TO:Outreach Partners and Interested Parties

TO:Outreach Partners and Interested Parties

FROM:Prescription Advantage

Date:October 8, 2004

BULLETIN

This bulletin is one of a series of routine updates regarding Prescription Advantage, designed to inform a broad network of outreach partners and other interested parties about Plan updates that affect both current and future Plan members.

Co-Payment Relief for Low Income Members

Prescription Advantage members with incomes up to 188% FPL will pay lower co-payments for their prescriptions. Beginning October 25th, single members with incomes under $17,503 and married members with incomes under $23,481 will save $2 on their generic Level 1 medicines, $5 on their brand name Level 2 medicines, and $5 on their brand name Level 3 medicines.

These members will be receiving a letter with their updated rates. (Attached) Please see the chart below for more clarification.

Rates Effective October 1, 2003- October 24, 2004

Category / If you are single and your income is / OR / If you are married and your income is / Your retail (up to 30-day Supply) co-payments are / Your mail service co-payments (up to a 90 day supply) are
Level 1 / Level 2 / Level 3 / Level 1 / Level 2 / Level 3
1 / 0-$12,569 / 0-$16,862 / 9 / 23 / 45 / 18 / 46 / 80
2 / $12,570-$17,503 / $16,863 - $23,481 / 9 / 23 / 45 / 18 / 46 / 80

NEW Rates EFFECTIVE OCTOBER 25, 2004

Category / If you are single and your income is / OR / If you are married and your income is / Your retail (up to 30-day Supply) co-payments are / Your mail service co-payments (up to a 90 day supply) are
Level 1 / Level 2 / Level 3 / Level 1 / Level 2 / Level 3
1 / 0-$12,569 / 0-$16,862 / 7 / 18 / 40 / 14 / 36 / 80
2 / $12,570-$17,503 / $16,863 - $23,481 / 7 / 18 / 40 / 14 / 36 / 80

If you have any questions or comments, please contact Prescription Advantage Customer Service at 1-800-AGE-INFO (1-800-243-4636), TTY 1-877-610-0241 for the deaf and hard of hearing.

Attachment #1

October 8, 2004

Dear Member:

This letter is to inform you that Prescription Advantage is lowering your co-payments as of October 25, 2004. Although only your co-payments have changed, all of your rates are listed below for your reference. Please keep this updated Plan Change letter for your records to replace the letter you received in August.

The rates listed below will be effective October 25, 2004 through June 30, 2005:

Your monthly premium will be:$ 0

Your quarterly deductible will be:$ 0

Your co-payments for up to a 30-day supply purchased at a retail pharmacy:

Generic Drugs (Level 1)$ 7

Brand Name Drugs (Level 2)$ 18

Additional Brand Name Drugs (Level 3)$ 40

Your co-payments for up to a 90-day supply purchased through mail service:

Generic Drugs (Level 1)$ 14

Brand Name Drugs (Level 2)$ 36

Additional Brand Name Drugs (Level 3)$ 80

If you have any questions, please call customer service at 1-800-AGE-INFO (1-800-243-4636) or TTY (toll free) for the deaf and hard of hearing at 1-877-610-0241.

Sincerely,

Prescription Advantage

Commonwealth of Massachusetts Executive Office of Health and Human Services Executive Office of Elder Affairs

Prescription Advantage 1-800-AGE-INFO (1-800-243-4636) TTY: 1-877-610-0241

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