SFEHACL PART D MEDICARE PLAN (EMPLOYER PDP) BENEFIT GUIDE

Transcription

1 SFEHACL PART D MEDICARE PLAN (EMPLOYER PDP) BENEFIT GUIDE Yur 2017 Medicare Prescriptin Drug cverage as a Member f the SFEHACL Part D Medicare Plan A $9 cpayment gets yu a 90-day supply f any Tier 1 Generic drug frm the Dept Drug Mail Pharmacy while yu are in yur Initial Cverage benefit stage. This Benefit Guide gives the details abut yur Medicare Prescriptin Drug cverage frm January 1, 2017 thrugh December 31, It may therwise be knwn as yur Evidence f Cverage (EOC). It is an imprtant legal dcument. Please keep it in a safe place. Benefits, frmulary, pharmacy netwrk, premiums, deductible, and/r cpayments/cinsurance may change n January 1, SFEHACL Custmer Service Fr help r infrmatin, please call Custmer Service Mnday thrugh Friday frm 7:30 am t 4:00 pm Pacific Time. Calls t this number are free: TTY/TDD Call the natinal number 711 S8841EOC2017

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3 Table f Cntents IMPORTANT PHONE NUMBERS AND RESOURCES 1 Hw t cntact the SFEHACL Custmer Service...1 Medicare...1 State Health Insurance Assistance Prgram (SHIP) Free Help...2 Quality Imprvement Organizatin...2 Scial Security Administratin...2 Railrad Retirement Bard...2 State Pharmacy Assistance Prgram...3 Medicaid...3 Medicare s Extra Help Prgram...3 SECTION 1 PLAN BASICS 4 What is the SFEHACL Part D Medicare Prescriptin Drug Plan?...4 Overview f Medicare Prescriptin Drug cverage...4 Hw ther insurance wrks with ur plan...4 If yu have Medicare and Medicaid...5 If yu are a member f a State Pharmacy Assistance Prgram (SPAP)...5 If yu have cverage frm an AIDS Drug Assistance Prgram (ADAP)...5 Help us keep yur membership recrd up-t-date...5 What is the gegraphic service area fr ur Plan?...5 Use yur SFEHACL ID Card fr prescriptins instead f yur Medicare card...6 Using plan pharmacies t get yur prescriptin drugs cvered by us...6 Hw d I fill a prescriptin at a retail netwrk pharmacy?...6 Finding a retail netwrk pharmacy...6 What if yur retail netwrk pharmacy is n lnger in ur plan?...6 Getting new prescriptins frm the Dept Drug Mail Pharmacy...6 Refills by mail...7 Filling prescriptins utside the netwrk...8 Hw d I submit a request fr payment?...8 Hme Infusin Pharmacies...9 Lng-term Care Pharmacies...9 Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies...9 What yu pay fr vaccinatins cvered by Part D...9 SECTION 2 PLAN PREMIUM 11 Hw much is yur mnthly plan premium and hw d yu pay it?...11 There are tw ways t pay yur mnthly plan premium...11 What happens if yu dn t pay yur plan premiums, r dn t pay them n time?...11 Yu have t cntinue t pay yur Part A and/r Part B premiums...11 Can yur plan premiums change during the year?...12 In sme situatins yur plan premium culd be less...12 In sme situatins yur plan premium culd be mre...12 What is the late enrllment penalty?...12 Wh pays an extra Part D amunt because f incme?...12 SECTION 3 PRESCRIPTION DRUG COVERAGE 14 What is a frmulary?...14 Hw d yu find ut what drugs are n ur frmulary?...14 What are drug tiers?...14 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017 I

4 2017 Cpayment chart fr drug tiers...15 Changes t available drug supplies frm Dept Drug Mail Pharmacy...15 Smetimes yu can get less than a full mnth s supply...15 Can the frmulary change?...16 What if yur drug is nt n the frmulary?...16 If there are extra rules that apply t the drug yu take...17 Temprary (r transitin) drug supplies...17 What types f drugs des Medicare r SFEHACL nt cver?...18 There are restrictins n cverage fr sme drugs...18 Prgrams n drug safety...19 Medicatin Therapy Management Prgram t help members manage their medicatins...20 Des yur enrllment in ur Plan affect the drugs cvered under Medicare Part A r Part B?...20 Hw much d yu pay fr drugs cvered by ur Plan in the different benefit levels?...20 Deductible...21 Initial Cverage Benefit Stage...21 Out-f-pcket Stage (Cverage Gap) befre yu qualify fr Catastrphic Cverage...21 Catastrphic Cverage...22 Hw is yur ut-f-pcket cst calculated?...22 Wh can pay fr yur prescriptin drugs, and hw d these payments apply t yur ut-f-pcket csts?...22 Explanatin f Benefits...23 Hw des yur prescriptin drug cverage wrk if yu g t a hspital r skilled nursing facility?...23 SECTION 4 MAKING COMPLAINTS 24 Prblems that are handled by the cmplaint prcess...24 Cmplaints related t the timeliness f ur actins n cverage decisins and appeals...25 Step-by-step prcess fr making a cmplaint...25 Step 1 fr making cmplaints...25 Step 2 fr making cmplaints...26 Fr quality f care prblems, yu may als cmplain t the QIO...26 SECTION 5 WHAT TO DO IF YOU HAVE A PROBLEM AND NEED A COVERAGE DECISION, OR APPEAL 27 Intrductin...27 Is yur prblem r cncern abut yur benefits r cverage?...27 Legal Terms...27 Get help frm an independent gvernment rganizatin nt cnnected t SFEHACL...27 Yu can get help and infrmatin frm Medicare...28 What is an exceptin (cverage decisin)?...28 Imprtant things t knw abut asking fr exceptins (cverage decisins)...28 We can say yes r n t yur request...29 Step-by-Step instructins t ask fr a cverage decisin r an exceptin...29 Step 1 fr Cverage Decisins and Exceptins...29 Step 2 fr Cverage Decisins and Exceptins...30 Step 3 fr Cverage Decisins and Exceptins...31 Making an appeal...31 Step-by-Step instructins t make an Appeal...31 Step 1 t make a Level 1 Appeal...31 Step 2 t make a Level 1 Appeal...32 Step 3 t make a Level 1 Appeal...33 Step-by-step instructins t make a Level 2 Appeal...33 Step 1 t make a Level 2 Appeal...33 II SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

