2015 Plan and Enrollment Guide

NEW FOR 2015 Lower Premiums in most states.* 2015 Plan and Enrollment Guide A helpful resource for choosing and enrolling in the SilverScript Medica...
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NEW FOR 2015

Lower Premiums in most states.*

2015 Plan and Enrollment Guide A helpful resource for choosing and enrolling in the SilverScript Medicare Part D Prescription Drug Plan that’s right for you.

*Lower premiums do not apply in Alaska. Y0080_12009_ACQ_2015 Approved

15-PG-AG

Your path to better health begins with

SilverScript

Questions about SilverScript?   Please consult your certified SilverScript Agent for more information. 2

SilverScript is the Nation’s second largest1 stand-alone Medicare prescription drug plan (PDP) sponsor. We cover more than 4 million2 members of all incomes, backgrounds and lifestyles. At SilverScript, we believe you shouldn’t have to sacrifice the prescription coverage you want for a plan you can afford.

Consider just a few of the reasons why millions2 of people trust SilverScript for their prescription drug coverage: 1. Affordable SilverScript Choice (PDP) coverage

• $0 annual deductible3 (coverage begins with your first prescription) • Premiums between $12.60 and $45.90 • The same low copays and coinsurance at any network pharmacy coast to coast • Save money and time with 90-day prescriptions—in store or through the mail

2. Two extensive pharmacy networks that include:

• Most national pharmacy chains including CVS, Walgreens & Rite Aid • Most mass retail and grocery store pharmacies including Walmart & Target • Many community based, independent pharmacies • More than 40,0004 preferred pharmacies in our SilverScript Plus (PDP) network • Convenient access to CVS Caremark Mail Service Pharmacy with free standard5

delivery for 90-day supply and you can choose to sign up for automated mail order delivery

3. Comprehensive prescription drug coverage • A

formulary that covers more than 3,2506 brand, generic and specialty drugs often prescribed for people with Medicare

4. US-based Customer Care and online support • Round-the-clock Customer Care ready to assist you • User-friendly website with numerous helpful tools and

resources

5. Added Value ExtraCare® Health Card • SilverScript

membership offers you a complementary ExtraCare Health Card. This value-added card features a healthy 20%7 discount on thousands of regularly priced CVS/pharmacy Brand® health-related items at any of more than 7,6004 CVS/pharmacy stores nationwide8 or online at www.cvs.com

How does SilverScript compare?

Use our Plan Comparison Aid on page 4 to compare Medicare Part D plans.

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Plan Comparison Aid Use this tool to compare Medicare Part D plans and find the one that is right for you based on your individual needs. The four simple steps below will help you compare coverage, pricing and overall plan value. Step 1 List your prescription drugs here, as well as the dosage and frequency as shown on the drug label. Name of Prescription Drug

Dosage

Frequency

1. 2. 3. 4. 5.

Step 2 Here, list costs and coverage information for the Medicare Part D plans you are considering. To find Medicare Part D plans in your area, see the Medicare contact information below. Annual Deductible Amount 1. Part D Plan Name: $ $ 2. Part D Plan Name: $ $ 3. Part D Plan Name: $ $ Monthly Premium

Number of my drugs covered

Copay for 90-Day Supply

Copay for 30-Day Supply

Copay in Coverage Gap

$

$

$

$

$

$

$

$

$

Is my pharmacy in network?

Note: Find the monthly premium for SilverScript plans in your state on pages 7 & 9. Step 3 Compare each plan’s value using the information you entered above. Keep in mind that an annual deductible is an out-of-pocket expense you will pay before the plan begins to share the cost of your prescriptions. That isn’t a concern with SilverScript Choice because it is a $0 deductible3 plan. Step 4 When you’re ready to enroll in the plan that’s right for you, remember that SilverScript offers you three ways to enroll. See the back cover of this guide for more information.

