Page 44 - MAPD_HMO_FLIP

Medicare HMO Blue Medicare HMO Blue Medicare HMO Blue
ValueRx (HMO) PlusRx (HMO) FlexRx (HMO-POS)

Wellness Programs
Fitness: $150 per calendar year $150 per calendar year $150 per calendar year

Weight Loss: $150 per calendar year $150 per calendar year $150 per calendar year
See back of this
booklet for more
details
Medicare Part B 15% coinsurance 10% coinsurance In and Out-of-network:
Drugs 10% coinsurance
PRESCRIPTION DRUG BENEFITS
Initial Coverage After you pay your yearly After you pay your yearly After you pay your yearly
deductible, you pay the deductible, you pay the deductible, you pay the
following until your total following until your total following until your total
yearly drug costs reach yearly drug costs reach yearly drug costs reach
$3,700. Total yearly drug $3,700. Total yearly drug $3,700. Total yearly drug
costs are the total drug costs are the total drug costs are the total drug
costs paid by both you costs paid by both you costs paid by both you
and our Part D plan. and our Part D plan. and our Part D plan.
You may get your You may get your You may get your
drugs at network retail drugs at network retail drugs at network retail
pharmacies and mail pharmacies and mail pharmacies and mail
order pharmacies. order pharmacies. order pharmacies.
Standard Retail Cost-Sharing
Tier One- Two- Three- One- Two- Three- One- Two- Three-
month month month month month month month month month
supply supply supply supply supply supply supply supply supply
Tier 1 $4 $8 $12 $2 $4 $6 $2 $4 $6
(Preferred Generic) copay copay copay copay copay copay copay copay copay
Tier 2 $8 $16 $24 $6 $12 $18 $6 $12 $18
(Generic) copay copay copay copay copay copay copay copay copay

Tier 3 $45 $90 $135 $45 $90 $135 $45 $90 $135
(Preferred Brand) copay copay copay copay copay copay copay copay copay

Tier 4 $95 $190 $285 $95 $190 $285 $95 $190 $285
(Non-Preferred Brand) copay copay copay copay copay copay copay copay copay
Tier 5 (Specialty Tier) 26% 26% 26% 25% 25% 25% 26% 26% 26%
of the of the of the of the of the of the of the of the of the
cost cost cost cost cost cost cost cost cost

12

5901 163138M-3_HMO Summary.indd 14 11/11/16 4:23 PM