Page 23 - 2013 Allied Printing Benefit & Notices

Allied Printing Co., Inc. 2013

Notice of Creditable Coverage for Medicare Rx

Important Notice from Allied Printing Co., Inc.

About Your Prescription Drug Coverage and Medicare

Please read this notice carefully and keep it where you can find it. This notice has information about
DRAFT
your current prescription drug coverage with Allied Printing 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) Allied Printing has determined that the prescription drug coverage offered by the Allied Printing
BCBSM PPO plans and the Allied Printing BCN HMO Plan, is, 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.

2013 Allied Printing BCBSM & BCN Prescription Drug Details
Allied Printing Retail Copays (30-day supply)

BCBSM PPO plan BCN HMO Plan

Generic (Tier I) Drugs Covered 100% after deductible Up to $15.00 copay per script
Brand Formulary (Tier II) Drugs Covered 100% after deductible Up to $50.00 copay per script

Brand Non-Formulary (Tier III) Drugs Covered 100% after deductible Up to $50.00 copay per script

Sexual Dysfunction Drugs Covered 100% after deductible 50% co-insurance per script

Allied Printing Retail or Mail Order (90-day supply)
Generic (Tier I) Drugs Covered 100% after deductible Up to $30.00 copay per script

Brand Formulary (Tier II) Drugs Covered 100% after deductible Up to $100.00 copay per script

Brand Non-Formulary (Tier III) Drugs Covered 100% after deductible Up to $100.00 copay per script
Sexual Dysfunction Drugs Covered 100% after deductible 50% co-insurance per script

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