How to Contact Medicare Call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users call 1-877-486-2048. 4

To comparison shop if you want to see other non-SilverScript plans visit Medicare online at www.medicare.gov

Two Extensive Nationwide Pharmacy Networks At home or traveling the U.S., it’s reassuring to know that we’re never far from where you are. SilverScript Choice Pharmacy Network­­—More than 57,0004 pharmacies, one low copay More than 57,000 pharmacies4 welcome your SilverScript Choice plan coverage. Each pharmacy will fill your prescriptions for the same low copay at any of the familiar names you see below and thousands more. You may also choose the convenience of CVS Caremark Mail Service Pharmacy for standard delivery at no extra cost of 90-day supplies. CVS Caremark Mail Service pharmacy

Plus, thousands of community based, independent pharmacies.4

SilverScript Plus Pharmacy Network—More than 68,0004 standard and preferred pharmacies SilverScript Plus (PDP) members may use their benefit at more than 68,0004 pharmacies, including the familiar names shown above and many more. More than 40,0004 pharmacies in the nationwide SilverScript Plus network are preferred pharmacies, meaning members enjoy the lowest copays and coinsurance at these pharmacies. Preferred pharmacies include retail leaders like CVS/pharmacy, Walmart, Walgreens & Target, just to name a few; as well as thousands of community based, independent pharmacies and CVS Caremark Mail Service Pharmacy.

Locate any pharmacy in the SilverScript network Call us toll free at 1-866-552-6106, 24 hours a day, 7 days a week. TTY users call 1-866-552-6288.

Use our online pharmacy locator at www.silverscript.com 5

SilverScript

Choice

This $0 deductible9 plan combines affordable premiums, low copays and the convenience of an extensive, nationwide pharmacy network to offer uncommon value for anyone who needs Medicare prescription drug coverage. No deductible means you could save hundreds of dollars in out-of-pocket costs, and your plan shares the cost of your prescriptions the very first day of coverage.

STAGE 1: Annual Deductible STAGE 2: Initial Coverage

$0 Deductible SilverScript Choice is a $0 deductible plan,† meaning the Initial Coverage Stage begins the day your plan takes effect.

Your copays ($) and coinsurance (%) Standard CVS Caremark Mail Service Pharmacy

Standard Pharmacy Drug Tiers

30-day

90-day

90-day

Tier 1† Generic Drugs

$7 – $10

$17.50 – $25

$17.50 – $25

$22 – $41

$55– $102.50

$55– $102.50

Tier 2† Preferred Brand Drugs

42%– 47%

Tier 3† Non-Preferred Brand Drugs

33%

Tier 4† Specialty Drugs

STAGE 3: Coverage Gap (Donut Hole)

You leave the Initial Coverage Stage and enter the Coverage Gap when you have reached $2,960 in total yearly drug costs (not including monthly premiums).

Generic Drugs You pay 65% of the cost Brand Drugs STAGE 4: Catastrophic Coverage

You pay 45% of the cost

You enter the Catastrophic Coverage Stage when you have spent $4,700 out of pocket (not including monthly premiums).

Generic Drugs You pay the greater of 5% coinsurance or $2.65 copay All Other Drugs You pay the greater of 5% coinsurance or $6.60 copay All Tiers may include generic and brand drugs. Alaska Choice Plan has a $320 deductible and Stage 2 copays/coinsurance of $2 / 17% / 37% / 25% (Tiers 1-4). Call or visit the SilverScript website for more information9. †

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Choice Plan Costs by State Your premium may be lower if you qualify for Extra Help. See page 11 for more information. Your Monthly Tier 1 State Premium Copay AK10 $45.90 $2 AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS

Tier 2 Tier 3 Copay Coinsurance

$21.80 $17.90 $18.70 $22.20 $24.20 $23.30

$7 $7 $9 $8 $8 $8

17% $33 $33 $35 $41 $40 $27

$26.00 $26.00 $20.60 $20.00 $22.00 $26.10 $32.00 $21.70 $22.60 $25.00 $22.60 $21.30 $23.30 $26.00 $24.00 $25.40 $26.10 $24.10 $21.60

$7 $7 $8 $7 $10 $9 $8 $8 $7 $7 $7 $8 $8 $7 $7 $7 $9 $7 $7

$40 $40 $40 $35 $36 $22 $33 $37 $34 $36 $34 $29 $27 $40 $38 $40 $22 $31 $37

37% 47% 44% 46% 43% 45% 45% 46% 46% 42% 46% 45% 43% 42% 43% 45% 42% 45% 45% 45% 46% 43% 43% 43% 43% 47%

