Tufts Medicare Preferred PPO: Prescription Benefit

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Prescription Benefit

Plan Information

PFFS

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PFFS Terms and Conditions of Payment

Tufts Medicare Preferred PPO: Prescription Benefit

Tufts Medicare Preferred offers two prescription drug options. By selecting either one of these options, you are automatically enrolled in a qualified Medicare Part D prescription drug plan. Please compare the two prescription drug options below. If you enroll in the Tufts Medicare Preferred PPO and you want the Medicare prescription benefit, you must purchase it through our plan.

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	PPO Rx Option	PPO Rx Plus Option
Description	You pay NO upfront deductible.	You pay NO upfront deductible.
Yearly drug costs paid by both you and Tufts Medicare Preferred	Covered up to $2,700	Covered up to $2,700
For up to a 30-day supply at a retail pharmacy	Tier 1: $10 Tier 2: $35 Tier 3: $65	Tier 1: $10 Tier 2: $30 Tier 3: $60
For up to a 90-day supply through mail order	Tier 1: $20 Tier 2: $70 Tier 3: $130	Tier 1: $20 Tier 2: $60 Tier 3: $120
"Coverage Gap" After your yearly drug costs paid by you and Tufts Medicare Preferred reach $2,700 but before your yearly out-of-pocket costs reach $4,350	You pay 100% of the Tufts Medicare Preferred negotiated price for your prescription drug costs.	You are covered for Tier 1 (member pays 100% for Tier 2 and 3):
Copays for up to a 30-day supply at a retail pharmacy		Tier 1: $10
Copays for up to a 90-day supply through mail order		Tier 1: $20
After the "Coverage Gap" Copays for retail and mail order	Tier 1: $2 Tier 2: $8 Tier 3: $14	Tier 1: $2 Tier 2: $8 Tier 3: $14

Note:
See the list of covered drugs (formulary) and directory of participating pharmacies for locations where you can get your prescriptions filled. Some medications require prior authorization or dispensing limits. For more information, see the Summary of Benefits booklet.

H2229-2009-19 9/30/08

This document was last modified: 9/30/08

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The Medicare Advantage contract between Tufts Health Plan and the Centers for Medicare & Medicaid Services (CMS) is valid for one calendar year. The benefits, premiums, copayments and service area offered by Tufts Health Plan are subject to change on an annual basis. Please contact Tufts Health Plan Medicare Preferred for details. Tufts Health Plan Medicare Preferred is a medicare advantage organization that contracts with the Federal Government.

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