oak ridge retiree town hall meeting #2 medicare prescription drug coverage retiree town hall...
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Oak Ridge Retiree Town Hall Meeting #2
Medicare Prescription Drug Coverage
Retiree Town Hall Presentation:Comparing Prescription Drug Coverage
November 2005
2Oak Ridge Retiree Town Hall Meeting #2
Today’s Agenda
What’s happening?
Why we’re here today
Considerations as you evaluate coverage
Comparing your Oak Ridge retiree prescription drug coverage to local provider plans
Considerations for limited income and resources individuals
What happens next?
4Oak Ridge Retiree Town Hall Meeting #2
What’s Happening?
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 — or the Medicare Modernization Act (MMA) — signed into law on December 8, 2003
Effective January 1, 2006, Medicare will provide optional prescription drug coverage called Medicare Part D It replaces prescription drug discount card, which will phase out by
May 15, 2006 Beginning November 15, anyone with Medicare is eligible to enroll
for this coverage Legislation encourages employers to continue to be the primary
provider of prescription drug benefits for their Medicare-eligible population
5Oak Ridge Retiree Town Hall Meeting #2
What’s Happening? (cont.)
The benefits of this legislation include: Offers prescription drug coverage to Medicare beneficiaries who
don’t have access to adequate prescription drug coverage today Provides enhanced benefits with lower out-of-pocket costs to limited-
income beneficiaries, as defined by the government Gives employers the choice to continue to be the primary provider of
prescription drug benefits ― not intended to replace employer-sponsored coverage that’s as generous or more generous
6Oak Ridge Retiree Town Hall Meeting #2
What’s Happening? (cont.)
Oak Ridge will continue to offer the current prescription drug coverage, which is as generous as or more generous than Medicare Part D for 2006 Anyone who participates in an Oak Ridge retiree medical plan
receives prescription drug coverage automatically Oak Ridge prescription drug coverage does not coordinate with
Medicare Part D coverage This means, for most Medicare-eligible Oak Ridge employees and
retirees, enrolling in Medicare Part D will not provide additional benefits
If you are a Medicare-eligible retiree or LTD recipient enrolled in Oak Ridge coverage and you elect Medicare drug coverage, your Oak Ridge medical and prescription drug coverage will be cancelled
7Oak Ridge Retiree Town Hall Meeting #2
Why We’re Here Today
By now, you may have received mailings from a number of carriers who want to offer you prescription drug coverage These mailings will encourage you to enroll “just to be safe” The companies sending you these mailings do not know that you already
have prescription drug coverage through Oak Ridge
— They are mailing to all Medicare-eligible individuals
Oak Ridge wants you to understand: What Medicare drug coverage means to you as a Medicare-eligible Oak
Ridge retiree or employee That your current prescription drug coverage is as generous as or more
generous than the standard Medicare coverage Enrolling in Medicare Part D will not offer any additional benefits, although
there are some exceptions Enrolling in private Medicare prescription drug coverage for 2006 will
jeopardize your Oak Ridge-provided coverage
9Oak Ridge Retiree Town Hall Meeting #2
Medicare Part D Terminology
Terms and abbreviations: CMS – Centers for Medicare and Medicaid Services Medicare Part D – also refers to Medicare prescription drug coverage “As generous as or more generous than” – the Medicare phrase applied
to employer-provided coverage that offers a benefit comparable to (or better than) the standard Medicare Part D coverage
Creditable Coverage – verification that an individual has coverage that is as generous as or more generous than standard Medicare Part D coverage
Formulary – a specific list of drugs that are considered “covered” by a health plan or prescription drug plan
Limited Income and Resources – individuals who meet specific criteria established by CMS that qualify them for extra assistance through CMS
TrOOP – True out-of-pocket maximum that is defined as the amount of out-of-pocket costs a retiree would expect to pay if enrolled in a Medicare Part D plan, not including monthly premiums or out-of-pocket costs for catastrophic coverage
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Oak Ridge Retiree Town Hall Meeting #2
Considering Other Prescription Drug Coverage
As mentioned, choosing Medicare prescription drug coverage will jeopardize your Oak Ridge retiree medical coverage
However, we understand that you will receive mailings from many providers offering coverage and you may want to compare those plans with your Oak Ridge retiree medical coverage
To help you, we’ll be comparing some of the plans offered in our area during today’s session
In evaluating coverage, we’ll be asking these questions: Does the plan cover all my drugs? How much will this plan cost me? Does the plan have a coverage gap? How does the plan limit my out-of-pocket expenses? Is my pharmacy in the network? Does the plan offer mail order?