Tier 4 Coinsurance10

Your Monthly Tier 1 State Premium Copay MT $26.10 $9 NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

Tier 2 Tier 3 Copay Coinsurance

$23.10 $26.10 $26.10 $24.00 $30.40 $12.60

$7 $9 $9 $7 $8 $8

$22 $37 $22 $22 $38 $34 $40

$30.80 $25.70 $21.70 $23.10 $25.80 $22.00 $23.30 $25.00 $26.10 $21.80 $21.00 $32.00 $22.30 $23.30 $25.80 $27.10 $22.00 $26.10

$8 $7 $8 $7 $7 $7 $8 $8 $9 $7 $8 $8 $8 $8 $7 $8 $7 $9

$35 $34 $27 $33 $37 $32 $27 $34 $22 $33 $37 $33 $36 $27 $37 $26 $32 $22

43% 47% 43% 43% 43% 47% 44% 45% 47% 46% 46% 43% 47% 45% 46% 43% 47% 47% 42% 45% 45% 43% 43% 47% 43%

33%

Questions about our plans or premiums?   Please consult your certified SilverScript Agent for more information. 7

SilverScript

Plus

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This enhanced plan is for people who take several prescriptions and are likely to reach the Coverage Gap. SilverScript Plus provides more coverage for Tier 1 drugs in the Gap to help lower your out-of-pocket costs.

STAGE 1: Annual Deductible STAGE 2: Initial Coverage

$0 Deductible SilverScript Plus is a $0 deductible plan, meaning the Initial Coverage Stage begins the day your plan takes effect.

Your copays ($) and coinsurance (%) Preferred Pharmacy Drug Tiers

Standard Pharmacy

Preferred CVS Caremark Mail Service Pharmacy

30-day

90-day

30-day

90-day

90-day

Tier 1† Generic Drugs

$0

$0

$7

$21

$0

Tier 2† Preferred Brand Drugs

$24

$60

$31

$93

$60

Tier 3† Non-Preferred Brand Drugs

40%

50% 33%

Tier 4† Specialty Drugs

STAGE 3: Coverage Gap (Donut Hole)

40%

You leave the Initial Coverage Stage and enter the Coverage Gap when you have reached $2,960 in total yearly drug costs (not including monthly premiums).

30-day

90-day

30-day

90-day

90-day

No more than Tier 1 Tiers 2, 3 and 4

$0

$21

$0

Generic Drugs You pay 65% of the cost Brand Drugs

STAGE 4: Catastrophic Coverage

$7

You pay 45% of the cost

You enter the Catastrophic Coverage Stage when you have spent $4,700 out of pocket (not including monthly premiums).

Generic Drugs You pay the greater of 5% coinsurance or $2.65 copay All Other Drugs You pay the greater of 5% coinsurance or $6.60 copay 8

All Tiers may include generic and brand drugs



Plus Plan Costs by State Your premium may be lower if you qualify for Extra Help. See page 11 for more information. Your State

Monthly Premium

Your State

Monthly Premium

AK

N/A

MT

$79.60

AL

$76.40

NC

$78.90

AR

$70.80

ND

$79.60

AZ

$81.10

NE

$79.60

CA

$89.30

NH

$84.80

CO

$89.20

NJ

$91.90

CT

$74.30

NM

$67.20

DC

$85.30

NV

$82.50

DE

$85.30

NY

$79.90

FL

$81.30

OH

$76.10

GA

$68.40

OK

$79.80

HI

$78.30

OR

$77.80

IA

$79.60

PA

$84.70

ID

$94.20

RI

$74.30

IL

$87.80

SC

$71.00

IN

$76.80

SD

$79.60

KS

$84.60

TN

$76.40

KY

$76.80

TX

$76.90

LA

$75.10

UT

$94.20

MA

$74.30

VA

$80.30

MD

$85.30

VT

$74.30

ME

$84.80

WA

$77.80

MI

$76.80

WI

$80.30

MN

$79.60

WV

$84.70

MO

$78.20

WY

$79.60

MS

$80.20

Questions about our plans or premiums?   Please consult your certified SilverScript Agent for more information. 9