5 Step 2 t make a Level 2 Appeal...34 Step 3 t make a Level 2 Appeal...34 Taking yur appeal t Level 3 and beynd...35 Level 3 Appeal...35 Level 4 Appeal...35 Level 5 Appeal...36 SECTION 6 ENDING YOUR MEMBERSHIP IN THE SFEHACL MEDICARE PLANS 37 When can yu end yur membership in SFEHACL?...37 What is disenrllment?...37 Usually, yu can end yur membership during the Annual Enrllment Perid...37 In certain situatins, yu can end yur membership during a Special Enrllment Perid...38 T get mre infrmatin abut when yu can end yur membership...39 Hw d yu end yur membership in SFEHACL?...39 Yu must keep getting yur prescriptins thrugh ur plan until yur membership ends...39 SFEHACL must end yur membership in ur Medicare plans under certain situatins...40 If yu mve ut f ur plan s service area...40 We cannt ask yu t leave ur plan because f yur health...40 Yu have the right t make a cmplaint if we ask yu t leave ur plan...41 SECTION 7 YOUR RIGHTS, RESPONSIBILITIES AND PROTECTIONS 42 Abut yur rights, respnsibilities and prtectins...42 Yur right t be treated with fairness and respect...42 We must ensure that yu get timely access t yur cvered drugs...42 We must prtect the privacy f yur persnal health infrmatin...42 Hw d we prtect the privacy f yur health infrmatin?...42 Yu can see the infrmatin in yur recrds and knw hw it has been shared with thers Yur right t get infrmatin abut ur plan, pharmacies and yur cvered drugs...43 We must supprt yur right t make decisins abut yur care...44 Yur right t make cmplaints and t ask us t recnsider decisins we have made...44 What can yu d if yu think yu are being treated unfairly r yur rights are nt being respected?...45 Hw t get mre infrmatin abut yur rights...45 Yu have sme respnsibilities as a member f the SFEHACL Medicare Plans...45 SECTION 8 LEGAL NOTICES 47 Ntice abut gverning law...47 Ntice abut nndiscriminatin...47 Ntice abut Medicare Secndary Payer subrgatin rights...47 Infrmatin required by the Emplyee Retirement Incme Security Act f 1974 ( ERISA )...47 SECTION 9 DEFINITIONS OF IMPORTANT WORDS USED IN THIS BENEFIT GUIDE (EVIDENCE OF COVERAGE) 49 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017 III

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7 Imprtant phne numbers and resurces Hw t cntact the SFEHACL Custmer Service If yu have any questins r cncerns, please call r write t Custmer Service. We will be happy t help yu. Our Custmer Service hurs are 7:30 am t 4:00 pm, Pacific Time, Mnday thrugh Friday. CALL , this number is als n the cver f this Benefit Guide fr easy reference. Calls t this number are free. TTY/TDD Please use 711, the natinal access number. FAX WRITE OR IN PERSON SFEHACL, 551 East San Bernardin Rad, Cvina, CA PART D DRUG APPEALS OR COVERAGE DECISIONS Call OptumRx, frmerly Catamaran, tll free at r fax t them at Please use these numbers fr the fllwing: Medicare When yu want t cntact us fr a cverage decisin abut yur Part D prescriptin drugs. A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur Part D prescriptin drugs. When yu want t make an appeal abut yur Part D prescriptin drugs. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu want t make a cmplaint abut yur Part D prescriptin drugs. Yu can make a cmplaint abut us r ne f ur netwrk pharmacies, including a cmplaint abut the quality f yur care. This type f cmplaint des nt invlve a cverage r payment dispute. If yur prblem is abut ur cverage r payment, refer t the text abve abut making an appeal. When yu want t send a request t ask us t pay fr ur share f the cst f a drug yu have received. The cverage decisin prcess includes determining requests that ask us t pay fr ur share f the csts f a drug that yu have received. This may ccur n Part D cvered vaccinatins, hspital take-hme-drugs, r ut-f-netwrk pharmacy purchases. CALL Medicare, r calls t this number are free and available 24 hurs a day, 7 days a week (TTY/TDD ) WEBSITE Use a cmputer t lk at the fficial gvernment Website fr Medicare infrmatin. This Website gives yu up-t-date infrmatin abut Medicare and current issues. It includes Medicare publicatins yu can print directly frm yur cmputer. It has tls t help yu cmpare Medicare Health Plans and Prescriptin Drug Plans in yur area. Yu can als search the Helpful Cntacts Sectin fr the Medicare cntacts in yur state. If yu d nt have a cmputer, yur lcal library r senir center may be able t help yu visit this Website using their cmputer. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