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Oak Ridge Retiree Town Hall Meeting #2
Does The Plan Cover All Of My Drugs?
Many plans have formularies, which limit the drugs that are covered under the plan
All of the Medicare prescription drug plans include a formulary
In most cases, these formularies limit the number of drugs offered under each class of drugs and may cover a generic rather than brand-name drug
We will not cover specific formularies for each of the plans today Contact each provider if you’d like more information about their
formulary
Your Oak Ridge prescription drug coverage does not include a formulary
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Oak Ridge Retiree Town Hall Meeting #2
How Much Will This Plan Cost Me?
The first consideration will be the premium or contribution for joining the plan The national average cost of Medicare prescription drug plans is
$32 per month, but prices will vary, depending on the level of coverage provided in each plan — increased coverage will generally cost more
The next consideration is the deductible that must be met before coverage will begin Most plans require that you pay the full cost up to a certain dollar
limit, after which the plan’s benefits begin The standard Medicare prescription drug plan includes a $250
annual deductible Your Oak Ridge prescription drug coverage requires a $150
deductible for retail pharmacy prescriptions
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Oak Ridge Retiree Town Hall Meeting #2
How Much Will This Plan Cost Me? (continued)
Finally, consider what you may pay, in coinsurance or copays, each time you obtain a prescription Coinsurance is a percentage of the cost
— The standard Medicare prescription drug plan includes 25% coinsurance on total annual drug costs up to $2,250 and 5% of the cost after you have spent $3,600 out-of-pocket
— Your Oak Ridge prescription drug coverage includes coinsurance for prescription drugs obtained through a retail pharmacy
Copays are a fixed dollar amount— For example, generic drug copays through a mail order program
may cost $25 for a 90-day supply— Your Oak Ridge prescription drug coverage includes copays for
prescription drugs obtained through mail order
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Oak Ridge Retiree Town Hall Meeting #2
Does The Plan Have A Coverage Gap?
A coverage gap – or “doughnut hole” – is like a second deductible
When your total prescription drug costs reach a certain level, you assume the full cost of prescription drugs
You pay for prescription drugs up to another limit of out-of-pocket expenses, upon which the coverage gap closes
The standard Medicare prescription drug coverage plan has a coverage gap that takes effect when your total prescription drug expenses reach $2,250
The standard Medicare plan resumes paying benefits when you reach a total of $3,600 in out of pocket expenses
Your Oak Ridge prescription drug coverage does not have a coverage gap
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Oak Ridge Retiree Town Hall Meeting #2
How Does The Plan Limit My Out-of-Pocket Expenses?
A plan may include an out-of-pocket maximum that will limit the amount you pay in coinsurance toward prescription drugs in a given year
The standard Medicare prescription drug coverage has an out-of-pocket maximum of $3,600 each year, after which Medicare catastrophic coverage begins
When you reach that threshold, your coinsurance is reduced from 25% to 5% for prescription drugs for the remainder of that calendar year
Your Oak Ridge prescription drug coverage does not have an out-of-pocket maximum
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Oak Ridge Retiree Town Hall Meeting #2
Is My Pharmacy In The Network?
Participating pharmacies vary by plan
You will need to refer to the materials you receive from the insurers offering Medicare prescription drug plans in your area
You should also confirm participation with your local or preferred pharmacy
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Oak Ridge Retiree Town Hall Meeting #2
Does The Plan Offer Mail Order?
Mail order availability will vary by plan as well
Confirm that mail order is an option and verify how you can submit prescriptions as well as how prescriptions are mailed to you
In some cases, plans allow you to purchase up to a 90-day supply of your medication through a participating retail pharmacy in addition to mail order
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Oak Ridge Retiree Town Hall Meeting #2
Let’s stop for a minute to see if there are any questions?
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Your Oak Ridge Retiree Prescription Drug Coverage to Local Provider Plans
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Oak Ridge Retiree Town Hall Meeting #2
2006 Prescription Drug Coverage for Oak Ridge Retirees: Snapshot of Benefits under the Retiree Medical Plan
Retail(up to a 30 day supply)
Mail Order (up to a 90 day supply)
Deductible: $150 $0
For In-Network Pharmacy
COINSURANCEBrand name: Plan pays 70%
Participant pays 30% (minimum $10)Generic:
Plan pays 80%Participant pays 20% (minimum $10) COPAYMENT
Brand name: $35Generic: $15
For Non-Network Pharmacy
COINSURANCEBrand name: Plan pays 50%
Participant pays 50% Generic:
Plan pays 50%Participant pays 50%
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Oak Ridge Retiree Town Hall Meeting #2
Standard Medicare Part D Drug Benefit: A Visual
*TrOOP is “true out-of-pocket” maximum — amount retiree must pay before catastrophic (95%) benefit begins. Employer and insurance company payments do not count toward satisfaction of TrOOP.