Something Extra for SilverScript Members Your SilverScript membership qualifies you to receive a complementary ExtraCare® Health Card. You may use it as soon as it arrives in the mail, at any of more than 7,6004 CVS/pharmacy stores nationwide8 or online at www.cvs.com. As a valued SilverScript member, your ExtraCare Health Card entitles you to a healthy 20%7 discount on thousands of regularly priced CVS/pharmacy Brand® health-related items valued at $1 or more12 including: • Allergy Remedies • Incontinence Products • Baby Care • Cough

• Nicotine

• Deodorant

• Oral

Care

• Diabetes

• Pain

Relievers

• Skin

Care

and Cold Remedies Testing

Supplies

Replacement

• Ear

Care

• Stomach

• Eye

Care

• Sunscreen

• Foot

Care

• Visual

• First

Aid Supplies

• Vitamins

Remedies

Aids

There is no cost to use your ExtraCare Health Card and no usage limit The ExtraCare Health Card is not a plan benefit, but a no-cost value-added service.

Questions about the ExtraCare Health Card program? Call toll free, 1-888-543-5938, between 8:30 a.m. and 7:00 p.m. EST. TTY users call 1-800-863-5488. 10

Need assistance to help pay for Medicare prescription drug coverage?

Extra Help is available from Medicare People with limited resources and incomes can get Extra Help to pay all or some of their Medicare Part D prescription drug costs. To qualify, you must meet three requirements:

1. Your Residence

You must reside in one of the 50 States or the District of Columbia.

2. Your Resources

Your resources must be limited to $13,440** for an individual or $26,860** for a married couple living together. (Resources include bank accounts, stocks and bonds, but do not include your home, car, or life insurance policies).

3. Your Income

Your income must be limited to $17,505** for an individual or $23,595** for a married couple living together. Even if your income is higher, you may be eligible for some help.

If you are eligible for Medicare, Medicaid and Extra Help, you may qualify for a $0 monthly premium plan from SilverScript13. Copays as low as $1.20 with Extra Help14.

Apply for Extra Help through the Social Security Administration If you believe you are eligible for Extra Help, complete the Application for Extra Help with Medicare Prescription Drug Plan Costs and submit it to the Social Security Administration. The Social Security Administration will notify you if you qualify. There are three ways to contact Social Security:

By Phone

Call Social Security toll free at 1-800-772-1213 (TTY 1-800-325-0778), between 7:00 a.m. and 7:00 p.m. EST, Monday through Friday

Online

Visit the Social Security website at www.socialsecurity.gov

In Person

Apply at your local Social Security office

** 2014 limits may change in 2015.

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Medicare Enrollment Periods There are three Medicare enrollment periods for enrolling in or changing your Part D coverage. Use this guide to determine the enrollment period that applies to your situation. Your Situation You’re eligible for Initial Enrollment Medicare because you’ve turned 65 Period (IEP)

What You Can Do Enroll in • A

Medicare Part D Prescription Drug Plan

• Original

Medicare,15 or

• A

Medicare Advantage Plan

You’re eligible for Medicare because you are disabled15

Enroll in • A

Medicare Part D Prescription Drug Plan

• Original

Medicare, or

When You Can Do It Begins 3 months before the month you turn 65 and includes the month you turn 65 Ends 3 months after the month you turn 65

Begins 21 months after you get Social Security (SS) or Railroad Retirement Board (RRB) benefits

• A

Ends on the 27th month after you get SS or RRB benefits

Begins October 15

Medicare Advantage Plan

Annual Election Period (AEP)

You want to enroll in or change a Medicare prescription drug plan

Enroll in, drop or change

Special Election Period (SEP)

You need to change coverage due to a special circumstance

If qualifying circumstances occur, Special Election Periods can be anytime during the year. An SEP allows you to make changes to your Medicare Part D coverage or Medicare Advantage plan due to special circumstances. Visit www.medicare.gov for more information.

