GHI and HIP are EmblemHealth companies
SuMMAry of benefitS
2011 Medicare Prescription Drug Plan (PDP)
new york State
S5966_121953 CMS Approved 9/15/2010
Medicare Summary of benefits
INTRODUCTION
I
ntroductiontotheSummaryofBenefits WHO IS ELIGIBLE TO JOIN?
MedicarePrescriptionDrugPlan(PDP)
You can join this plan if you are entitled to Medicare
January1,2011-December31,2011
Part A and/or enrolled in Medicare Part B and live in
NEWYORKSTATE
the service area.
Thank you for your interest in Medicare Prescription
If you are enrolled in an MA coordinated care (HMO or
Drug Plan (PDP). Our plan is offered by GROUP
PPO) plan or an MA PFFS plan that includes Medicare
HEALTH INCORPORATED/EmblemHealth Medi-
prescription drugs, you may not enroll in a PDP unless
care PDP, a Medicare Prescription Drug Plan that
you disenroll from the HMO, PPO or MA PFFS plan.
contracts with the Federal government. This Summary
of Benefits tells you some features of our plan. It doesn’t Enrollees in a private fee-for-service plan (PFFS) that
list every drug we cover, every limitation, or exclu- does not provide Medicare prescription drug coverage,
sion. To get a complete list of our benefits, please call or an MA Medical Savings Account (MSA) plan may
Medicare Prescription Drug Plan (PDP) and ask for the enroll in a PDP. Enrollees in an 1876 Cost plan may
“Evidence of Coverage”. enroll in a PDP.
YOU HAVE CHOICES IN YOUR MEDICARE WHERE CAN I GET MY PRESCRIPTIONS?
PRESCRIPTION DRUG COVERAGE Medicare Prescription Drug Plan (PDP) has formed a
As a Medicare beneficiary, you can choose from different network of pharmacies. You must use a network phar-
Medicare prescription drug coverage options. One option macy to receive plan benefits. We will not pay for your
is to get prescription drug coverage through a Medicare prescriptions if you use an out-of-network pharmacy,
Prescription Drug Plan, like Medicare Prescription Drug except in certain cases.
Plan (PDP). Another option is to get your prescription Medicare Prescription Drug Plan (PDP) has a list of pre-
drug coverage through a Medicare Advantage Plan that ferred pharmacies. At these pharmacies, you may get your
offers prescription drug coverage. You make the choice. drugs at a lower co-pay or co-insurance. A non-preferred
pharmacy is still a network pharmacy, but you may have
HOW CAN I COMPARE MY OPTIONS?
to pay more for your prescription drugs.
The charts in this booklet list some important drug ben-
The pharmacies in our network can change at any
efits. You can use this Summary of Benefits to compare
time. You can ask for a Pharmacy Directory or visit us
the benefits offered by Medicare Prescription Drug Plan
at www.emblemhealth.com. Our customer service
(PDP) to the benefits offered by other Medicare Pre-
number is listed at the end of this introduction.
scription Drug Plans or Medicare Advantage Plans with
prescription drug coverage. DOES MY PLAN COVER MEDICARE PART
WHERE IS MEDICARE PRESCRIPTION B OR PART D DRUGS?
DRUG PLAN (PDP) AVAILABLE? Medicare Prescription Drug Plan (PDP) does not
The service area for this plan The service area for this cover drugs that are covered under Medicare Part B
plan includes: New York. You must live in one of these as prescribed and dispensed. Generally, we only cover
areas to join this plan. drugs, vaccines, biological products and medical sup-
S5966_121953 CMS Approved 9/15/2010 1
plies that are covered under the Medicare Prescription with other Medicare costs. To see if you qualify for
Drug Benefit (Part D) and that are on our formulary. getting extra help, call:
• 1-800-MEDICARE (1-800-633-4227).
WHAT IS A PRESCRIPTION DRUG
TTY/TDD users should call 1-877-486-2048,
FORMULARY?
24 hours a day/7 days a week; and see
Medicare Prescription Drug Plan (PDP) uses a for- www.medicare.gov ‘Programs for People with
mulary. A formulary is a list of drugs covered by your Limited Income and Resources’ in the publication
plan to meet patient needs. We may periodically add, Medicare & You.
remove, or make changes to coverage limitations on
• The Social Security Administration at
certain drugs or change how much you pay for a drug.