8 State Health Insurance Assistance Prgram (SHIP) Free Help State Health Insurance Assistance Prgram r SHIP is a gvernment prgram with trained cunselrs in every state. Cunselrs give free health insurance infrmatin and help t peple with Medicare. SHIPs have different names depending n which state they are in. Yur SHIP can explain yur Medicare rights and prtectins, help yu make cmplaints abut care r treatment, and help straighten ut prblems with Medicare bills. Yur SHIP has infrmatin abut Medicare Prescriptin Drug Plans, Medicare Health Plans, and abut Medigap (Medicare supplement insurance) plicies. CALL Medicare at t find the SHIP in yur state WEBSITE t find the SHIP in yur state Quality Imprvement Organizatin Quality Imprvement Organizatin r QIO is a grup f dctrs and ther health care experts paid by Medicare t check n the quality f care fr peple with Medicare. This is an independent rganizatin that is nt cnnected with SFEHACL. There is a QIO in each state. QIOs have different names, depending n which state they are in. Yu shuld cntact yur QIO if yu have a cmplaint abut the quality f care yu have received. Yu can find cntact infrmatin fr the QIO in yur state by calling Medicare at Scial Security Administratin The Scial Security Administratin is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder, r wh have a disability r End Stage Renal Disease and meet certain cnditins, are eligible fr Medicare. If yu are already getting Scial Security checks, enrllment int Medicare is autmatic. If yu are nt getting Scial Security checks, yu have t enrll in Medicare. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call Scial Security at TTY/TDD users shuld call Calls t these numbers are free and are available 7:00 AM t 7:00 pm, Mnday thrugh Friday. Yu can als visit Scial Security is als respnsible fr determining wh has t pay an extra amunt fr their Part D drug cverage because they have a higher incme. If yu gt a letter frm Scial Security telling yu that yu have t pay the extra amunt and have questins abut the amunt r if yur incme went dwn because f a life-changing event, yu can call Scial Security t ask fr a recnsideratin. Railrad Retirement Bard Mst SFEHACL members receive their Medicare benefits thrugh the Railrad Retirement Bard. The Railrad Retirement Bard is an independent Federal agency that administers cmprehensive benefit prgrams fr the natin s railrad wrkers and their families. Yu can call yur lcal Railrad Retirement Bard ffice r (calls t this number are free) frm 9:00 AM t 4:00 PM, Mnday thrugh Friday. TTY/TDD users shuld call Yu can als visit 2 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

9 State Pharmacy Assistance Prgram Many states have State Pharmacy Assistance Prgrams (SPAP s). SPAP s are State-funded prgrams that prvide financial assistance fr prescriptin drugs t lw-incme and medically needy senir citizens and individuals with disabilities. Each state has different rules t prvide drug cverage t its members. Sme SPAP s will help pay fr the premiums, deductibles, and/r cpayments fr thse wh qualify. Please cntact the SPAP in yur state t determine what benefits may be available t yu. Yu can find the SPAP in yur area by calling Medicare at Medicaid A jint Federal and state prgram that helps with medical csts fr sme peple with lw incmes and limited resurces. Sme peple with Medicare are als eligible fr Medicaid. In additin there are prgrams ffered thrugh Medicaid that help peple with Medicare pay their Medicare csts, such as their Medicare premiums. These Medicare Savings Prgrams help peple with limited incme and resurces save mney each year: T find ut mre abut Medicaid and its prgrams, cntact yur specific state Medicaid ffice. Yu can find yur state Medicaid ffice by calling Medicare at Medicare s Extra Help Prgram Medicare prvides Extra Help t pay prescriptin drug csts fr peple wh have limited incme and resurces. Resurces include yur savings and stck, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium and prescriptin cpayments. This Extra Help als cunts tward yur ut-f-pcket csts. Peple with limited incme and resurces may qualify fr Extra Help. Sme peple autmatically qualify fr Extra Help and dn t need t apply. Medicare mails a letter t peple wh autmatically qualify fr Extra Help. Yu may be able t get Extra Help t pay fr yur prescriptin drug premiums and csts. T see if yu qualify fr getting Extra Help, call: MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call ; r Yur state Medicaid Office. If yu believe yu have qualified fr Extra Help and yu believe that yu are paying an incrrect cstsharing amunt when yu get yur prescriptin at a pharmacy, ur plan has established a prcess that allws yu t either request assistance in btaining evidence f yur prper c-payment level, r, if yu already have the evidence, t prvide this evidence t us. SFEHACL will apply an adjusted cst sharing amunt using Best Available Evidence (BAE) that yu prvide prir t Medicare s ntificatin t us. BAE wuld be a ntice frm yur state Medicaid ffice r Medicare presented t the pharmacy, r faxed t ur Custmer Service. When we receive the evidence shwing yur cpayment level frm Medicare r frm yu, we will update ur system s that yu can pay the crrect cpayment when yu get yur next prescriptin at the pharmacy. If yu verpay yur cpayment, we will reimburse yu. We will frward a check t yu in the amunt f yur verpayment. Please cntact Custmer Service if yu have questins. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

10 Sectin 1 Plan Basics What is the SFEHACL Part D Medicare Prescriptin Drug Plan? SFEHACL is cntracted with the Centers fr Medicare & Medicaid Service (CMS) as an Emplyer Grup Waiver Plan (EGWP) Medicare Part D Prescriptin Drug Plan. Medicare must apprve ur cntract each year. As an EGWP, ur membership is available nly t Santa Fe Railrad r affiliated Railrad Medicare retires, and their spuse/widw/widwer. CMS des nt require an EGWP t perfrm sme f the cntractual requirements that apply t fr-prfit Part D plans because f ur membership restrictins. SFEHACL was funded slely t serve yu - ur members. Current SFEHACL Medicare members have been autmatically enrlled in ur Plan s that SFEHACL can cntinue t prvide yur prescriptin drug benefits while yu receive Medicare benefits. Nw that yu are enrlled in the SFEHACL Part D Medicare Plan yu are getting yur Medicare Prescriptin Drug cverage thrugh SFEHACL. This Benefit Guide explains yur benefits, what yu have t pay, and the rules yu must fllw t get yur prescriptin drugs cvered. Overview f Medicare Prescriptin Drug cverage Medicare Prescriptin Drug cverage is insurance that helps pay fr yur prescriptin drugs, vaccines, bilgicals, and sme supplies nt cvered by Medicare Part B. We will generally cver the drugs listed in ur frmulary as lng as the drug is medically necessary, the prescriptin is filled at a cntracted plan pharmacy, Medicare Part D cvers it, and ther cverage rules are fllwed. We d nt pay fr drugs under Medicare Part D that are cvered by Medicare Part B. As a member, all yu have t d is cntinue t pay yur Part B premium and yur SFEHACL mnthly premium and cpayments. The amunt f the mnthly premium is nt affected by yur health status r hw many prescriptins yu need. If yu have limited incme and resurces, yu may get Extra Help frm Medicare t pay yur premium and cpayments s that yu get yur prescriptin drugs fr little r n cst. Please call Custmer Service t learn mre. Hw ther insurance wrks with ur plan If yu have any ther prescriptin drug cverage in additin t ur plan, yu are required t tell us. Please call Custmer Service t let us knw. We are required t fllw rules set by Medicare t make sure that yu are using all f yur benefits in cmbinatin when yu get yur cvered drugs frm ur plan. This is called crdinatin f benefits because it invlves crdinating the drug benefits yu get frm ur plan with any ther drug benefits available t yu. We ll help yu with it. Medicare law requires us t cllect this infrmatin frm yu when yu r yur spuse enrlls in the SFEHACL Medicare Plans, r when ther insurance becmes invlved. If yu have Medicare because f ESRD, yur grup health plan will pay first fr the first 30 mnths after yu becme eligible fr Medicare. These types f cverage usually pay first fr services related t each type: N-fault insurance (including autmbile insurance) Liability (including autmbile insurance) Black lung benefits Wrkers cmpensatin 4 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

