Preferred Choice creditable coverage status
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1 Preferred Choice creditable coverage status Effective Date: 01/01/2018 The Centers for Medicare & Medicaid Services (CMS) requires plan sponsors (employer groups) to disclose to Medicare Part D eligible active and retired employees and their spouses and dependents whether their coverage is creditable prescription drug coverage when compared to Medicare Part D. This information is essential to an individual s decision whether to enroll in a Medicare Part D prescription drug plan. Medicare eligible individuals whose prescription drug plan is deemed not creditable have an opportunity to join Medicare Part D during the annual enrollment period, and may be eligible at other qualifying times. Effective January 1, 2018, Premera has determined the creditable coverage status of the prescription drug coverage for Preferred Choice plans per CMS guidelines as shown below. For more information on Medicare Part D click here: As a courtesy we have tested our plans using actuarial tools to determine if the plans provide creditable coverage. These results do not constitute statements of actuarial opinion. The obligation to test plans and send notices to group members is the employer s responsibility. Employers should consult their financial consultants and/or legal counsel to determine their obligations and whether the information presented is appropriate for the plans you ve selected and implemented. 1
2 Preferred Choice creditable coverage results for CMS Medicare Part D thresholds for 2018 and 2019 Plan Name Pharmacy Tiers/Description 2018 Result 2019 Result Your Future $1,500 HSA Creditable Creditable Your Future $2,500 HSA Creditable Creditable Your Future $3,000 HSA Creditable Creditable Your Future $5,000 HSA Creditable Creditable Your Future $6,450 HSA Creditable Creditable Your Choice $250 PPO $15/$35 Creditable Creditable Your Choice $250 PPO $10/$25/$45 Creditable Creditable Your Choice $250 PPO $15/$35, Your Choice $250 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $250 PPO $15/$30/$50 Creditable Creditable Your Choice $250 PPO $15/$30/$50, Your Choice $250 PPO $20/$50/50%/30% Creditable Creditable Your Choice $250 PPO $10/$25/$45/30% Creditable Creditable Your Choice $250 PPO $15/$30/$50/30% Creditable Creditable Your Choice $250 PPO Your Choice $500 PPO $15/$35 Creditable Creditable Your Choice $500 PPO $10/$25/$45 Creditable Creditable Your Choice $500 PPO $15/$35, Your Choice $500 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $500 PPO $15/$30/$50 Creditable Creditable Your Choice $500 PPO $15/$30/$50, Your Choice $500 PPO $20/$50/50%/30% Creditable Creditable Your Choice $500 PPO $10/$25/$45/30% Creditable Creditable Your Choice $500 PPO $15/$30/$50/30% Creditable Creditable Your Choice $500 PPO Your Choice $750 PPO $15/$35 Creditable Creditable Your Choice $750 PPO $10/$25/$45 Creditable Creditable Your Choice $750 PPO $15/$35, Your Choice $750 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $750 PPO $15/$30/$50 Creditable Creditable Your Choice $750 PPO $15/$30/$50, Your Choice $750 PPO $20/$50/50%/30% Creditable Creditable Your Choice $750 PPO $10/$25/$45/30% Creditable Creditable Your Choice $750 PPO $15/$30/$50/30% Creditable Creditable Your Choice $750 PPO 2
3 Your Choice $1,000 PPO $15/$35 Creditable Creditable Your Choice $1,000 PPO $10/$25/$45 Creditable Creditable Your Choice $1,000 PPO $15/$35, Your Choice $1,000 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $1,000 PPO $15/$30/$50 Creditable Creditable Your Choice $1,000 PPO $15/$30/$50, Your Choice $1,000 PPO $20/$50/50%/30% Creditable Creditable Your Choice $1,000 PPO $10/$25/$45/30% Creditable Creditable Your Choice $1,000 PPO $15/$30/$50/30% Creditable Creditable Your Choice $1,000 PPO Your Choice $1,500 PPO $15/$35 Creditable Creditable Your Choice $1,500 PPO $10/$25/$45 Creditable Creditable Your Choice $1,500 PPO $15/$35, Your Choice $1,500 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $1,500 PPO $15/$30/$50 Creditable Creditable Your Choice $1,500 PPO $15/$30/$50, Your Choice $1,500 PPO $20/$50/50%/30% Creditable Creditable Your Choice $1,500 PPO $10/$25/$45/30% Creditable Creditable Your Choice $1,500 PPO $15/$30/$50/30% Creditable Creditable Your Choice $1,500 PPO Your Choice $2,000 PPO $15/$35 Creditable Creditable Your Choice $2,000 PPO $10/$25/$45 Creditable Creditable Your Choice $2,000 PPO $15/$35, Your Choice $2,000 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $2,000 PPO $15/$30/$50 Creditable Creditable Your Choice $2,000 PPO $15/$30/$50, Your Choice $2,000 PPO $20/$50/50%/30% Creditable Creditable Your Choice $2,000 PPO $10/$25/$45/30% Creditable Creditable Your Choice $2,000 PPO $15/$30/$50/30% Creditable Creditable Your Choice $2,000 PPO Your Choice $2,500 PPO $15/$35 Creditable Creditable Your Choice $2,500 PPO $10/$25/$45 Creditable Creditable Your Choice $2,500 PPO $15/$35, Your Choice $2,500 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $2,500 PPO $15/$30/$50 Creditable Creditable Your Choice $2,500 PPO $15/$30/$50, Your Choice $2,500 PPO $20/$50/50%/30% Creditable Creditable Your Choice $2,500 PPO $10/$25/$45/30% Creditable Creditable Your Choice $2,500 PPO $15/$30/$50/30% Creditable Creditable Your Choice $2,500 PPO Your Choice $3,000 PPO $15/$35 Creditable Creditable 3