1-800-772-1213 between 7 a.m. and 7 p.m.,
If we make any formulary change that limits our
Monday through Friday. TTY/TDD users should
members’ ability to fill their prescriptions, we will no-
call 1-800-325-0778; or
tify the affected enrollees before the change is
made. We will send a formulary to you and you • Your State Medicaid Office.
can see our complete formulary on our Web site at
www.emblemhealth.com. WHAT ARE MY PROTECTIONS IN
THIS PLAN?
If you are currently taking a drug that is not on our
formulary or subject to additional requirements or All Medicare Prescription Drug Plans agree to stay in
limits, you may be able to get a temporary supply of the program for a full year at a time. Each year, the
the drug. You can contact us to request an exception or plans decide whether to continue for another year.
switch to an alternative drug listed on our formulary Even if a Medicare Prescription Drug Plan leaves the
with your physician’s help. Call us to see if you can program, you will not lose Medicare coverage. If a plan
get a temporary supply of the drug or for more details decides not to continue, it must send you a letter at
about our drug transition policy. least 90 days before your coverage will end. The letter
will explain your options for Medicare coverage in
WHAT SHOULD I DO IF I HAVE OTHER your area.
INSURANCE IN ADDITION TO MEDICARE? As a member of Medicare Prescription Drug Plan
If you have a Medigap (Medicare Supplement) policy (PDP), you have the right to request a coverage de-
that includes prescription drug coverage, you must termination, which includes the right to request an
contact your Medigap Issuer to let them know that exception, the right to file an appeal if we deny cov-
you have joined a Medicare Prescription Drug Plan. If erage for a prescription drug, and the right to file a
you decide to keep your current Medigap supplement grievance. You have the right to request a coverage
policy, your Medigap Issuer will remove the prescrip- determination if you want us to cover a Part D drug
tion drug coverage portion of your policy. Call your that you believe should be covered. An exception is a
Medigap Issuer for details. type of coverage determination. You may ask us for an
exception if you believe you need a drug that is not on
If you or your spouse has, or is able to get, employer our list of covered drugs or believe you should get a
group coverage, you should talk to your employer to non-preferred drug at a lower out-of-pocket cost. You
find out how your benefits will be affected if you join can also ask for an exception to cost utilization rules,
Medicare Prescription Drug Plan (PDP). Get this such as a limit on the quantity of a drug. If you think
information before you decide to enroll in this plan. you need an exception, you should contact us before
you try to fill your prescription at a pharmacy. Your
HOW CAN I GET EXTRA HELP WITH
doctor must provide a statement to support your ex-
MY PRESCRIPTION DRUG PLAN COSTS
ception request. If we deny coverage for your prescrip-
OR GET EXTRA HELP WITH OTHER
tion drug(s), you have the right to appeal and ask us to
MEDICARE COSTS?
review our decision. Finally, you have the right to file
You may be able to get extra help to pay for your pre- a grievance if you have any type of problem with us or
scription drug premiums and costs as well as get help
2
one of our network pharmacies that does not involve WHERE CAN I FIND INFORMATION ON
coverage for a prescription drug. If your problem PLAN RATINGS?
involves quality of care, you also have the right to file
The Medicare program rates how well plans perform
a grievance with the Quality Improvement Organiza-
in different categories (for example, detecting and
tion (QIO) for your state. Please refer to the Evidence
preventing illness, ratings from patients and customer
of Coverage (EOC) for the QIO contact information.
service). If you have access to the web, you may use the
WHAT IS A MEDICATION THERAPY web tools on www.medicare.gov and select “Com-
MANAGEMENT (MTM) PROGRAM? pare Medicare Prescription Drug Plans” or “Compare
Health Plans and Medigap Policies in Your Area” to
A Medication Therapy Management (MTM) Program compare the plan ratings for Medicare plans in your
is a free service we offer. You may be invited to partici- area. You can also call us directly to obtain a copy of the
pate in a program designed for your specific health and plan ratings for this plan. Our customer service number
pharmacy needs. You may decide not to participate but is listed below.
it is recommended that you take full advantage of this
covered service if you are selected. Contact Medicare
Prescription Drug Plan (PDP) for more details.
PLEASE CALL EMBLEMHEALTH FOR MORE INFORMATION
ABOUT MEDICARE PRESCRIPTION DRUG PLAN (PDP).