0%
25%
50%
75%
100%
$250 $2,250 $5,100
Retiree pays 100%
of first $250
Retiree pays 25% of next $2,000, up to $500
Ded
uctib
leCo
ins
ura
nce Plan pays 75%
Part D benefits Retiree liability (counts toward $3,600 true out-of-pocket maximum (TrOOP)*
Retiree pays 5% (no maximum)Retiree pays 100% of
next $2,850, up to $3,600total out-of-pocket limit
Retiree out-of-pocket costs$250 $750 $3,600
Annual drug costs
Plan pays 95%
Coi
nsur
ance
Cov
erag
e G
ap
(“D
onut
Hol
e”)
Cat
ast
rop
hic
Ben
efit
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Medicare Prescription Drug Plans
We’ll be comparing the following plans: Aetna Medicare Rx Essentials, Plus and Premium Plans Community Care Rx Basic, Choice and Gold Plans Coventry AdvantraRx Value, Premier and Premier Plus Plans Humana PDP Standard, Enhanced and Complete Plans AARP Medicare Rx by UnitedHealthcare
Please note that we have used each of the plan’s summary of benefits to create this comparison
We cannot answer specific details about any of the plans, with the exception of your Oak Ridge coverage
These comparisons were created using information that we believe to be current and accurate; however, you should contact each of the providers directly for the most up-to-date information on any of the plans discussed during today’s session
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans
Oak Ridge Aetna Medicare Rx Essentialssm
Aetna Medicare Rx Plussm
Aetna Medicare Rx Premiersm
Monthly Premium Per Person
Included in your Retiree Medical contributions
$38.86 $50.45 $66.75
Annual Deductible $150 (retail only)
$250(retail and mail order)
$0 $0
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)Generic:
Plan pays 80%You pay 20%
(minimum $10)
Brand name:$25 copay
Generic:$5 copay
Brand name:$35 copay
Generic:$7 copay
Non-Preferred Brand name:
$40 copay
Preferred Brand name:
$20 copay
Generic:$2 copay
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans
Oak Ridge Aetna Medicare Rx Essentialssm
Aetna Medicare Rx Plussm
Aetna Medicare Rx Premiersm
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Brand name:$50 copay
Generic:$10 copay
Brand name:$70 copay
Generic:$14 copay
Non-Preferred Brand name:
$80 copay
Preferred Brand name:
$40 copay
Generic:$4 copay
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail
as noted
You pay 100% for all drugs
Brand name:You pay 100%
for all drugs
Generic:$7 copay – retail
$14 copay – mail
Brand name:You pay 100% for
all drugs
Non-Preferred Generic:
$40 copay – retail
$80 – mail
Preferred Generic:
$2 copay – retail
$4 copay – mail
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Aetna Medicare Prescription Drug Plans
Oak Ridge Aetna Medicare Rx Essentialssm
Aetna Medicare Rx Plussm
Aetna Medicare Rx Premiersm
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail
as noted
The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost
The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost
The greater of:
Brand name:
$5 copay
Generic:
$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan
Oak Ridge Community Care Rx Basic
Community Care Rx Choice
Community Care Rx Gold
Monthly Premium Per Person
Included in your Retiree Medical contributions
$33.31 $41.41 $45.23
Annual Deductible $150 (retail only)
$250(retail)
$250(retail)
$100(retail)
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)Generic:
Plan pays 80%You pay 20%
(minimum $10)
Formulary Brand name:
Plan pays 55%You pay 45%
Formulary Preferred Brand
name:Plan pays 75%You pay 25%
Formulary Generic:$0 copay
Formulary Brand name:
$40 copay
Formulary Preferred
Brand name:$20 copay
Formulary Generic:$4 copay
Formulary Brand name:
$50 copay
Formulary Preferred
Brand name:$25 copay
Formulary Generic:$4 copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan
Oak Ridge Community Care Rx Basic
Community Care Rx Choice
Community Care Rx Gold
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
In addition to paying the copayment/coinsurance listed on the prior page, you pay the difference between the cost of the drug if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Formulary Brand name:
Plan pays 55%You pay 45%
Formulary Preferred Brand
name:Plan pays 75%You pay 25%
Formulary Generic:$0 copay
Formulary Brand name:$120 copay
Formulary Preferred
Brand name:$60 copay
Formulary Generic:
$12 copay
Formulary Brand name:
$150 copay
Formulary Preferred Brand
name:$75 copay
Formulary Generic:
$12 copay
Mail order not available but 90-day supply can be obtained at participating pharmacies
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Community Care Rx Basic Prescription Drug Plan