• A

Medicare Part D Prescription Drug Plan

Ends December 7

Be aware of Medicare’s Late Enrollment Penalty If you do not enroll in Medicare prescription drug coverage or do not have other creditable coverage when your Initial Enrollment Period ends, Medicare will add a Late Enrollment Penalty (LEP) to your premium when you do enroll. Creditable means prescription drug coverage as good as Medicare, such as employer or union coverage. Note: The LEP may not apply to you if you receive both Medicare and Medicaid. Visit www.medicare.gov for more information. 12

Medicare’s Four “Parts” Part A

Original Medicare

Hospital Coverage • Inpatient

hospital care • Inpatient stays at most skilled facilities • Home health and Hospice care

Part B Medical Coverage • Doctor

and clinical lab services • Outpatient and preventive care • Screenings, surgical fees and supplies • Physical and Occupational therapy • Limited outpatient prescription drugs

Part C Medicare Advantage Part A and Part B into one plan that can include Part D • MA plan = Medicare Advantage Plan • MA-PD = Medicare Advantage plan with a prescription drug benefit

Part A +

Part B

Original Medicare is coverage managed by the Federal government.

Prescription Drug Coverage (PDP) Part D There are two ways to get prescription drug coverage: • If you choose Original Medicare, you can enroll in a stand-alone Medicare prescription drug plan (a PDP), OR • Through a Medicare Advantage Plan that includes prescription drug coverage (an MA-PD).

• Combines

Part D Prescription Drug Coverage • PDP

= Prescription Drug Plan • MA-PD plan = Medicare Advantage plan with a prescription drug benefit

Hospital  + Medical  + Prescription Drug Coverage Part A +

Part B +

Part D

Remember, if you choose Original Medicare, you must enroll in a standalone Part D plan (i.e. a PDP) to have prescription drug coverage.

Adding Part D to Original Medicare Part D coverage is not included with Original Medicare. If you do not have prescription drug coverage from an employer, union or third party when you join Medicare, consider enrolling in a stand-alone SilverScript plan to help cover the cost of your prescriptions.

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Glossary of Terms Deductible An amount you are required to pay before a plan begins to share the cost of covered prescriptions. Coinsurance An amount you may be required to pay as your share of the cost for prescription drugs after you pay any deductibles. Coinsurance is a percentage of the cost (for example 20%). Copay (Copayment) An amount you may be required to pay as your share of the cost for a prescription drug. A copay is usually a set dollar amount, for example a $10 copay. Cost Sharing Any combination of deductible, copay and/or coinsurance (not including monthly premiums) that you may be required to pay for covered prescription drugs.

Mail Service Pharmacy A pharmacy that fills and delivers prescriptions ordered by phone, mail or secure website5 that makes prescriptions available only through mail order. Network Pharmacy A contracted pharmacy where plan members can use their prescription drug benefits. In most cases, your prescriptions are covered by your plan only if they are filled at a network pharmacy. Preferred Pharmacy A pharmacy where SilverScript Plus members get the lowest copays and coinsurance on covered drugs. Premium The periodic payment to Medicare, an insurance company or health care plan for health or prescription drug coverage.

Coverage Gap (Donut Hole) The third stage of Medicare Part D prescription drug coverage following the Initial Coverage stage.

Questions about SilverScript?   Please consult your certified SilverScript Agent for more information. 14

