Minneapolis Public Schools

2020

MEDICA MEDICARE PLAN OPTIONS

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MEDICA ADVANTAGE SOLUTION ELIGIBILITY

Enrolled in Medicare Parts A & B

Pay your Medicare Part B premium

Must not have end-stage renal disease (ESRD)*

Unless coming off a Medica plan

Permanently reside in Medica’s 66 county Medicare Advantage service area or most counties through the United States and it’s territories

– MINNESOTA: Anoka, Becker, Beltrami, Benton, Big Stone, Blue Earth, Brown, Carver, Cass, Chippewa, Chisago, Clay, Clearwater, Cottonwood, Crow Wing, Dakota, Dodge, Douglas, Faribault, Fillmore, Freeborn, Grant, Hennepin, Houston, Hubbard, Isanti, Jackson, Kandiyohi, Kittson, Lac qui Parle, Lake of the Woods, Lincoln, Lyon, Mahnomen, Marshall, Martin, Morrison, Mower, Murray, Nicollet, Nobles, Norman, Olmsted, Otter Tail, Pennington, Polk, Pope, Ramsey, Red Lake, Redwood, Renville, Roseau, Scott, Sherburne, Stearns, Steele, Swift, Todd, Wabasha, Wadena, Waseca, Washington, Watonwan, Wilkin, Winona, Wright

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MEDICA PRIME SOLUTION COST PLAN ELIGIBILITY

Enrolled in Medicare Parts A and B, or only Part B

Pay your Medicare Part B premium

Must not have end-stage renal disease (ESRD)*

unless coming off a Medica plan

Permanently reside in a Medica Cost plan service area

MINNESOTA: Aitkin, Carlton, Cook, Goodhue, Itasca, Kanabec,

Koochiching, Lake, Le Sueur, McLeod, Meeker, Mille Lacs, Pine, Pipestone, Rice, Rock, Sibley, St. Louis, Stevens, Traverse, Yellow Medicine

All Counties in South Dakota, most counties in North Dakota, 13 counties in western Wisconsin, and 15 counties in Iowa

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MINNEAPOLIS PUBLIC SCHOOLS PLAN OPTIONSPlan 2 Plan 6

Monthly Premium $299.00 $148.00

Medical Benefit

Primary Care Office Visit $15 copay $0 copay

Specialist Office Visit $15 copay $10 copay

Urgent Care $15 copay $0-10 copay

Inpatient Hospital $100 copay $100 copay

Outpatient Hospital $0 copay $50 copay

Ambulance $0 ground/20% air $25 copay

Worldwide Emergency Room $50 copay $50 copay

Preventive Care $0 copay $0 copay

Hearing Aids $500 $400

Eyewear Reimbursement $150 $75

Dental Reimbursement $500 $500

Durable Medical Equipment 10% coinsurance 20% coinsurance

Part B Drugs 20% coinsurance 20% coinsurance

Part D Prescription Drug Coverage Preferred Standard Preferred Standard

Tier 1 $5 copay $10 copay $2 copay $6 copay

Tier 2 $15 copay $25 copay $5 copay $12 copay

Tier 3 $30 copay $35 copay $30 copay $35 copay

Tier 4 $60 copay $65 copay 50% coinsurance

Tier 5 25% coinsurance 33% coinsurance

Gap Coverage Yes No

Deductibles & Max. Out-of-Pocket Limits

Medical Deductible $0 $0

Pharmacy Deductible $0 $0

Medical Out-of-Pocket Max. $1,500 $3,000

Rx Out-of-Pocket Maximum Medicare limits Medicare Limits

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MINNEAPOLIS PUBLIC SCHOOLS | PART D COVERAGE

Highlights of Benefit Structure

No Part D Deductible

5-Tier formulary with more than 3,600 prescription drugs

Large Nationwide Pharmacy Network

65,000+ pharmacies nationwide, including all major chains and thousands of independent pharmacies

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MINNEAPOLIS PUBLIC SCHOOLS | PART D COVERAGE

Option to Save When Using Preferred Pharmacies

Advantages to you

Copay savings when using preferred pharmacies

Includes Walgreens, Hy-Vee Pharmacy, Walmart, Sam’s Club and Costco, and other independent pharmacies (25,000 nationwide)

Save when using

preferred retail

pharmacies

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MINNEAPOLIS PUBLIC SCHOOLS | PART D COVERAGE

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Mail Service Pharmacy

For 3-month supplies through preferred mail order vendor: 3 month supply for 2 preferred copayments

Order refills online anytime, anywhere

Set up handy automatic refills for most maintenance medications

Real-time order tracking and typically receive in 3-5 days

Save when

using convenient mail service.

Great for maintenance

drugs.

EXTRA BENEFITS & SERVICES

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SILVERSNEAKERS® FITNESS & LIFESTYLE BENEFIT PROGRAM

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Membership toFitness Locations

SilverSneakersOn-DemandTM

SilverSneakers GoTM

Mobile App

Unlimited access to more than 16,000 locations nationwide. Visit as many as you wish!

Online workout videos that feature tips on fitnessand nutrition

Workout programs, location finder and more

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PERSONAL SUPPORT PROGRAMS | Available 365 days a year 24/7

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24/7 NurseLineHighly-trained nurses answer questions about symptoms, medications, health conditions and offer self-care tips for non-urgent medical issues.

Personal Advocacy Support

Personal Health Advocates help in a variety of ways from finding the right doctor to resolving claims questions to answering questions about coverage, find network providers, schedule appointments, and more.

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ACCESS PLAN INFORMATION 24/7

mymedica.com

Secure personal account information

Mobile app

Check prescription drug coverage info on the go

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Acknowledgement Letter

Member ID Card

Member Packet

Verification Information

Confirmation Letter

WHAT TO EXPECT NEXT

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COMMITMENT TO MEMBERS

Caring, personal service you deserve from local Medicare experts.

Toll free 1-800-575-2330 8 a.m.– 8 p.m. Central, 7 days a weekAccess to representatives may be limited at times

medica.com/Medicare