Oak Ridge Community Care Rx Basic
Community Care Rx Choice
Community Care Rx Gold
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% of the cost of all prescription drugs through coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage
Oak Ridge AdvantraRx Value Plan
AdvantraRx Premier Plan
AdvantraRx Premier Plus
Monthly Premium Per Person
Included in your Retiree Medical contributions
$22.86 $33.99 $43.85
Annual Deductible $150 (retail only)
No deductible No deductible No deductible
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)Generic:
Plan pays 80%You pay 20%
(minimum $10)
Non-Formulary Brand name:You pay 100%
Formulary Brand name:
$36 copay
Formulary Generic:
$15 copay
Non-Formulary Brand name:
$53 copay
Formulary Brand name:
$20 copay
Formulary Generic:$5 copay
Non-Formulary
Brand name:$63 copay
Formulary Brand name:
$20 copay
Formulary Generic:$0 copay
90 day supply available at participating pharmacies – copay equals three times 30 day supply copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage
Oak Ridge AdvantraRx Value Plan
AdvantraRx Premier Plan
AdvantraRx Premier Plus
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You pay the difference between what the plan would pay if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Non-Formulary Brand name:You pay 100%
Formulary Brand name:
$72 copay
Formulary Generic:
$30 copay
Non-Formulary Brand name:$106 copay
Formulary Brand name:
$40 copay
Formulary Generic:
$10 copay
Non-Formulary
Brand name:$126 copay
Formulary Brand name:
$40 copay
Formulary Generic:$0 copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Coventry Advantra®Rx Prescription Drug Coverage
Oak Ridge AdvantraRx Value Plan
AdvantraRx Premier Plan
AdvantraRx Premier Plus
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% of the cost of all prescription drugs through coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Oak Ridge Humana PDP Standard
Humana PDP Enhanced
Humana PDP Complete
Monthly Premium Per Person
Included in your Retiree Medical contributions
$14.08 $22.48 $67.16
Annual Deductible $150 (retail only)
$250(retail only)
No deductible No deductible
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)Generic:
Plan pays 80%You pay 20%
(minimum $10)
Non-Preferred Brand name:
Plan pays 75%You pay 25%
Preferred Brand name:
Plan pays 75%You pay 25%
Preferred Generic:
Plan pays 75%You pay 25%
Non-Preferred Brand name:
$60 copay
Preferred Brand name:
$30 copay
Preferred Generic:$7 copay
($0 copay until total drug costs
reach $250)
Non-Preferred Brand name:
$60 copay
Preferred Brand name:
$30 copay
Preferred Generic:$7 copay
($0 copay until total drug costs
reach $250)
90 day supply available at participating pharmacies – copay equals three times 30 day supply copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Oak Ridge Humana PDP Standard
Humana PDP Enhanced
Humana PDP Complete
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You pay the difference between what the plan would pay if the prescription was filled at a participating pharmacy and what the out-of-network pharmacy charged for the drug
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Non-Preferred Brand name:
Plan pays 75%You pay 25%
Preferred Brand name:
Plan pays 75%You pay 25%
Preferred Generic:
Plan pays 75%You pay 25%
Non-Preferred Brand name:$150 copay
Preferred Brand name:
$75 copay
Preferred Generic:
$17.50 copay ($0 copay until total drug costs
reach $250)
Non-Preferred Brand name: $150 copay
Preferred Brand name:
$75 copay
Preferred Generic:
$17.50 copay ($0 copay until total drug costs
reach $250)
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Oak Ridge Humana PDP Standard
Humana PDP Enhanced
Humana PDP Complete
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% for all drugs Retail and mail order copays apply through
coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage
Oak Ridge AARP Medicare Rx by UnitedHealthcare
Monthly Premium Per Person
Included in your Retiree Medical contributions
$27.28
Annual Deductible $150 (retail only)
No deductible
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%
You pay 30% (minimum $10)Generic:
Plan pays 80%You pay 20% (minimum $10)
Non-Preferred Brand name:$55 copay
Preferred Brand name:$28 copay
Preferred Generic:$5 copay
90 day supply available at participating pharmacies – copay equals three times
30 day supply copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage
Oak Ridge AARP Medicare Rx by UnitedHealthcare
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere.
You will generally pay more for prescriptions filled at a non-participating retail pharmacy.