11 Veterans Administratin. Medicare Part D des nt crdinate with prescriptins supplied by the VA. Either the VA pays, r Medicare Part D pays, but nt bth. Medicaid and TRICARE never pay first fr Medicare-cvered services. They nly pay after Medicare, emplyer grup health plans, and/r Medigap have paid. If yu have ther insurance, tell yur dctr, hspital, and pharmacy. Yu may need t give yur plan member ID number t yur ther insurers (nce yu have cnfirmed their identity) s yur bills are paid crrectly and n time. The infrmatin yu prvide helps us calculate hw much yu and thers have paid fr yur drugs. In additin, if yu lse r get additinal prescriptin drug cverage, please call Custmer Service at t update yur membership recrds. If yu have Medicare and Medicaid Medicare, nt Medicaid, will pay fr mst f yur prescriptin drugs. Yu will cntinue t get yur health cverage under bth Medicare and Medicaid as lng as yu still qualify fr Medicaid benefits. If yu are a member f a State Pharmacy Assistance Prgram (SPAP) If yu are currently enrlled in a SPAP, yu may get help paying yur premiums, and/r cpayments. Please cntact yur SPAP t determine what benefits are available t yu. Please see the Intrductin fr mre infrmatin. If yu have cverage frm an AIDS Drug Assistance Prgram (ADAP) What is the AIDS Drug Assistance Prgram (ADAP)? The AIDS Drug Assistance Prgram (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access t life-saving HIV medicatins. Medicare Part D prescriptin drugs that are als cvered by ADAP qualify fr prescriptin cst-sharing assistance Nte: T be eligible fr the ADAP perating in yur State, individuals must meet certain criteria, including prf f State residence and HIV status, lw incme as defined by the State, and uninsured/under-insured status. Help us keep yur membership recrd up-t-date We have a file f infrmatin abut yu as a plan member. Pharmacists use this membership recrd t knw what drugs are cvered fr yu. The membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage and ther infrmatin. Please help us keep yur membership recrd up-t-date by letting Custmer Service knw right away if there are any changes in yur name, address, r phne number, r if yu g int a nursing hme. Als, tell Custmer Service abut any changes in prescriptin drug cverage yu have frm ther surces, such as frm Medicaid r frm a current r different frmer emplyer, r yur spuse s current r frmer emplyer. Yu shuld tell Custmer Service abut any changes in cverage due t claims filed under liability insurance, such as wrkers cmpensatin claims r claims against anther driver in an autmbile accident. What is the gegraphic service area fr ur Plan? SFEHACL is a Natinal Medicare Prescriptin Drug Plan and includes the states f Alaska, Hawaii, and the territry f Puert Ric. We cannt pay fr any prescriptins that are filled by pharmacies utside f the United States, even fr a medical emergency. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

12 Use yur SFEHACL ID Card fr prescriptins instead f yur Medicare card As a member f ur plan, ne card des it fr yu! Yu have a cmbined SFEHACL Health Insurance and Rx ID card. Use yur SFEHACL ID card t btain prescriptins (nt yur Medicare card). Hwever, yu will need bth yur red, white and blue Medicare and SFEHACL ID cards fr yur medical service. During the time yu are a plan member and using Plan Service, yu must use yur SFEHACL ID card. This ID card prtects yur privacy by using a SFEHACL unique ID number that we use t identify yu. Yur SFEHACL number is NOT yur Scial Security number r yur Medicare Part A & B number. Yu must use yur number n yur card t identify yurself when btaining prescriptins thrugh the Dept Drug Mail Pharmacy and retail netwrk pharmacies, and when cntacting SFEHACL Custmer Service. Please carry yur Plan membership card with yu at all times. If yur membership card is ever damaged, lst, r stlen, call SFEHACL Custmer Service right away and we will send yu a new card. Using plan pharmacies t get yur prescriptin drugs cvered by us What is the Dept Drug Mail Pharmacy? Dept Drug Mail Pharmacy prvides prescriptins in 90-day supplies. Yu need t btain 90-day supplies f all Tiers when using the Dept Drug Mail Pharmacy. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. What is a retail netwrk pharmacy? This is a pharmacy at which yu can get prescriptins that yu want in less than 90-day supplies. Cpayments at these pharmacies are higher than thse at Dept Drugs pharmacies. We call them retail netwrk pharmacies because they are under cntract with ur plan. What are cvered drugs? Mst Medicare Part D cvered drugs are included in ur frmulary. A cvered drug is the general term we use t mean all f the utpatient prescriptin drugs that are cvered by ur plan and Medicare Part D. Hw d I fill a prescriptin at a retail netwrk pharmacy? T fill yur prescriptin at a retail netwrk pharmacy, yu must shw yur SFEHACL ID card. If yu d nt have yur ID card with yu when yu fill yur prescriptin, yu may have t pay the full cst f the prescriptin (rather than paying just yur cpayment). If this happens, yu can ask us t reimburse yu fr ur share f the cst by submitting yur prescriptin receipt t us. T learn hw t submit a paper claim, please refer t the paper claims prcess described at the end f this Sectin. Finding a retail netwrk pharmacy Mst lcal and natinal chain pharmacies are in ur retail pharmacy netwrk. Since ur plan is a natinal plan, all pharmacies cannt be listed in a directry. The pharmacist can tell yu if their pharmacy is in netwrk simply by shwing them yur SFEHACL ID card. Yu can call ur Custmer Service if yu have questins. What if yur retail netwrk pharmacy is n lnger in ur plan? Very rarely a pharmacy might leave ur netwrk. If this happens, yu will need t fill yur prescriptins at anther retail netwrk pharmacy. Please call Custmer Service t find anther pharmacy in yur area. Getting new prescriptins frm the Dept Drug Mail Pharmacy There are sme maintenance prescriptin drugs that cannt be sent thrugh the mail. Dept Drug Mail Pharmacy des NOT supply thse prescriptins. Please refer t yur Frmulary bk and lk fr the BI (benefit indicatr clumn). Then lk fr the RO (Retail Only) indicatr. SFEHACL has determined 6 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

