Page 31 - 2015 Advia CU Benefits & Notices
P. 31
Advia CU - MI 2015
About Your Prescription Drug Coverage and Medicare – Notice of Creditable
Coverage
Important Notice from Advia Credit Union (Advia CU)
Please read this notice carefully and keep it where you can find it. This notice has information about
your current prescription drug coverage with Advia CU and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not to join a Medicare drug
plan. Information about where you can get help to make decisions about your prescription drug
coverage is at the end of this notice.
(1) Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare Prescription Drug Plan (PDP) or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug
plans provide at least a standard level of coverage set by Medicare. Some plans may also offer
more coverage for a higher monthly premium.
(2) Advia CU has determined that the prescription drug coverage offered by the Advia CU BCBSM
PPO plans and the Advia CU BCN HMO Plan, are, on average for all plan participants, expected
to pay out as much as standard Medicare prescription drug coverage pays and is considered
Creditable Coverage.
Because this drug coverage is, on average, at least as good as standard Medicare prescription drug
coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join
a Medicare drug plan.
2015 Advia CU BCBSM/BCN Prescription Drug Details
Advia CU Retail Copays (30-day supply)
BCBSM PPO plans BCN HMO Plan
(Tier I) Drugs Value Generic Drugs Up to $20.00 copay per script Up to $ 6.00 copay per script
(Tier IA) Drugs Generic Drugs Up to $20.00 copay per script Up to $40.00 copay per script
(Tier II) Drugs Formulary Brand Drugs Up to $60.00 copay per script Up to $60.00 copay per script
(Tier III) Drugs Non-Formulary Drugs 50% up to $200 copay per script Up to $80.00 copay per script
(Tier IV) Drugs Formulary Specialty Drugs 20% up to $200 copay per script 20% up to $200 copay per script
(Tier V) Non-Formulary Specialty Drugs 25% up to $300 copay per script 20% up to $300 copay per script
HMO has a 50% co-insurance on covered sexual dysfunction prescription medication
Advia CU Retail or Mail Order (90-day supply)
Tiers I, IA, II & III Drugs 2x regular retail copay 3x regular retail co-pay LESS $10
Tiers IV & V Drugs 30-day supply only 30-day supply only
Salus Group© Copyright 2014 Page | 31
About Your Prescription Drug Coverage and Medicare – Notice of Creditable
Coverage
Important Notice from Advia Credit Union (Advia CU)
Please read this notice carefully and keep it where you can find it. This notice has information about
your current prescription drug coverage with Advia CU and about your options under Medicare’s
prescription drug coverage. This information can help you decide whether or not to join a Medicare drug
plan. Information about where you can get help to make decisions about your prescription drug
coverage is at the end of this notice.
(1) Medicare prescription drug coverage became available in 2006 to everyone with Medicare. You
can get this coverage if you join a Medicare Prescription Drug Plan (PDP) or join a Medicare
Advantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug
plans provide at least a standard level of coverage set by Medicare. Some plans may also offer
more coverage for a higher monthly premium.
(2) Advia CU has determined that the prescription drug coverage offered by the Advia CU BCBSM
PPO plans and the Advia CU BCN HMO Plan, are, on average for all plan participants, expected
to pay out as much as standard Medicare prescription drug coverage pays and is considered
Creditable Coverage.
Because this drug coverage is, on average, at least as good as standard Medicare prescription drug
coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later decide to join
a Medicare drug plan.
2015 Advia CU BCBSM/BCN Prescription Drug Details
Advia CU Retail Copays (30-day supply)
BCBSM PPO plans BCN HMO Plan
(Tier I) Drugs Value Generic Drugs Up to $20.00 copay per script Up to $ 6.00 copay per script
(Tier IA) Drugs Generic Drugs Up to $20.00 copay per script Up to $40.00 copay per script
(Tier II) Drugs Formulary Brand Drugs Up to $60.00 copay per script Up to $60.00 copay per script
(Tier III) Drugs Non-Formulary Drugs 50% up to $200 copay per script Up to $80.00 copay per script
(Tier IV) Drugs Formulary Specialty Drugs 20% up to $200 copay per script 20% up to $200 copay per script
(Tier V) Non-Formulary Specialty Drugs 25% up to $300 copay per script 20% up to $300 copay per script
HMO has a 50% co-insurance on covered sexual dysfunction prescription medication
Advia CU Retail or Mail Order (90-day supply)
Tiers I, IA, II & III Drugs 2x regular retail copay 3x regular retail co-pay LESS $10
Tiers IV & V Drugs 30-day supply only 30-day supply only
Salus Group© Copyright 2014 Page | 31