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Non-Preferred Brand name:$165 copay
Preferred Brand name:$84 copay
Preferred Generic:$15 copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to AARP Medicare Rx Prescription Drug Coverage
Oak Ridge AARP Medicare Rx by UnitedHealthcare
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% for all drugs
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Let’s review an example of how the costs might play out for a retiree.
Joe has a few medical conditions that require regular medication; 3 of them are brand-name Joe fills these three times at his pharmacy and then uses mail order
for the rest of the year (three 90-day supplies) Each of these drugs costs $100 for a 30-day supply or $300 for a 90-day supply
— 2 of those are on Humana’s Preferred Brand name list.
He also takes one drug that is a generic but does not take this regularly – he expects to refill that drug five times during the year at his pharmacy. The retail cost for this drug is $30 for a 30-day supply.
We’ll assume that Joe only uses participating pharmacies.
If Joe did not have any coverage, his total prescription drug costs would be $3,750.
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Oak Ridge Joe Pays Total Drug Cost
Humana PDP Enhanced
Joe Pays
Annual Deductible
$150 (retail only)
$150 No deductible $0
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)
Generic:Plan pays 80%You pay 20%
(minimum $10)
30% x {$900 Minus $150
deductible} =
30% X $750 = $225
1 Generic ($10) X 5 refills = $50
3 Brand names
($100) X 3 refills =
$900
1 Generic ($30) X 5 refills = $150
Non-Preferred Brand name:
$60 copay
Preferred Brand name:
$30 copay
Preferred Generic:$7 copay
($0 copay until total drug costs
reach $250)
1 Non-Preferred
Brand name ($60) X 3
refills = $180
2 Preferred Brand name
($30) X 3 refills = $180
1 Generic ($7) X 5 refills =
$35
Subtotal $425 $1,050 $395
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Humana Prescription Drug Coverage
Oak Ridge Joe Pays Total Drug Cost
Humana PDP Enhanced
Joe Pays
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
3 Brand name X 3
refills ($35) = $315
3 Brand name
($300) X 3 refills = $2,700
Joe hits Coverage Gap when
Total Drug Costs reach $2,250
Non-Preferred Brand name:$150 copay
Preferred Brand name:
$75 copay
Preferred Generic:
$17.50 copay ($0 copay until total drug costs
reach $250)
1 Non-Preferred
Brand name ($150) X 3
refills = $450
1 Preferred Brand name
($75) X 1 refill = $75
Coverage Gap Hit – Joe pays for remaining $1,500 in drug
costs
Subtotal this page
Subtotal prior page
$315
$425
$2,700
$1,050
$2,025
$395
Grand total
Premium Cost
$740
Included
$3,750 $2,420
$270
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Oak Ridge Retiree Town Hall Meeting #2
Let’s stop for a minute to see if there are any questions?
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Oak Ridge Retiree Town Hall Meeting #2
Medicare Part C
Originally known as Medicare+Choice plans, now called Medicare Advantage or Medicare Health plans
These plans deliver Medicare benefits through coordinated care plans (HMOs, PPOs) or private fee-for-service plans
— May include additional benefits such as dental, vision, hearing screenings and prescription drugs
— Must live in the geographic service area where the plan provides service— Premiums vary by plan
Available to:— Individuals entitled to Part A and enrolled in Part B— 65 and older— Disabled Medicare beneficiaries
– Except new enrollees with ESRD We’ll discuss the Medicare prescription drug coverage offered by some of the local
Medicare Advantage plans The premium we note for each is for the prescription drug coverage only – however,
many of these plans require additional premiums for medical coverage
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Medicare Advantage Prescription Drug Coverage
There are several providers who offer Medicare Advantage plans in the Oak Ridge area
These plans include Medicare prescription drug coverage as part of their overall medical coverage
We’ll be comparing prescription drug coverage for the following Medicare Advantage plans: BlueCross BlueShield of Tennessee’s BlueAdvantagePlus Cariten Senior Health John Deere SecurePlus
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage
Oak Ridge BlueAdvantagePlus
Monthly Premium Per Person
Included in your Retiree Medical contributions
$37.98
Annual Deductible $150 (retail only)
No deductible
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%
You pay 30% (minimum $10)Generic:
Plan pays 80%You pay 20% (minimum $10)
Formulary Non-Preferred Brand name:$64 copay
Formulary Preferred Brand name:$32 copay
Formulary Generic:$8 copay
90 day supply available at participating pharmacies – copay equals three times 30
day supply copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage
Oak Ridge BlueAdvantagePlus
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Only covered in special circumstances: in case of emergency, traveling outside network or drug unavailable elsewhere. 10-day supply only at the following copays:
Formulary Non-Preferred Brand name:$64 copay