Visit us at www.emblemhealth.com or, call us:
Customer Service Hours:
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8 a.m. - 8 p.m. Eastern
Current members should call toll-free (877)-444-7097 for questions related to the Medicare
Advantage Program. (TTY/TDD (866)-248-0640)
Prospective members should call toll-free (800)-325-9792 for questions related to the Medicare
Advantage Program. (TTY/TDD (877)-444-2786)
Current members should call toll-free (877)-444-7097 for questions related to the Medicare Part D
Prescription Drug program. (TTY/TDD (888)-447-4833)
Prospective members should call toll-free (800)-325-9792 for questions related to the Medicare Part
D Prescription Drug program. (TTY/TDD (877)-444-2786)
For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
Or, visit www.medicare.gov on the web.
This document may be available in a different format or language.
For additional information, call customer service at the phone number listed above.
3
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs Most drugs are not covered under DrugsCoveredunderMedicare
Original Medicare. You can add pre- PartD
scription drug coverage to Original
General
Medicare by joining a Medicare
Prescription Drug Plan, or you can Most people will pay their Part D
get all your Medicare coverage, premium. However some people
including prescription drug coverage, will pay a higher premium because
by joining a Medicare Advantage of their yearly income (over $85,000
Plan or a Medicare Cost Plan that for singles, $170,000 for married
offers prescription drug coverage. couples). For more information about
Part D premiums based on income,
call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users should
call 1-877-486-2048. You may also call
Social Security at 1-800-772-1213.
TTY users should call 1-800-325-0778.
This plan uses a formulary. The plan
will send you the formulary. You
can also see the formulary at
www.emblemhealth.com.on
the web.
Different out-of-pocket costs may
apply for people who
-have limited incomes,
-live in long term care facilities,
or
-have access to Indian/Tribal/Urban
(Indian Health Service).
$55.50 monthly premium
The plan offers national in-network
prescription coverage (i.e., this would
include 50 states and DC). This means
that you will pay the same cost-
sharing amount for your prescription
drugs if you get them at an in-network
4
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs pharmacy outside of the plan’s service
area (for instance when you travel).
(Continued)
Total yearly drug costs are the total
drug costs paid by both you and the
plan.
The plan may require you to first
try one drug to treat your condition
before it will cover another drug for
that condition.
Some drugs have quantity limits.
Your provider must get prior autho-
rization from Medicare Prescription
Drug Plan (PDP) for certain drugs.
You must go to certain pharmacies
for a very limited number of drugs,
due to special handling, provider
coordination, or patient education
requirements that cannot be met by
most pharmacies in your network.
These drugs are listed on the plan’s
website, formulary, printed materi-
als, as well as on the Medicare
Prescription Drug Plan Finder on
www.medicare.gov.
If the actual cost of a drug is less
than the normal cost-sharing amount
for that drug, you will pay the actual
cost, not the higher cost-sharing
amount.
If you request a formulary exception
for a drug and Medicare Prescription
Drug Plan (PDP) approves the excep-
tion, you will pay Tier 3: Non-Preferred
Generic and Non-Preferred Brand
Drugs cost sharing for that drug.
5
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs In-Network
(Continued) $310 yearly deductible.
InitialCoverage
After you pay your yearly deduct-
ible, you pay the following until total
yearly drug costs reach $2,840:
RetailPharmacy
Tier1:PreferredGenericDrugs
- $4 copay for a one-month (30-day)
supply of drugs in this tier from a
preferred pharmacy
- $8 copay for a three-month (90-day)
supply of drugs in this tier from a
preferred pharmacy
- $12 copay for a 60-day supply of
drugs in this tier from a preferred
pharmacy
- $4 copay for a one-month (30-day)
supply of drugs in this tier from a non-
preferred pharmacy
- $12 copay for a three-month (90-
day) supply of drugs in this tier from a
non-preferred pharmacy
- $12 copay for a 60-day supply of
drugs in this tier from a non-preferred
pharmacy
Not all drugs on this tier are available
at this extended day supply. Please
contact the plan for more information.
Tier2:PreferredBrandDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a preferred pharmacy
6
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs - 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
(Continued)
from a preferred pharmacy
- 25% coinsurance for a 60-day sup-
ply of drugs in this tier from a pre-
ferred pharmacy
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a non-preferred pharmacy
- 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
from a non-preferred pharmacy
- 25% copay for a 60-day supply of
drugs in this tier from a non-preferred
pharmacy
Not all drugs on this tier are available
at this extended day supply. Please
contact the plan for more information.
