PEIP Retiree Health - Medica



PEIP Retiree Health

Medica Group Prime Solution Options

January 1, 2013 through December 31, 2013

| |Group Number 70506 |Group Number 70555 |Group Number 70623 |

| |Drug Coverage With Copays |No Drug Coverage |Drug Coverage With Copays |

| |$242.00 monthly |$82.00 monthly |With Coverage Gap (Donut Hole) |

| | | |$145.00 monthly |

|Prescription Drugs |$10 Copay Generic Drugs |No Coverage |$10 copay generic drugs |

|(Medica Part D Rx Formulary required, 31-day supply) |$25 Copay Preferred Brand Drugs | |$34 preferred brand copay |

| |$50 Non-Preferred Brand Drugs | |$74 non-preferred brand copay |

| |$75 Specialty Drugs | |25% specialty drug copay |

| |Mail order (2 copays for 93-day supply) | |Mail order (2 copays for 93-day supply) |

| |(open formulary) | |(open formulary) |

| | | |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). |

|Preventive Care (Including annual physical, cancer |100% coverage in network. |

|screenings, eye exam, and immunizations) | |

|Physician Services |$15 copay in network. Extended Absence Option available outside service area. |

|(Office visit for illness or injury/urgent care) | |

|Inpatient Hospital Care |$100 copay. Extended Absence Option available outside service area. |

|Outpatient Services |$50 copay |

|Emergency Care |$65 copay (waived if admitted with 24 hours) |

|Extended Absence Option |Includes routine, non-emergency coverage outside the service area, but within the United States for up to 9 consecutive months (member must call Medica to |

| |activate this option) |

|Additional Benefits |$500 annual allowance for hearing aids/hearing aid exams |

| |$150 annual eyewear benefit |

| |SilverSneakers Fitness Program |

|Out-of-pocket Maximum |$1,000 includes only medical copays |$1,000 includes all medical copayments |$2,000 includes all medical copayments |

| |Members continue paying their copays through the gap | | |

| |(Medica no longer offers $1,000 out-of-pocket maximum for | | |

| |prescription drugs) | | |

|Billing Options |Monthly invoice or monthly automatic withdrawal. |

|Service Area |Service area includes: |

| |Minnesota Counties: all 87 counties in Minnesota. |

| |South Dakota Counties: Aurora, Beadle, Bon Homme, Brookings, Brown, Brule, Buffalo, Campbell, Charles Mix, Clark, Clay, Codington, Davison, Day, Deuel, |

| |Douglas, Edmunds, Grant, Gregory, Hamlin, Hand, Hanson, Hughes, Hutchinson, Jerauld, Kingsbury, Lake, Lincoln, Lyman, Marshall, McCook, McPherson, Miner, |

| |Minnehaha, Moody, Roberts, Sanborn, Spink, Stanley, Tripp, Turner, Union, Yankton |

| | |

| |North Dakota Counties: Barnes, Burleigh, Cass, Cavalier, Dickey, Eddy, Emmons, Foster, Grand Forks, Griggs, Kidder, La Moure, Logan, McIntosh, Morton, |

| |Oliver, Pembina, Ransom, Richland, Sargent, Sioux, Steele, Stutsman, Traill, Walsh |

| |Wisconsin Counties: Ashland, Barron, Bayfield, Burnett, Chippewa, Douglas, Dunn, Eau Claire, Pierce, Polk, Sawyer, St. Croix, Washburn. |

| |Please call 952-992-2330 or 1-800-575-2330 for specific information. |

This is a brief summary of benefits. Not all covered services, exclusions, and limitations are shown here.

Please contact PEIP/Innovo at 952-746-3101 or 1-800-829-5601 or for more information.

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Medica Group Prime Solution Options

January 1, 2013 through December 31, 2013

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