Formulary Preferred Brand name:$32 copay
Formulary Generic:$8 copay
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Formulary Non-Preferred Brand name:$128 copay
Formulary Preferred Brand name:$64 copay
Formulary Generic:$16 copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to BCBS of Tennessee’s BlueAdvantagePlus Prescription Drug Coverage
Oak Ridge BlueAdvantagePlus
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% of the cost of all prescription drugs through coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage
Oak Ridge Cariten Senior Health (PPO & HMO)
Monthly Premium Per Person
Included in your Retiree Medical contributions
$39.24 – PPO or HMO
Annual Deductible $150 (retail only)
$100(retail)
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%
You pay 30% (minimum $10)Generic:
Plan pays 80%You pay 20% (minimum $10)
Multi-source Brand name, Non-Preferred Brand name and Non-Preferred
Injectables:$50 copay
Other Preferred Brand name and Preferred Injectables:$30 copay
Preferred Brand name:$15 copay
All Generics except omeprazole:$5 copay
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage
Oak Ridge Cariten Senior Health (PPO & HMO)
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
Multi-source Brand name, Non-Preferred Brand name and Non-Preferred Injectables:
$150 copay
Other Preferred Brand name and Preferred Injectables:$90 copay
Preferred Brand name:$45 copay
All Generics:$15 copay
90-day supply can be obtained at participating pharmacies or through mail-order pharmacy
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage
Oak Ridge Cariten Senior Health (PPO & HMO)
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pockets covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as
noted
You pay 100% of the cost of all prescription drugs through coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail as
noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage
Oak Ridge John Deere’s SecurePlus Medicare
Part D Basic Alternative
John Deere’s SecurePlus Medicare
Part D Enhanced Alternative
Monthly Premium Per Person
Included in your Retiree Medical contributions
$29.29 $43.90
Annual Deductible $150 (retail only)
No deductible No deductible
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%
You pay 30% (minimum $10)
Generic:Plan pays 80%
You pay 20% (minimum $10)
Non-Formulary Brand name, Formulary Brand name and
Generic:$10 copay
All drugs: Plan pays 75%You pay 25%
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage
Oak Ridge John Deere’s SecurePlus Medicare Part D Basic
Alternative
John Deere’s SecurePlus Medicare Part D
Enhanced Alternative
Coinsurance or Copayment for prescription drugs obtained at non-participating retail pharmacy (30 day supply)
Brand name: Plan pays 50%You pay 50%
Generic:Plan pays 50%You pay 50%
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere. You can obtain a 30 day supply:
Non-Formulary Brand name, Formulary Brand
name and Generic:$10 copay
Not covered except in case of emergency, traveling outside network or drug unavailable elsewhere. You can obtain a 30 day supply:
Non-Formulary Brand name, Formulary Brand
name and Generic: Plan pays 75%You pay 25%
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
One month (30-day supply) available at mail
order:
Non-Formulary Brand name, Formulary Brand
name and Generic:$10 copay
One month (30-day supply) available at mail
order:
Non-Formulary Brand name, Formulary Brand
name and Generic:Plan pays 75%You pay 25%
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Oak Ridge Retiree Town Hall Meeting #2
Comparing Oak Ridge Coverage to John Deere’s SecurePlus Prescription Drug Coverage
Oak Ridge John Deere’s SecurePlus Medicare Part D Basic
Alternative
John Deere’s SecurePlus Medicare Part D Enhanced
Alternative
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pockets covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail as noted
Coverage gap begins at $1,825 and you pay 100% of the cost of all prescription drugs through coverage gap
Coverage gap begins at $2,250 and you pay 100% of the cost of all prescription drugs through coverage gap
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not apply
Coverage for retail and mail as noted
The greater of:
Non-Preferred Brand name:$5 copay
Formulary Preferred Brand name or Generic:$2 copay
Or 5% of drug cost
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage Prescription Drug Coverage
Let’s review an example of how the costs might play out for a retiree.
Joe has a few medical conditions that require regular medication; 3 of them are brand-name Joe fills these three times at his pharmacy and then uses mail order
for the rest of the year (three 90-day supplies) Each of these drugs costs $100 for a 30-day supply or $300 for a 90-day supply
— 2 of those are on Cariten’s Preferred Brand name list.
He also takes one drug that is a generic but does not take this regularly – he expects to refill that drug five times during the year at his pharmacy. The retail cost for this drug is $30 for a 30-day supply.
We’ll assume that Joe only uses participating pharmacies.