Tier3:Non-PreferredGeneric
andNon-PreferredBrandDrugs
- 30% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a preferred pharmacy
- 30% coinsurance for a three-month
(90-day) supply of drugs in this tier
from a preferred pharmacy
- 30% coinsurance for a 60-day sup-
ply of drugs in this tier from a pre-
ferred pharmacy
- 30% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a non-preferred pharmacy
7
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs - 30% coinsurance for a three-month
(Continued) (90-day) supply of drugs in this tier
from a non-preferred pharmacy
- 30% copay for a 60-day supply of
drugs in this tier from a non-preferred
pharmacyNot all drugs on this tier are
available at this extended day supply.
Please contact the plan for more
information.
Tier4:SpecialtyTierDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a preferred pharmacy
- 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
from a preferred pharmacy
- 25% coinsurance for a 60-day sup-
ply of drugs in this tier from a pre-
ferred pharmacy
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
from a non-preferred pharmacy
- 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
from a non-preferred pharmacy
- 25% copay for a 60-day supply of
drugs in this tier from a non-preferred
pharmacy
Not all drugs on this tier are available
at this extended day supply. Please
contact the plan for more information.
8
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs LongTermCarePharmacy
(Continued) Tier1:PreferredGenericDrugs
- $4 copay for a one-month (31-day)
supply of drugs in this tier
Tier2:PreferredBrandDrugs
- 25% coinsurance for a one-month
(31-day) supply of drugs in this tier
Tier3:Non-PreferredGeneric
andNon-PreferredBrandDrugs
- 30% coinsurance for a one-month
(31-day) supply of drugs in this tier
Tier4:SpecialtyTierDrugs
- 25% coinsurance for a one-month
(31-day) supply of drugs in this tier
MailOrder
Tier1:PreferredGenericDrugs
- $4 copay for a one-month (30-day)
supply of drugs in this tier
- $8 copay for a three-month (90-day)
supply of drugs in this tier
- $8 copay for a 60-day supply of
drugs in this tier
Not all drugs on this tier are available
at this extended day supply. Please
contact the plan for more information.
Tier2:PreferredBrandDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
- 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
9
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs - 25% coinsurance for a 60-day sup-
(Continued) ply of drugs in this tier
Not all drugs on this tier are avail-
able at this extended day supply.
Please contact the plan for more
information.
Tier3:Non-PreferredGeneric
andNon-PreferredBrandDrugs
- 30% coinsurance for a one-month
(30-day) supply of drugs in this tier
- 30% coinsurance for a three-month
(90-day) supply of drugs in this tier
- 30% coinsurance for a 60-day sup-
ply of drugs in this tier
Not all drugs on this tier are avail-
able at this extended day supply.
Please contact the plan for more
information.
Tier4:SpecialtyTierDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
- 25% coinsurance for a three-month
(90-day) supply of drugs in this tier
- 25% coinsurance for a 60-day
supply of drugs in this tier Not all
drugs on this tier are available at this
extended day supply. Please contact
the plan for more information.
10
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs CoverageGap
(Continued) After your total yearly drug costs
reach $2,840, you pay 100% until
your yearly out-of-pocket drug costs
reach $4,550.
CatastrophicCoverage
After your yearly out-of-pocket drug
costs reach $4,550, you pay the
greater of:
- A $2.50 copay for generic (includ-
ing brand drugs treated as ge-
neric) and a $6.30 copay for all other
drugs,
or
- 5% coinsurance.
Out-of-Network
Plan drugs may be covered in special
circumstances, for instance, illness
while traveling outside of the plan’s
service area where there is no net-
work pharmacy. You may have to pay
more than your normal cost-sharing
amount if you get your drugs at an
out-of-network pharmacy. In addi-
tion, you will likely have to pay the
pharmacy’s full charge for the drug
and submit documentation to receive
reimbursement from Medicare Pre-
scription Drug Plan (PDP).
Out-of-NetworkInitialCoverage
After you pay your yearly deductible,
you will be reimbursed up to the full
cost of the drug minus the following for
drugs purchased out-of-network until
total yearly drug costs reach $2,840:
11
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs Tier1:PreferredGenericDrugs
(Continued) - $4 copay for a one-month (30-day)
supply of drugs in this tier
Tier2:PreferredBrandDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this
tierTier3:Non-PreferredGeneric
andNon-PreferredBrandDrugs
- 30% coinsurance for a one-month
(30-day) supply of drugs in this tier
Tier4:SpecialtyTierDrugs
- 25% coinsurance for a one-month
(30-day) supply of drugs in this tier
You will not be reimbursed for the
difference between the Out-of-Net-
work Pharmacy charge and the plan’s
In-Network allowable amount.