4 Your Choice $3,000 PPO $10/$25/$45 Creditable Creditable Your Choice $3,000 PPO $15/$35, Your Choice $3,000 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $3,000 PPO $15/$30/$50 Creditable Creditable Your Choice $3,000 PPO $15/$30/$50, Your Choice $3,000 PPO $20/$50/50%/30% Creditable Creditable Your Choice $3,000 PPO $10/$25/$45/30% Creditable Creditable Your Choice $3,000 PPO $15/$30/$50/30% Creditable Creditable Your Choice $3,000 PPO Your Choice $4,000 PPO $15/$35 Creditable Creditable Your Choice $4,000 PPO $10/$25/$45 Creditable Creditable Your Choice $4,000 PPO $15/$35, Your Choice $4,000 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $4,000 PPO $15/$30/$50 Creditable Creditable Your Choice $4,000 PPO $15/$30/$50, Your Choice $4,000 PPO $20/$50/50%/30% Creditable Creditable Your Choice $4,000 PPO $10/$25/$45/30% Creditable Creditable Your Choice $4,000 PPO $15/$30/$50/30% Creditable Creditable Your Choice $4,000 PPO Your Choice $5,000 PPO $15/$35 Creditable Creditable Your Choice $5,000 PPO $10/$25/$45 Creditable Creditable Your Choice $5,000 PPO $15/$35, Your Choice $5,000 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $5,000 PPO $15/$30/$50 Creditable Creditable Your Choice $5,000 PPO $15/$30/$50, Your Choice $5,000 PPO $20/$50/50%/30% Creditable Creditable Your Choice $5,000 PPO $10/$25/$45/30% Creditable Creditable Your Choice $5,000 PPO $15/$30/$50/30% Creditable Creditable Your Choice $5,000 PPO Your Choice $6,350 PPO $15/$35 Creditable Creditable Your Choice $6,350 PPO $10/$25/$45 Creditable Creditable Your Choice $6,350 PPO $15/$35, Your Choice $6,350 PPO $15/$35, $300 Rx deductible Creditable Creditable Your Choice $6,350 PPO $15/$30/$50 Creditable Creditable Your Choice $6,350 PPO $15/$30/$50, Your Choice $6,350 PPO $20/$50/50%/30% Creditable Creditable Your Choice $6,350 PPO $10/$25/$45/30% Creditable Creditable Your Choice $6,350 PPO $15/$30/$50/30% Creditable Creditable Your Choice $6,350 PPO Flex Advantage: $500/$1,000 $10/$25/$45/30% Creditable Creditable Flex Advantage: $500/$1,000 $15/$30/$50/30% Creditable Creditable 4
5 Flex Advantage: $500/$1,000 Flex Advantage: $500/$1,000 $10/$25/$45 Creditable Creditable Flex Advantage: $500/$1,000 $15/$35 Creditable Creditable Flex Advantage: $500/$1,000 $15/$35, Flex Advantage: $500/$1,000 $15/$35, $300 Rx deductible Creditable Creditable Flex Advantage: $500/$1,000 $15/$30/$50 Creditable Creditable Flex Advantage: $500/$1,000 $15/$30/$50, Flex Advantage: $500/$1,000 $20/$50/50%/30% Creditable Creditable Flex Advantage: $1,000/$2,000 $10/$25/$45/30% Creditable Creditable Flex Advantage: $1,000/$2,000 $15/$30/$50/30% Creditable Creditable Flex Advantage: $1,000/$2,000 Flex Advantage: $1,000/$2,000 $10/$25/$45 Creditable Creditable Flex Advantage: $1,000/$2,000 $15/$35 Creditable Creditable Flex Advantage: $1,000/$2,000 $15/$35, Flex Advantage: $1,000/$2,000 $15/$35, $300 Rx deductible Creditable Creditable Flex Advantage: $1,000/$2,000 $15/$30/$50 Creditable Creditable Flex Advantage: $1,000/$2,000 $15/$30/$50, Flex Advantage: $1,000/$2,000 $20/$50/50%/30% Creditable Creditable Flex Advantage: $1,500/$3,000 $10/$25/$45/30% Creditable Creditable Flex Advantage: $1,500/$3,000 $15/$30/$50/30% Creditable Creditable Flex Advantage: $1,500/$3,000 Flex Advantage: $1,500/$3,000 $10/$25/$45 Creditable Creditable Flex Advantage: $1,500/$3,000 $15/$35 Creditable Creditable Flex Advantage: $1,500/$3,000 $15/$35, Flex Advantage: $1,500/$3,000 $15/$35, $300 Rx deductible Creditable Creditable Flex Advantage: $1,500/$3,000 $15/$30/$50 Creditable Creditable Flex Advantage: $1,500/$3,000 $15/$30/$50, Flex Advantage: $1,500/$3,000 $20/$50/50%/30% Creditable Creditable Flex Advantage: $2,000/$4,000 $10/$25/$45/30% Creditable Creditable Flex Advantage: $2,000/$4,000 $15/$30/$50/30% Creditable Creditable Flex Advantage: $2,000/$4,000 Flex Advantage: $2,000/$4,000 $10/$25/$45 Creditable Creditable Flex Advantage: $2,000/$4,000 $15/$35 Creditable Creditable Flex Advantage: $2,000/$4,000 $15/$35, Flex Advantage: $2,000/$4,000 $15/$35, $300 Rx deductible Creditable Creditable Flex Advantage: $2,000/$4,000 $15/$30/$50 Creditable Creditable Flex Advantage: $2,000/$4,000 $15/$30/$50, Flex Advantage: $2,000/$4,000 $20/$50/50%/30% Creditable Creditable Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association ( ) 5
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