Customer Care and Online Support We call it Customer Care because all of us at SilverScript care about providing friendly, efficient service and resolving any issue you may have as soon as possible. Visit us online at www.silverscript.com to access the information you need, search for drugs, review pricing, and find pharmacy locations. You can even communicate online with a Customer Care Representative by using the Chat Now or Call Me buttons located on the SilverScript website. By phone or online, SilverScript is here for you 24 hours a day, 7 days a week. It’s good to know that when you start on your path to better health with SilverScript, we will be with you every step of the way. You can reach SilverScript Customer Care by calling toll free, 1-866-552-6106, 24 hours a day, 7 days a week. TTY users call 1-866-552-6288. Benefits Reminders • The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. • Limitations, copayments and restrictions may apply. • Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. • You must continue to pay your Medicare Part B premium. • This information is available for free in other languages. Please call our Customer Care number at 1-866-552-6106 (TTY: 1-866-5526288), 24 hours a day, 7 days a week. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Servicio al Miembro, al 1-866-552-6106 (teléfono de texto (TTY): 1-866-552-6288), las 24 horas del día, los 7 días de la semana. 1 CMS, Monthly Enrollment by Plan report, July, 2014. https://www.cms.gov/Research-StatisticsData-and-Systems/Statistics-Trends-andReports/MCRAdvPartDEnrolData/MonthlyEnrollment-by-Plan.html 2 CMS, Monthly Enrollment by Contract report, July, 2014. https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trendsand-Reports/MCRAdvPartDEnrolData/MonthlyEnrollment-by-Contract.html 3 Choice plan in Alaska has a premium of $45.90 and deductible of $320. 4 Internal SilverScript Insurance Company report dated July 2014. 5 Typical number of business days after the pharmacy receives an order to receive your shipment is 5 to 7 days.

SilverScript Insurance Company Formulary, July 2014. 7 Some restrictions apply. ExtraCare Card must be presented to get these savings. Savings applied to total purchase with specified product. Excludes prescriptions, alcohol, tobacco, lottery, postage stamps, gift cards, money orders, prepaid cards and photo finishing, and is not valid on items reimbursed by a government program. No cash back. Tax charged on pre-coupon price where required. Any disputes regarding the products and services described may be subject to the SilverScript grievance process. 8 You are not obligated to fill your prescriptions at a CVS/pharmacy in order to use the CVS Caremark ExtraCare Health Card. 9 Alaska Choice Plan has a $320 deductible and Stage 2 copays/coinsurance of $2/17%/37%/25% (Tiers 1-4). 10 Tier 4 Coinsurance is 33% for all plans except Alaska. 11 SilverScript Plus (PDP) not available in Alaska. 12 Purchases using the ExtraCare Health Card will not count towards your true-out-of-pocket (TrOOP) costs under SilverScript. Any disputes regarding the products and services described may be subject to the SilverScript grievance process. 13 You must qualify for Medicare, Medicaid and Extra Help from Medicare to be eligible for $0 premiums on your prescription drug coverage. Note: $0 premium plans are not available in Alaska and Nevada. 14 CMS 2014 Your Guide to Medicare Prescription Drug Coverage June 2014. 15 Original Medicare refers to Medicare Part A and Part B. 6

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Serving your best interest is what I do As a contracted SilverScript Insurance Company agent, I am uniquely qualified to help you choose the Medicare Part D prescription drug coverage that’s right for you. Here’s why: 1. I am trained and certified

I am certified by the SilverScript Insurance Company and have successfully completed their annual broker/agent Medicare Part D training program.

Your Enrollment Checklist

2. I am your personal advocate

I may be compensated directly by SilverScript based on your enrollment in a plan. As my valued customer, I am committed to your satisfaction by ensuring that you choose the right plan for your individual needs.

3. I will help research important information

I can let you know if the prescription drugs you take are covered and help estimate your annual costs for Medicare Part D coverage. I can also tell you if a pharmacy is in network, and if it qualifies as a preferred pharmacy that offers you lower cost sharing.

4. I will help process your application

Leave it to me to assist you in properly completing and submitting your enrollment application.

Your red, white and blue Medicare card (or the letter you received from either the Social Security Administration or Railroad Retirement Board)

Your Medicaid number (if you have Medicaid) An up-to-date list of all prescription drugs you take Information about other health coverage you or your spouse have including: • Group

health plan information

• Employment • Dates

information

of coverage

I can help you become a SilverScript member This Plan and Enrollment Guide will help you choose the SilverScript plan that’s right for you. When you’re ready to enroll or have questions, call me at your convenience. I am happy to provide the answers you need and personally guide you through the enrollment process.

Call _______________________________________ at ___________________________

(Agent Name)

(Phone Number)

Once you enroll in a plan, you will receive a Member ID card and a Welcome Kit from SilverScript. SilverScript is a Prescription Drug Plan with a Medicare contract offered by SilverScript Insurance Company. Enrollment in SilverScript depends on contract renewal.

©2014 SilverScript Insurance Company. All Rights Reserved.