Out-of-NetworkCoverageGap
After your total yearly drug costs
reach $2,840, you pay 100% of the
pharmacy’s full charge for drugs
purchased out-of-network until your
yearly out-of-pocket drug costs reach
$4,550. You will not be reimbursed
by Medicare Prescription Drug Plan
(PDP) for out-of-network purchases
when you are in the coverage gap.
However, you should still submit
documentation to Medicare Pre-
scription Drug Plan (PDP) so we can
add the amounts you spent out-of-
network to your total out-of-pocket
costs for the year.
12
Medicare Summary of benefits
IN-NETWORK AND OUT-OF-NETWORK COVERAGE
NEW YORK STATE
Medicare Prescription
Benefit Original Medicare Drug Plan (PDP)
Prescription Drugs You will not be reimbursed for the
difference between the Out-of-Net-
(Continued)
work Pharmacy charge and the plan’s
In-Network allowable amount.
Out-of-Network
CatastrophicCoverage
After your yearly out-of-pocket drug
costs reach $4,550, you will be
reimbursed for drugs purchased out-
of-network up to the full cost of the
drug minus your cost share, which is
the greater of:
- A $2.50 copay for generic (including
brand drugs treated as generic) and a
$6.30 copay for all other drugs,
or
- 5% coinsurance.
You will not be reimbursed for the
difference between the Out-of-
Network Pharmacy charge and the
In-Network allowable amount.
13
Medicare Prescription Drug Plan (PDP)
We understand that getting a grasp on tion drug plan. This plan offers
both generic and brand name drugs from the
your prescription drug coverage can be
EmblemHealth Medicare Drug Formulary.
confusing. that’s why we’ve produced
Drugs that are not on the EmblemHealth
this Special features section to simplify
formulary are not covered.
things. it covers your prescription drug
To view the EmblemHealth Medicare Drug
coverage benefits in more detail that Formulary, visit www.EmblemHealth.com or call
were only referenced in the prior EmblemHealth Customer Service.
section of the Summary of benefits The EmblemHealth Formulary is organized into
charts. now let’s get started. four Tiers of coverage:
Tier 1 Preferred Generic formulary medications
Tier 2 Preferred Brand formulary medications
Tier 3 Non-preferred Generic/Brand formulary medi-
cations
Tier 4 Specialty formulary medications
THE EMBLEMHEALTH DRUG FORMULARY
The EmblemHealth Drug Formulary is a list of both
brand name and generic drugs covered by
EmblemHealth. Drugs that are not on the
EmblemHealth formulary are not covered. Members
who use Tier 1 Preferred Generic prescription drugs
SAVE EVEN MORE: MEDICARE SAVINGS will receive the best value and lowest cost available
PROGRAM under the plan.
If your monthly income is less than $1,239 ($1,660 EmblemHealth is dedicated to providing you with
combined if married), you could be eligible for addi- treatment that is safe and effective, at the most rea-
tional benefits from New York State through the State sonable and affordable cost. Treatment with generic
medical assistance program. This may even include medications is one way that you can save money at the
receiving more money in your Social Security checks. To pharmacy and continue to maintain your health.
learn more and see if you may be eligible, call
The United States Food and Drug Administration
1-800-325-9792 Monday to Friday, 9 am - 5 pm
(FDA) requires that generic medications stocked in a
(TDD: 1-877-444-2786). [Note: Referenced income
pharmacy contain the same active ingredient as the
values are for 2010 and may change.]
brand version. For example, the generic version (such
as simvastatin) must meet the same quality standards
PRESCRIPTION DRUG BENEFITS -
as the equivalent brand medication (such as Zocor).
COVERAGE WHEN YOU NEED IT The EmblemHealth Drug Formulary only includes
As a member of the Prescription Drug Plan, you are generic drugs that have met FDA standards.
enrolled in EmblemHealth’s Medicare Part D prescrip-
14
Prescription Drug Plan
DEDUCTIBLE INITIAL GAP CATASTROPHIC
$310 $310–$2,840a Over $2,840b Over $4,550c
You Pay You Pay You Pay You Pay
Tier 1
Preferred Generic
100% $4 100% 5%d
formulary
medications
Tier 2
Preferred Brand
100% 25% 100% 5%d
formulary
medications
Tier 3
Non-preferred
Brand/Generic 100% 30% 100% 5%d
formulary
medications
Tier 4
Specialty formu- 100% 25% 100% 5%d
lary medications
* After you have paid $4,550 out-of-pocket, you will pay the greater of $2.50 or 5% for generic drugs or $6.30
or 5% for Preferred Brand, Brand and Specialty Drugs.
a Amounts between $0 and $2840 are paid by both the member and the plan.
b All of these drug amounts are paid by the member, with the exception of the balance the plan pays for Tier 1
medications.
c The member enters the catastrophic phase once they have paid a total out-of-pocket amount of $4,550.
d After you have paid $4,550 out-of-pocket, you will pay the greater of $2.50 or 5% for generic drugs or $6.30
or 5% for Preferred Brand, Brand and Specialty Drugs.