If Joe did not have any coverage, his total prescription drug costs would be $3,750.
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage
Oak Ridge Joe Pays Total Drug Costs
Cariten Senior Health (PPO &
HMO)
Joe Pays
Annual Deductible
$150 (retail only)
$150 $100(retail)
$100
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)
Generic:Plan pays 80%You pay 20%
(minimum $10)
30% x {$900 Minus $150
deductible} =
30% X $750 = $225
1 Generic ($10) X 5 refills = $50
3 Brand names
($100) X 3 refills =
$900
1 Generic
($30) X 5 refills = $150
Other Preferred
Brand name and Preferred Injectables:$30 copay
Preferred Brand name:
$15 copay
All Generics:$5 copay
1 Other Preferred Brand name ($30) X 3
refills = $90
2 Preferred Brand name
($15) X 3 refills = $90
= $180
1 Generic ($5) X 5 refills = $25
Subtotal $425 $1,050 $305
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Oak Ridge Retiree Town Hall Meeting #2
An Example: Comparing Oak Ridge Coverage to Cariten Senior Health Prescription Drug Coverage
Oak Ridge Joe Pays Total Drug Costs
Cariten Senior Health (PPO &
HMO)
Joe Pays
Coinsurance or Copayment for prescription drugs obtained through mail order (90 day supply)
Brand name: $35 copayGeneric:
$15 copay
3 Brand name X 3 refills ($35) =
$315
3 Brand name
($300) X 3 refills = $2,700
Joe hits Coverage Gap when Total Drug
Costs reach $2,250
Other Preferred
Brand name and Preferred Injectables:$90 copay
Preferred Brand name:
$45 copay
All Generics:$15 copay
1 Other Preferred Brand name ($90) X 3
refills = $270
1 Preferred Brand name
($45) X 1 refill = $45
Coverage Gap Hit – Joe pays for remaining $1,500 in drug
costs
Subtotal this page
Subtotal prior page
$315
$425
$2,700
$1,050
$1,815
$275
Grand Total
Premium Cost
$740
included
$2,210
$471
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Oak Ridge Retiree Town Hall Meeting #2
Let’s stop for a minute to see if there are any questions?
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Oak Ridge Retiree Town Hall Meeting #2
Special Considerations for Limited Income and Resources Individuals
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Oak Ridge Retiree Town Hall Meeting #2
Who Should Enroll in a Medicare Prescription Drug Plan?
Those without drug coverage For people without the benefit of
employer-sponsored coverage
Those who qualify for “extra help” The Social Security Administration
has identified people who may qualify for assistance in paying for drugs based on their income and assets ― applications were mailed directly to people in May 2005
Medicare prescription drug plans are designed for people who need them most…
…but it’s completely up to each individual to decide what prescription drug coverage option makes the best financial sense for his or her family.
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Oak Ridge Retiree Town Hall Meeting #2
Who’s Eligible for Extra Help?
“Limited income and resources” defined as: Income less than 150% of federal poverty level
— $14,355 for individuals in 2006— $19,245 for couples in 2006
Limited liquid assets— $11,500 for individuals— $23,000 for couples in 2006
The Social Security Administration is sending applications to those who may qualify for the extra benefit
If you receive an application, you should complete it. Submitting this application does not enroll you for Medicare drug coverage
However, according to the Medicare and You 2006 Handbook, if you apply and qualify for assistance, you will automatically be enrolled in the plan for which you are considered eligible
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Oak Ridge Retiree Town Hall Meeting #2
What Does “Extra Help” Cover?
Oak Ridge <100%* <135%** <150%***
Monthly Premium Per Person
Included in your Retiree Medical contributions
$0 $0 Subsidy phased out at 150%
Annual Deductible $150 (retail only)
$0 $0 $50
Coinsurance or Copayment for prescription drugs obtained at participating retail pharmacy (30 day supply)
Brand name: Plan pays 70%You pay 30%
(minimum $10)Generic:
Plan pays 80%You pay 20%
(minimum $10)
Formulary Brand name:
$3 copay
Formulary Generic:$1 copay
Formulary Brand name:
$5 copay
Formulary Generic:$2 copay
Formulary Brand name:
Plan pays 85%You pay 15%
Formulary Generic:
Plan pays 85%You pay 15%
* Income must be less than $9,570 for individuals/$12,830 for a couple. Must also be eligible for Medicaid.** Income must be less than $12,920 for individuals/$17,321 for a couple. Liquid assets <$6,000 ind; $9,000 couple*** Income must be less than $14,355 for individuals/$19,245 for a couple. Liquid assets <$11,500 ind; $23,000 couple
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Oak Ridge Retiree Town Hall Meeting #2
What Does “Extra Help” Cover?