13 that it is in yur best interest t have these drugs supplied thrugh yur lcal retail netwrk pharmacy and nt in the mail. Beginning January 1, 2017, Dept Drug Mail Pharmacy can nly ship 90-day supplies f Tier 1 generic prescriptin drugs. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. Yu may cntinue t btain a 30, 60 r 90-day supply f Tier 2 r 3 prescriptin drugs. Ordering new prescriptins is easy, and yu are nt charged shipping csts. Fllw these directins t fill new prescriptins: Mst physicians send prescriptins electrnically (e-prescribe) t yur preferred pharmacy. Yur SFEHACL ID card includes Dept Drug Mail Pharmacy electrnic prescribing infrmatin. They must fllw Federal Medicare rules prhibiting autmatically shipping when filling these prescriptins. They cannt fill prescriptins at all withut yur permissin, s be sure t call Dept Drug Custmer Service at when yur dctr sends yur new prescriptins electrnically. If yu mail a paper prescriptin t Dept Drug Mail, use a separate sheet f paper t shw hw many mnths supply yu want, yur name and SFEHACL ID card number exactly as they appear n yur ID card, yur return address, and yur dctr s name and telephne number with the area cde. Remember, Dept Drug Mail Pharmacy fills nly 3-mnth (90-day), r the amunt left n yur prescriptin fr each Tier 1 generic drug prescriptin. Dept Drug Mail Pharmacy cannt fill yur prescriptins sent by yur dctr unless they have yur specific authrizatin t d s. Yu need t call Dept Drug Custmer Service t give this authrizatin when yu knw the dctr is sending a new prescriptin. Withut cpayment(s), yur prescriptin(s) cannt be filled. Yu can pay by check r mney rder payable t the Dept Drug Mail Pharmacy. It is easier fr yu t pay yur cpayment with yur debit r credit card. That way, yu will nt need t guess the amunt f yur cpayment. T use yur debit r credit card, write dwn the type f card (MasterCard, Discver r VISA nly) and the entire debit r credit card number and expiratin date f yur card. Once yur card number is n file with Dept Drug Mail Pharmacy, yu d nt need t send the number each time, but yu must specifically authrize us t use yur debit r credit card n file fr yur cpayment t fill prescriptins. Allw ten (10) wrking days fr mail delivery f yur prescriptins. Debit r credit card payment is the mst cnvenient way t pay yur prescriptin cpayments when yu dn t knw hw much t pay. We tell yu hw much we applied t yur debit r credit card fr yur cpayment n yur receipt. Mail the prescriptin(s), yur fill instructins, yur persnal infrmatin, and yur applicable Tier cpayment (r debit r credit card infrmatin and yur authrizatin t charge yur card) fr the prescriptin(s) t: Dept Drug Mail Pharmacy, PO Bx , Salt Lake City, UT Refills by mail Yur prescriptins are easy t refill nce they are already n file with the Dept Drug Mail Pharmacy. Yu must rder a 90-day supply f Tier 1 generic prescriptin drugs, r the number f refill mnths left n yur prescriptin. Yu may re-rder anther 3-mnth supply in 69 days, r mre after yur last 3- mnth refill s that yu wn t run ut f yur medicatin. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