To view the EmblemHealth Medicare Formulary, phase, in which you have a copay for Tier 1 drugs and
visit the EmblemHealth Medicare plans and a coinsurance (a percentage of drug cost) for Tier 2,
Part D information section of our Web site, Tier 3 and Tier 4 drugs, until the total costs, including
www.emblemhealth.com or call EmblemHealth your deductible, reach $2,840.
Customer Service.
Once the total drug costs have exceeded $2,840, you
The Drug Plan has a $310 yearly deductible. After will then pay 100% of your prescription drug costs
your deductible, you will enter the initial coverage until your true out-of-pocket drug costs reach $4,550.
15
This is called the coverage gap phase. After your yearly
true out-of-pocket costs reach $4,550, EmblemHealth
will cover your remaining drug costs, and you will
continue to have some nominal copays or coinsurance
costs beyond this expense level.
FILLING YOUR PRESCRIPTIONS
You can choose from three easy ways to fill your pre-
scriptions:
• Online at www.emblemhealth.com. Order online
through our partner, a leading Internet pharmacy
service staffed by licensed pharmacists, and save up
to 33% on applicable copays for Preferred formulary PAYMENT MADE EASY: DIRECT DEBIT
drugs.
If you must pay a monthly plan premium, you will be
• At EmblemHealth Participating Pharmacies. With billed monthly unless you have chosen to have this
a network of over 36,000 nationwide chains, local money directly deducted from your Social Security
and independent pharmacies, there is sure to be a check. Most members pay by check, but you can also
EmblemHealth participating pharmacy near you. choose to pay through our convenient Direct Debit Pro-
For a list of participating pharmacies, visit gram. With Direct Debit, your monthly plan premium
www.EmblemHealth.com or call EmblemHealth will be automatically taken out of your checking account
Customer Service. each month. To sign up for Direct Debit, call Em-
blemHealth Customer Service for an enrollment form.
• By Mail. Just like filling your prescriptions online,
you can save up to 33% on applicable copays for
RESOURCES
Preferred formulary drugs. For a EmblemHealth
Mail Order Pharmacy Program application, please For a list of participating pharmacies, visit
call EmblemHealth Customer Service and listen to www.emblemhealth.com or call EmblemHealth
prompts for the “Forms and Literature” menu. Customer Service.
CUSTOMER SERVICE
EmblemHealth Members: Non-Members:
1-877-444-7097 1-800-325-9792
Daily, 8 am to 8 pm Daily, 8 am to 8 pm
TDD: 1-866-248-2786 TDD: 1-877-444-2786
Monday through Friday, 8 am to 8 pm Monday through Friday, 8 am to 8 pm
16
55 Water Street, new york, new york 10041-8190 | www.emblemhealth.com
GHI and HIP are EmblemHealth companies
the Plan described herein is offered by Group Health incorporated (GHi), a Medicare
Advantage organization with an annually renewed Medicare contract. the availability
of coverage beyond the current contract year (2011) is not guaranteed. benefits,
limitations, service areas and premiums are subject to change on January 1 of each year.
Anyone with Medicare Parts A or b who resides in the state of new york may apply
for emblemHealth Medicare PDP with drug coverage. beneficiaries must continue to
pay their Medicare Part b premium (and Part A, if applicable), if not otherwise paid for
under Medicaid or by another third party. Prior authorization may be needed for certain
in network services. Please refer to your evidence of Coverage for complete details
on participating provider networks and obtaining prior authorizations. the Medicare
Prescription Drug benefit is only available to members of the Medicare Advantage-
Prescription Drug (MA-PD) Plan. if a beneficiary is already enrolled in a
MA-PD plan, the enrollee must receive their Medicare Prescription Drug benefit through
that plan.
Group Health incorporated/emblemHealth Medicare PDP is a stand alone prescription
drug plan with a Medicare contract
S5966_121953 CMS Approved 9/15/2010
86-7569