The following section provides a brief summary of the Medicare Supplement Plan amounts, and how payments are determined.
The Plan provides benefits up to the Plan's reimbursement level when combined with Medicare. This means that Medicare's payments are subtracted from the Plan's benefits and any difference is paid by the Plan. For more information, check the Medicare Web site at www.medicare.gov.
|Annual Deductible Per covered individual||$300|
|Out-of-Pocket Maximum Per covered individual||$3,000|
|Medical Individual Lifetime Maximum||Unlimited
|Medical Services||80% of covered charges less any Medicare payment|
|Inpatient Hospital Services||80% of covered charges less any Medicare payment|
|Outpatient Hospital Services||80% of covered charges less any Medicare payment|
|Physician Services||80% of covered charges less any Medicare payment|
|Prescription drugs — Annual out-of-pocket maximums for prescription drugs--$2,500/individual and $5,000/family.|
|Short Term Retail Pharmacy Co-Pay* ** *** ****||Long Term Express Scripts, or Smart90 Pharmacy|
|(up to 34-day supply)||Maximum Per Prescription
3rd+ Retail Refill****
|(up to 90-day supply)||Maximum Per Prescription|
|Formulary Brand Drugs||30%||$125
|Non-Formulary Brand Drugs||50%||$200
*If using a non-network pharmacy, you pay 100% of the difference between the actual cost and the discounted network cost plus retail copays.
** If your doctor prescribes a brand name drug for which a generic equivalent is available, you will be responsible for paying the generic copay and the full difference in the cost between the brand name and the generic equivalent. The difference in the cost between the brand and the generic does not apply to the annual out-of-pocket maximum for prescription drugs.
*** You must present your Express Scripts Prescription Card or Social Security number of the primary participant or benefits will be paid at the non-network level.
**** Preferred means Express Scripts’ formulary of preferred prescription drugs. Although the percentage copayments and maximum per prescription for specialty drugs are generally the same as for brand name drugs, higher copayments may be charged for certain preferred specialty medications determined to be non-essential health benefits. However, many of these medications may be available at no cost when purchased through the Plan’s copay assistance program. If the specialty medication being purchased qualifies for copay assistance, you will be contacted by a pharmacist from the Accredo specialty pharmacy and asked to enroll in the program. If you choose not to enroll in the program, you will be responsible for the higher copayment.
|Care Outside of the U.S.||80% of the covered charge|
|Home Health Care||80% of Medicare approved charges less any Medicare payment, must be approved in advance|
|Blood||80% of Medicare pre-approved covered charges less any Medicare payment|
|Skilled Nursing Facility Charges||80% of covered charges less any Medicare payment|
|Hospice Care||80% of covered charges less any Medicare payment
|Mental Health Treatment||80% of reasonable and customary charges less any Medicare payment
|Claim 1||Claim 2||Claim 3||Claim 4||Claim 5||Total|
|Eligible Expenses Medicare Approved Amount||$200.00||$300.00||$2,600.00||$15,100.00||$1,310.00||$19,510.00|
|Medicare Coinsurance||$3.40||$60.00||$520.00||$3,020.00||$262.00||$ 3,865.40|
|Medicare Paid based on 80% benefit after Medicare Part B deductible ($166 applied) Please reference your Medicare Handbook for current deductible/coinsurance for the expenses incurred||$13.60 ($200 ‐ $183 = $17 x 80%)||$240 ($300 x 80%)||$2,080 ($2,600 x 80%)||$12,080 ($15,100 x 80%)||$1048 ($1,310 x 80%)||$15,461.60|
|Amount Applied to $300 MSP Annual Deductible||$200.00||$100.00||$0.00||$0.00||$0.00||$300.00|
|True Out of Pocket Expense Applied to $3000 Annual Out of Pocket Maximum||$186.40||$60.00||$520.00||$2,233.60||$0.00||$3,000.00|
|Amount Paid by MSP after Medicare’s Payment and Applicable Yearly Plan Deductible and Coinsurance is Applied||$0.00||$0.00||$0.00||$786.40||$262.00||$1,048.40|
|Paid by Participant||$186.40
|MSP Plan Benefit Calculation:
Medicare Paid = Plan
applied to deductible
= $0 plan
100 applied deductible
= $200 x
80% = $160-$240 Medicare paid = $0
|$2,600 x 80% = $2,080
Medicare paid = $0 plan paid
|$15,100 x 80% = $12,080
out of pocket maximum met at
$12,866.40 $12,080 Medicare paid =
$786.40 plan paid
|$1310 x 100% annual out of pocket met = $1310 - $1048 Medicare payment = $262 plan paid||$1,048.40|