14 A cnvenient rerder frm is included in each prescriptin sent t yu. Simply indicate a ne, tw r three-mnth supply and yur methd f payment. If yu are nt using yur debit r credit card, include a check r mney rder fr yur cpayment and mail the frm t the address indicated n the frm. Mail the prescriptin(s) rerders, and yur applicable Tier cpayment (r debit r credit card infrmatin) fr the prescriptin(s) t: Dept Drug Mail Pharmacy, PO Bx , Salt Lake City, UT Yu may call Dept Drug Custmer Service at Filling prescriptins utside the netwrk Befre yu fill yur prescriptin utside the pharmacy netwrk, call SFEHACL Custmer Service t see if there is a retail netwrk pharmacy in yur area where yu can fill yur prescriptin. Failure t d s may cause yur payment request t be denied. Generally, SFEHACL als limits the quantity f drugs cvered ut f netwrk when apprved. We will cver yur prescriptin at an ut f netwrk pharmacy if at least ne f the fllwing applies: If yu are trying t fill a prescriptin drug that is nt regularly stcked at the Dept Drug Mail Pharmacy, r an accessible retail netwrk pharmacy (including mst specialty, high cst and unique drugs). If yu are unable t btain a cvered drug in a timely manner because there is n retail netwrk pharmacy within a reasnable driving distance that prvides 24-hur service. If yu are getting a cvered vaccine that is medically necessary but nt cvered by Medicare Part B and/r sme cvered drugs that are administered in yur dctr s ffice. Sme hspital take-hme drugs are cvered by Part D. If yu d g t an ut f netwrk pharmacy fr the reasns listed abve, yu will have t pay the full cst (rather than paying just yur cpayment) when yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share f the cst by submitting a paper claim cmpleted by the pharmacy and yur receipt fr the medicatin with a letter explaining yur situatin t SFEHACL. If yu g t an ut f netwrk pharmacy, yu are respnsible fr paying the applicable cpayment and the difference between what we wuld have paid fr the medicatin and what the ut f netwrk pharmacy charged fr yur medicatin. Yu shuld submit a claim t us if yu fill a prescriptin at an ut f netwrk pharmacy as any amunt yu pay will help yu qualify fr catastrphic cverage (see Sectin 3). T learn hw t submit a request fr payment, please refer t the prcess described next. Hw d I submit a request fr payment? If yu g t an ut f netwrk pharmacy because f the reasns listed abve, the pharmacy will nt be able t submit the claim directly t us and yu will have t pay the full cst f yur prescriptin. Yu may have the pharmacy submit yur claim fr yu. Please submit yur receipt and yur letter explaining yur situatin t the fllwing address: Catamaran/OptumRx P.O. Bx Schaumburg, IL Upn receipt, an initial cverage decisin will be made. If it is determined that the prescriptin shuld be cvered, and the paper claims frm is cmpleted by the pharmacy, a payment fr ur cst f the drug minus the applicable cpay amunt will be mailed t yu. All payment requests will be paid at the SFEHACL pharmacy cntract rate and the applicable Tier c-payment will be applied based n yur Part D benefit level. Payment culd be denied if yur receipt des nt cntain all f the infrmatin that Medicare requires fr a cverage decisin. (Please refer t Sectin 5 fr mre infrmatin abut initial cverage decisins.) 8 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

15 T receive a cverage decisin and pssible payment fr vaccine and administratin csts frm yur physician that is nt cvered by Medicare Part B, please have yur physician print, cmplete and mail the Prescriptin Drug Claim Frm t SFEHACL. Yu may cntact ur Custmer Service at if yu have questins. Hme Infusin Pharmacies It is ur plicy t cntract with any willing Hme Infusin Pharmacy that meets state, Federal and SFEHACL requirements t becme a netwrk HI Pharmacy. The SFEHACL Part D Medicare Plan will cver hme infusin therapy if: Yur prescriptin drug is n ur frmulary; Yur prescriptin is written by an authrized prescriber; and Yu get yur hme infusin Service frm a SFEHACL Hme Infusin netwrk pharmacy. Lng-term Care Pharmacies SFEHACL has many Lng Term Care netwrk pharmacies thrugh ur netwrk that prvide special Lng Term Care prescriptin dsing and packaging. SFEHACL has a natinal pharmacy netwrk, but it is impssible fr us t cntract with every LTC pharmacy in the natin. It is ur plicy t cntract with any willing LTC pharmacy that meets state, Federal and SFEHACL requirements t becme a netwrk LTC Pharmacy. SFEHACL will cver Lng Term Care drugs that are nt btained thrugh either f these surces n a temprary basis if the need is urgent. Fr mre infrmatin, please cntact Custmer Service. Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies Only Native Americans and Alaska Natives have access t Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies thrugh ur netwrk pharmacy and in limited areas. It is ur plicy t cntract with any willing I/T/U pharmacy that meets state, Federal and SFEHACL requirements t becme a netwrk pharmacy. Please cntact Custmer Service fr mre infrmatin. What yu pay fr vaccinatins cvered by Part D We cver a number f Part D vaccines. There are tw parts t ur cverage f vaccinatins: The first part f cverage is the cst f the vaccine medicatin itself. The vaccine is a prescriptin medicatin. The secnd part f cverage is fr the cst f giving yu the vaccinatin sht. (This is smetimes called the administratin f the vaccine.) What yu pay fr a Part D vaccinatin depends n three things: 1. The type f vaccine (what yu are being vaccinated fr). Sme vaccines are cnsidered Part D drugs. Yu can find these vaccines listed in ur Frmulary Bk. Other vaccines are cnsidered medical benefits. They are cvered under Original Medicare. 2. Where yu get the vaccine medicatin. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

16 3. Wh gives yu the vaccinatin sht. What yu pay at the time yu get the Part D vaccinatin can vary depending n the circumstances. Fr example: Smetimes when yu get yur vaccinatin sht, yu will have t pay the entire cst fr bth the vaccine medicatin and fr getting the vaccinatin sht. Yu can ask ur plan t pay yu back fr ur share f the cst. Other times, when yu get the vaccine medicatin r the vaccinatin sht, yu will pay nly yur share f the cst. T shw hw this wrks, here are three cmmn ways yu might get a Part D vaccinatin sht: Situatin 1: Yu buy the Part D vaccine at the pharmacy and yu get yur vaccinatin sht at the netwrk pharmacy. (Whether yu have this chice depends n where yu live. Sme states d nt allw pharmacies t administer a vaccinatin.) Situatin 2: Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine and administratin f the vaccine. Yu get the Part D vaccinatin at yur dctr s ffice. When yu get the vaccinatin, yu will pay fr the entire cst f the vaccine and its administratin. Yu can then ask ur plan t pay ur share f the cst by using the prcedures fr submitting a request fr payment that is described in this Sectin f this bklet. Situatin 3: Yu buy the Part D vaccine at yur pharmacy, and then take it t yur dctr s ffice where they give yu the vaccinatin sht. Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine serum itself. When yur dctr gives yu the vaccinatin sht, yu will pay the entire cst fr this service. Yu can then ask ur plan t pay ur share f the cst by using the prcedures described in this Sectin. Yu will be reimbursed the amunt SFEHACL nrmally pays fr the dctr t administer the vaccine. The rules fr cverage f vaccinatins are cmplicated. We are here t help. We recmmend that yu call us first at Custmer Service whenever yu are planning t get a vaccinatin. We can tell yu abut hw yur vaccinatin is cvered by ur plan and explain yur share f the cst. 10 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

