefits must be activated by calling
Member Services
May be out of service area for up to 6 consecutive months;
then eligible for emergency services with $50 copay if not admitted, and non- emergency service at 80%; no need to notify
Member Services
Maximum Annual Out-of- Pocket (including deductible and coinsurance)
Lifetime Maximum
$1,000 for medical cost sharing; No cap on prescription
cost sharing
Unlimited
$842, $680 plus $132, Medicare B deductible amounts may change for 2012, (pharmacy
copayments do not count toward annual out-of-pocket
maximum)
Unlimited
$3,000 (pharmacy copayments do not count toward annual out-of-pocket
maximum)
Unlimited
$3,400 (pharmacy copays, hearing/
eyeware, and co-insurance for non-emergency out-
of-network care do not count toward annual maximum)
Unlimited
Travel
Medical Equipment
Maximums
Prime Solution Retiree Plan
Blue Cross Blue Shield with separate pharmacy coverage through Group
MedicareBlue Rx)
Freedom HealthPartners Retiree National
Choice
Seniorsfor
