PEIP Retiree Health Medica Group Prime Solution Options January 1, 2016 through December 31, 2016 Group Number 70623 Number 70506 Group Number 70555 Drug Coverage With Copays Drug Coverage With Copays No Drug Coverage With Coverage Gap (Donut Hole) $351.00 monthly $92.00 monthly $157.70 monthly Tier 1: $10 copay - Preferred Generic Tier 1: $8 copay - Preferred Generic Tier 2: $20 copay - Non-preferred Generic Tier 2: $15 copay - Non-preferred Generic Prescription Tier 3: $35 copay - Preferred Brand Tier 3: $43 copay - Preferred Brand Medica Part D Rx Formulary required, Tier 4: $65 - Non-preferred Brand Tier 4: $85 copay - Non-preferred Brand 31-day supply No Coverage Tier 5: - Specialty Tier 5: 33% copay - Specialty $100 copay (Medicare Excluded Drugs not included Mail order (2 for 93-day supply) Mail order (2 for 93-day supply) copays copays on Formulary) Fairview Pharmacy Services Fairview Pharmacy Services No coverage gap (no donut hole) Has coverage gap (donut hole) Must have Parts A & B or Part B only. *If a member does not have Part A Medicare there would be no coverage for Medicare Part A services under Prime Solutions. Must reside within the service area (see Area” at end of chart). Residency Requirements “Service None $150.00 None Medical Deductible Preventive Care (Including annual physical, cancer screenings, eye/hearing 100% coverage in network. and immunizations) Physician Services $0 copay for primary care (Office visit for illness or injury/urgent $15 copay primary care and specialist care in network. Extended $10 copay specialist. Extended Absence care) Absence Option outside service area. Option outside of service area Inpatient Care $100 copay. Extended Absence Option available outside service area. Outpatient Services $50 copay $65 copay (waived if admitted within 24 hrs) $50 copay if admitted within 24 hrs) Emergency Care (waived Includes routine, non-emergency coverage outside the service area, but within the for up to 9 consecutive months Extended Absence Option (member must call Medica to activate this option) $500 annual allowance for hearing aids $400 annual allowed for hear aids Additional Benefits $150 annual eyewear benefit $75 annual eyewear benefits
PEIP Retiree Health Medica Group Prime Solution Options January 1, 2016 through December 31, 2016 Number 70506 Drug Coverage With Copays $351.00 monthly Group Number 70555 No Drug Coverage $92.00 monthly Group Number 70623 Drug Coverage With Copays With Coverage Gap (Donut Hole) $157.70 monthly Prescription Medica Part D Rx Formulary required, 31-day supply (Medicare Excluded Drugs not included on Formulary) Tier 1: $10 copay - Preferred Generic Tier 2: $20 copay - Non-preferred Generic Tier 3: $35 copay - Preferred Brand Tier 4: $65 - Non-preferred Brand Tier 5: $100 copay - Specialty Mail order (2 copays for 93-day supply) Fairview Pharmacy Services No coverage gap (no donut hole) No Coverage Tier 1: $8 copay - Preferred Generic Tier 2: $15 copay - Non-preferred Generic Tier 3: $43 copay - Preferred Brand Tier 4: $85 copay - Non-preferred Brand Tier 5: 33% copay - Specialty Mail order (2 copays for 93-day supply) Fairview Pharmacy Services Has coverage gap (donut hole) Medicare Must have Parts A & B or Part B only. *If a member does not have Part A Medicare there would be no coverage for Part A services under Prime Solutions. Residency Requirements Must reside within the service area (see “Service Area” at end of chart). Medical Deductible None $150.00 None Preventive Care (Including annual physical, cancer screenings, eye/hearing and immunizations) 100% coverage in network. Physician Services (Office visit for illness or injury/urgent care) $15 copay primary care and specialist care in network. Extended Absence Option outside service area. $0 copay for primary care $10 copay specialist. Extended Absence Option outside of service area Inpatient Care $100 copay. Extended Absence Option available outside service area. Outpatient Services $50 copay Emergency Care $65 copay (waived if admitted within 24 hrs) $50 copay (waived if admitted within 24 hrs) Extended Absence Option Includes routine, non-emergency coverage outside the service area, but within the for up to 9 consecutive months (member must call Medica to activate this option) Additional Benefits $500 annual allowance for hearing aids $150 annual eyewear benefit $400 annual allowed for hear aids $75 annual eyewear benefits