Page 21 - 2013-14 AAACU Benefits & Notices

Alpena Alcona Area CU 2013-14

Notice of Creditable Coverage for Medicare Rx

Important Notice from Alpena Alcona Area Credit Union

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
your current prescription drug coverage with Alpena Alcona Area Credit Union 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) Alpena Alcona Area Credit Union has determined that the prescription drug coverage offered by
the Alpena Alcona Area Credit Union BCBSM PPO plans, 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 Alpena Alcona Area Credit Union BCBSM Prescription Drug Details
Alpena Alcona Area Credit Union Retail Copays (30-day supply)

BCBSM PPO 15/0 Plan

Generic (Tier I) Drugs Up to $15.00 copay per script
Brand Formulary (Tier II) Drugs Up to $50.00 copay per script

Brand Non-Formulary (Tier III) Drugs Up to 50%* copay per script
* (MIN $70 TO MAX $100 CO-PAY)

Alpena Alcona Area Credit Union Retail or Mail Order (90-day supply)
Generic (Tier I) Drugs Up to $30.00 copay per script

Brand Formulary (Tier II) Drugs Up to $100.00 copay per script

Brand Non-Formulary (Tier III) Drugs Up to 50%* copay per script
* (MIN $140 TO MAX $200 CO-PAY)

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