17 Sectin 2 Plan Premium NOTE: If yu are receiving Extra Help paying fr yur drug cverage, the premium amunt that yu pay as a member f ur plan is listed in yur Evidence f Cverage Rider. Or, if yu are a member f a State Pharmacy Assistance Prgram (SPAP), yu may get help paying yur premiums. Please cntact yur SPAP t determine what benefits are available t yu. Hw much is yur mnthly plan premium and hw d yu pay it? 2017 SFEHACL Part D Medicare Secndary Plan and Medicare Part D Prescriptin Plan members pay a cmbined premium fr all Medicare Plans each mnth. Because the premiums are cmbined, SFEHACL members are nt eligible fr premium withhld frm the RRB. SFEHACL charges a $20 service fee fr any premium payments rejected fr any reasn. There are tw ways t pay yur mnthly plan premium Optin ne pay quarterly: Pay yur plan premium quarterly (3 mnths at a time) by check, mney rder, we must receive yur payment n r befre the first f the mnth f every January, April, July, and Octber beginning with January 1, Optin tw pay mnthly: Pay yur premium mnthly by check, mney rder r autmatic premium deductin frm yur checking r savings accunt. If yu chse autmatic premium deductins, we will debit yur accunt n the 15 th day f the mnth. If yu have any questins abut signing up fr the autmatic premium payment ptin, t receive an authrizatin frm, yur plan premiums r the different ways t pay them, please call ur Custmer Service at What happens if yu dn t pay yur plan premiums, r dn t pay them n time? If yur plan premiums are past due, we will tell yu in writing within 15 days. Medicare requires us t disenrll yu frm ur plan after the secnd mnth f failure t pay yur past-due plan premiums. If yu are disenrlled frm SFEHACL fr any reasn including nnpayment f yur premium, yu may nt have anther pprtunity t enrll again. Als, if yu are disenrlled fr this reasn, yu will nt be able t enrll in anther Medicare Prescriptin Drug Plan until the next Annual Crdinated Enrllment Perid, unless yu qualify fr a Special Enrllment Perid. If yu d nt qualify fr a Special Enrllment Perid r have anther surce f creditable prescriptin drug cverage, yu may have t pay a late enrllment penalty the next time yu enrll in a Medicare Prescriptin Drug Plan r a Medicare Advantage Plan with prescriptin drug cverage. Please see Sectin 6 fr mre abut enrllment perids. Yu have t cntinue t pay yur Part A and/r Part B premiums T be a member f ur plan, yu must be entitled t Medicare Part A and enrlled in Medicare Part B. Yu must pay yur Part B premiums. If yu currently pay a premium fr Medicare Part A (mst peple dn t) and/r Medicare Part B, yu must cntinue paying yur premium in rder t keep yur Medicare Part A and/r Medicare Part B and t remain a member f ur SFEHACL Medicare Plans. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

18 Can yur plan premiums change during the year? Generally, SFEHACL cannt change yur plan premium during the calendar year. We will tell yu in advance if there will be any changes fr the next calendar year in yur plan premiums r in the amunts yu will have t pay when yu get yur prescriptins cvered. If there are any changes fr the next calendar year, they will take effect n January 1, Refer t yur 2018 Annual Ntice f Changes. In limited circumstances, yur plan premium may change during the calendar year. If yu aren t currently receiving Extra Help but yu qualify fr it during the year, yur mnthly premium culd be lwer. In sme situatins yur plan premium culd be less There are prgrams t help peple with limited resurces pay fr their drugs. These include Extra Help and State Pharmaceutical Assistance Prgrams. If yu qualify, enrlling in ne f these prgrams might lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, the infrmatin abut yur premiums in this Benefit Guide may nt apply t yu. In sme situatins yur plan premium culd be mre Sme members are required t pay a late enrllment penalty because they did nt jin a Medicare drug plan when they first became eligible r because they had a cntinuus perid f 63 days r mre when they didn t have creditable prescriptin drug cverage. (Creditable means the drug cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) Fr these members, the late enrllment penalty is added t the plan s mnthly premium. Their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. If yu are required t pay the late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. If yu have a late enrllment penalty and d nt pay it, yu culd be disenrlled frm the plan. What is the late enrllment penalty? Yu will have t pay a late enrllment penalty in additin t yur mnthly plan premium if bth f the fllwing tw factrs are present: Yu were eligible t enrll in a Medicare Prescriptin Drug Plan; and After the end f yur initial enrllment perid, there was a cntinuus perid f 63 days r lnger in which yu were nt enrlled in a Medicare Prescriptin Drug Plan r ther creditable prescriptin drug cverage. Creditable prescriptin drug cverage is cverage that is at least as gd as the standard Medicare Prescriptin Drug cverage that expects t pay, n average, at least as much as the Medicare Prescriptin Drug benefit expects t pay. Yu pay this late enrllment penalty fr as lng as yu have Medicare Prescriptin Drug cverage. The amunt f the late enrllment penalty may increase every year. The late enrllment penalty des nt apply t individuals wh qualify fr Extra Help with their drug plan csts. Wh pays an extra Part D amunt because f incme? Mst peple pay a standard mnthly Part D premium. Hwever, sme peple pay an extra amunt because f their yearly incme. If yur incme is abve a certain amunt fr an individual (r married 12 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