Oak Ridge <100% <135% <150%
Coinsurance or Copayment for prescription drugs during coverage gap ($2,250 in total prescription drug costs until you reach $3,600 in out-of-pocket covered prescription drug costs)
Coverage gap does not apply
Coverage for retail and mail
as noted
Formulary Brand name:
$3 copay
Formulary Generic:$1 copay
Formulary Brand name:
$5 copay
Formulary Generic:$2 copay
Formulary Brand name:
Plan pays 85%You pay 15%
Formulary Generic: Plan pays 85%You pay 15%
Coinsurance or Copayment for prescription drugs once you reach $3,600 in out-of-pocket expenses
Out of pocket limit does not
apply
Coverage for retail and mail
as noted
Formulary Brand name:
$3 copay
Formulary Generic:$1 copay
Formulary Brand name:
$5 copay
Formulary Generic:$2 copay
Formulary Brand name:
$5 copay
Formulary Generic:$2 copay
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Oak Ridge Retiree Town Hall Meeting #2
But Keep in Mind…
If you become enrolled in a plan offered to individuals with limited income and resources, you will lose your Oak Ridge retiree medical coverage
Medicare or, if you are eligible, Medicaid will be your sole source of medical coverage
Weigh the potential out-of-pocket costs — both your medical and prescription drug coverage — before filing your application For example, consider your Medicare inpatient deductible if you
anticipate being hospitalized in the coming year
You may also want to discuss this with your local Social Security office
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Oak Ridge Retiree Town Hall Meeting #2
What’s Next?
For 2006, a special Medicare Part D enrollment period will be held For individuals eligible by November 15: November 15, 2005 –
May 15, 2006 Individuals eligible later: If an individual becomes eligible for
Medicare after May 15, 2006, there will be an initial open enrollment period for both Parts B & D
In later years, from November 15 to December 31 for next benefit year (January 1 – December 31)
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Oak Ridge Retiree Town Hall Meeting #2
The Key Question…
If I already have coverage through Oak Ridge, does it makes sense for me to enroll in a private Medicare prescription drug plan in 2006?
The answer…
In most cases, no! Remember the reason ― Oak Ridge already provides drug coverage that is expected to pay out at least as much as — and in most cases more than — a standard Medicare prescription drug plan
Most retirees are better off under Oak Ridge’s plan, unless: You are eligible for “extra help” or on Tricare (the plan for military retirees and spouses), Remember, if you are Medicare-eligible and elect Medicare Part D coverage, your continued
coverage through Oak Ridge will be dropped
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Oak Ridge Retiree Town Hall Meeting #2
Oak Ridge Retiree Prescription Drug Coverage: Overview
Your Oak Ridge retiree medical plan includes prescription drug coverage Anyone enrolled in the Oak Ridge retiree medical plan receives
prescription drug coverage automatically Medical and prescription drug coverage is integrated; you cannot
enroll in one without the other
Oak Ridge prescription drug coverage is “creditable coverage,” which is defined by CMS as being “on average” at least as generous as the standard benefit Protects your right to leave the Oak Ridge retiree medical plan and
join another “certified” plan or Medicare prescription drug plan within 63 days without incurring a penalty on the Medicare Part D premium for coverage— Those without “creditable coverage” are penalized 1% of the
monthly Medicare Part D premium for each month enrollment is delayed past their initial enrollment period
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Oak Ridge Retiree Town Hall Meeting #2
Key Points to Remember
The Oak Ridge retiree medical plan includes prescription drug coverage. This means anyone who’s enrolled in an Oak Ridge retiree medical plan receives prescription drug coverage automatically Medical and prescription drug coverage are combined and a person can’t
enroll in one without the other
For 2006, your Oak Ridge coverage is at least as generous as private Medicare prescription drug coverage
Your Oak Ridge prescription drug coverage does not coordinate with private Medicare prescription drug coverage This means you do not need to enroll in Medicare Part D to keep your
Oak Ridge coverage In fact, if you enroll in Medicare Part D, you will lose your Oak Ridge
retiree medical coverage
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Oak Ridge Retiree Town Hall Meeting #2
Let’s stop for a minute to see if there are any questions?
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Oak Ridge Retiree Town Hall Meeting #2
Where to Get More Information
OneCall By phone at 574-1500 or 1-877-861-2255
— CSRs available Monday through Friday, 7:00 a.m. to 5:00 p.m. ET
Via the internet at http://www.y12.doe.gov — Employee & Retiree Benefits
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