AETNA LIFE INSURANCE COMPANY

Transcription

1 1 AETNA LIFE INSURANCE COMPANY Former Employer/Union/Trust Name: Kansas State Employee Health Plan Group Agreement Effective Date: January 1, 2018 Group Number: AE466595, AE466596, AE466597, AE This Prescription Drug Schedule of Cost Sharing is part of the Evidence of Coverage (EOC) for our plan. When the EOC refers to the attachment for details of Medicare Part D prescription benefits covered under our plan, it is referring to this Prescription Drug Benefits Chart. (See the EOC chapters titled Using the plan s coverage for your Part D prescription s and What you pay for your Part D prescription s. ) Annual Deductible Amount per Member $0 Formulary Type: GRP B2 Initial Coverage Limit: $3,750 True Out-of-Pocket Amount: $5,000 Retail Pharmacy Network: S2 The name of your pharmacy network is listed above. To find a network pharmacy, you can look in your Pharmacy Directory, visit our website ( or call Customer Service (phone numbers are printed on your member ID card). SOK_EGWP_PDP_K1_2018 ME RX SCH COPAY (Y2018)

2 2 Every on the plan s Drug List is in one of the tiers described below: Tier One Preferred generic s: Includes low-cost generic s Tier Two Generic s: Includes generic s Tier Three Preferred brand s: Includes preferred brand s and some high-cost generic s Tier Four Non-preferred s: Includes non-preferred brand s and some higher-cost generic s Tier Five Specialty s: Includes high-cost/unique brand and generic s To find out which tier is in, look it up in the plan s Drug List. If your covered costs less than the copayment amount listed in the chart, you will pay that lower price for the. either the full price of the or the copayment amount, whichever is lower.

3 Aetna Medicare Rx (PDP) 3 Initial Coverage Stage: Amount you pay, up to $3,750 in total covered prescription expenses. Initial Coverage retail (innetwork) One-Month Supply Long-term care (LTC) (up to a 31- Out-of network * Extended Supply retail or standard Preferred Tier 1 Preferred generic s - Includes low-cost generic s 25%, 25%, 25%, 25%, 25%, Tier 2 Generic s - Includes generic s 25%, 25%, 25%, 25%, 25%, Tier 3 Preferred brand s - Includes preferred brand s and some highcost generic s 25%, than 25%, than 25%, than 25%, 25%, Tier 4 Non-preferred s - Includes non-preferred brand s and some higher-cost generic s 50%, 50%, 50%, 50%, than $225, for 50%, than $225, for Tier 5 Specialty s - Includes highcost/unique brand and generic s 25% for 25% for 25% for *Out-of-network coverage is limited to certain situations; see the Evidence of Coverage chapter titled Using the plan s coverage for your Part D prescription s, Section 2.5.

4 4 Coverage Gap Stage: Amount you pay after you reach $3,750 in total covered prescription expenses and until you reach $5,000 in out-of-pocket covered prescription costs. Your Plans gap coverage is listed in the chart below. Supplemental Gap Coverage retail (innetwork) One-Month Supply Long-term care (LTC) (up to a 31- Out-ofnetwork * Extended Supply retail or standard Preferred Tier 1 Preferred generic s Includes lowcost generic s Tier 2 Generic s Includes generic s Tier 3 Preferred brand s Includes preferred brand s and some high-cost generic s Tier 4 Non-preferred s Includes nonpreferred brand s and some higher-cost generic s $225, for $225, for Tier 5 Specialty s Includes highcost/unique brand and generic s *Out-of-network coverage is limited to certain situations; see the Evidence of Coverage chapter titled Using the plan s coverage for your Part D prescription s, Section 2.5. The Kansas State Employee Health Plan provides additional coverage during the Coverage Gap

5 5 stage for covered s. This means that you will generally continue to pay the same amount for covered s throughout the Coverage Gap stage of the plan as you paid in the Initial Coverage stage. Coinsurance-based is applied against the overall cost of the, prior to the application of any discounts or benefits. Catastrophic Coverage Stage: Amount you pay for covered prescription s after reaching $5,000 in out-of-pocket prescription costs. Prescription Drug Quantity Per prescription or refill All covered prescription s Your share of the cost for a covered will be either coinsurance or a copayment, whichever is the larger amount: either coinsurance of 5% of the cost of the or $3.35 copayment for a generic or a that is treated like a generic. Or a $8.35 copayment for all other s. Our plan pays the rest of the cost. Step Therapy Your plan includes step therapy. This requirement encourages you to try less costly but just as effective s before the plan covers another. For example, if Drug A and Drug B treat the same medical condition, the plan may require you to try Drug A first. If Drug A does not work for you, the plan will then cover Drug B. This Plan Uses the GRP B2 Formulary: Your plan uses the GRP B2 formulary, which means that only s on Aetna s list will be covered under your plan as long as the is medically necessary and the plan rules are followed. Tiers labeled as brand, preferred brand, and non-preferred will also include some high-cost generic s. Non-preferred copayment levels may apply to some s on the list. If it is medically necessary for you to use a prescription that is eligible for coverage under the Medicare benefit, but is not on our formulary, you can contact Aetna to request a coverage exception. Your doctor must submit a statement supporting your exception request. Review the Aetna Medicare 2018 Group Formulary (List of Covered Drugs) for more information.