19 individuals filing separately) r abve a certain amunt fr married cuples, yu must pay an extra amunt directly t the gvernment fr yur Medicare Part D cverage. If yu have t pay an extra amunt, Scial Security, nt SFEHACL, will send yu a letter telling yu what that extra amunt will be and hw t pay it. The extra amunt will be withheld frm yur Scial Security, Railrad Retirement Bard, r Office f Persnnel Management benefit check, n matter hw yu usually pay yur plan premium, unless yur mnthly benefit isn t enugh t cver the extra amunt wed. If yur benefit check isn t enugh t cver the extra amunt, yu will get a bill frm Medicare. The extra amunt must be paid separately t the gvernment and cannt be paid with yur SFEHACL mnthly plan premium. If yu disagree abut paying an extra amunt because f yur incme, yu can ask Scial Security t review the decisin. T find ut mre abut hw t d this, cntact Scial Security at (TTY ). The extra amunt is paid directly t the gvernment (nt SFEHACL) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm SFEHACL Medicare plans and lse prescriptin drug cverage and yur Medicare HCPP and Medicare Secndary Plan cverage. This disenrllment actin is taken by Medicare. SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

20 Sectin 3 Prescriptin Drug Cverage This Sectin describes yur prescriptin drug cverage as a member f ur plan. We will explain what a frmulary is and hw t use it, ur drug management prgrams, hw much yu will pay when yu fill a prescriptin fr a cvered drug, and what an Explanatin f Benefits is. What is a frmulary? We have a frmulary that lists all drugs that we cver. Fr 2017, we have included mst Medicare Part D drugs in ur frmulary. We will generally cver the drugs listed in ur frmulary as lng as the drug is medically necessary; the prescriptin is filled thrugh Dept Drug Pharmacy r at a retail netwrk pharmacy, it is a cvered Medicare Part D drug, and ther cverage rules are fllwed. Fr certain prescriptin drugs, we have additinal requirements fr cverage r limits n certain drugs. These requirements and limits are described in detail in yur Frmulary Bk and in this Sectin. Medicare and ur plan, with the help f a team f health care prviders select the drugs n the frmulary. We select the prescriptin therapies believed t be a necessary part f a quality treatment prgram and bth brand name drugs and generic drugs are included n the frmulary. A generic drug has the same active ingredient frmula as the brand name drug. Generic drugs usually cst less than brand name drugs and are rated by the Fd and Drug Administratin (FDA) t be as safe and as effective as brand name drugs. We have included mst Medicare Part D cvered drugs n ur frmulary. In sme cases, the law prhibits us frm cvering certain types f drugs. See Drug Exclusins, later in this Sectin, fr mre infrmatin abut the types f drugs that cannt be cvered under a Medicare Prescriptin Drug Plan. In certain situatins, prescriptins filled at an ut f netwrk pharmacy may als be cvered. See Sectin 1 fr mre infrmatin abut filling prescriptin at ut f netwrk pharmacies. Hw d yu find ut what drugs are n ur frmulary? Yu have been sent a 2017 SFEHACL Part D Medicare Plan Drug Frmulary Bk with Tier 1, 2, 3 and 4 frmulary drugs listed. Yur Frmulary bk is an abridged versin that des nt list all strengths r multiple names f the drug. Mst cvered Medicare Part D drugs are n yur frmulary. Since a frmulary can change at any time, if there is any questin abut drug cverage, yu must call Custmer Service fr clarificatin at What are drug tiers? Drugs n ur frmulary are rganized int different drug tiers, r grups f different drug types. Yur cpayment depends n which drug tier yur drug is in. The table belw shws the cpayment and/r cinsurance amunt yu pay fr each tier when yu are in yur initial cverage limit and when yu btain yur prescriptin frm the Dept Drug Mail Pharmacy, r a retail netwrk r specialty drug pharmacy. As yu can see, yur benefits are stretched thrugh lwer cpayments when yu btain yur prescriptins frm the Dept Drug Mail Pharmacy. 14 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017

21 2017 Cpayment chart fr drug tiers 2017 Cpayment Amunts fr Part D Drugs Dept Drug Mail Pharmacy $$$ Yur Best Mney Saver Tier 1 Generic drugs 90-day supplies nly. Tiers 2 & 3 drugs may be 30, 60, r 90-day supplies. Natinal Retail Pharmacy Netwrk Includes Specialty Pharmacies 30, 60 r 90-day supplies Tier 1 Generic Drugs 30-Day $3 ($9 fr 90- day? Tier 2 Brand Preferred 30-Day $15 $15 $30 Tier 3 Brand Nn- Preferred 30-Day Higher f $75 r 33% f drug cst Higher f $90 r 33% f drug cst Tier 4 Specialty Drugs 30-Day Nt Supplied 33% f drug cst 30- day r less supply nly Nte: Out-f-Netwrk Pharmacy - Emergency Only We refund yu the SFEHACL cst fr the Part D drug minus yur Retail tier cpayment amunt. Yu pay any charges abve ur cst. If yu are in the Cverage gap and the generic and brand name discunts were nt applied frm the pharmacy, yu will nt be reimbursed fr the discunt amunts. Nn-Part D drugs are nt cvered. *If the actual cst plus dispensing fee fr a prescriptin is less than the Tier cpayment amunt fr that drug, yu will pay the actual cst plus dispensing fee, nt the cpayment! Sme drugs wuld cst yu less under this rule s make sure that yu use yur SFEHACL ID card! Changes t available drug supplies frm Dept Drug Mail Pharmacy Beginning January 1, 2017, Dept Drug Mail Pharmacy can nly ship 90-day supplies f Tier 1 generic prescriptin drugs. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. Yu may cntinue t btain a 30, 60 r 90-day supplies f Tier 2 r 3 prescriptin drugs frm Dept Drug Mail Pharmacy. Smetimes yu can get less than a full mnth s supply Dept Drug Mail Pharmacy des nt supply a partial fill fr a drug nrmally taken daily. Yu will need t get thse frm retail netwrk pharmacies. Usually yu pay a cpay t cver a full mnth s supply f a cvered drug, r fr a full prescriptin that is less than 30 days (like an antibitic). Fr drugs that wuld nrmally be taken daily, yur dctr can prescribe less than a mnth s supply f drugs. There may be times when yu want t ask yur dctr abut prescribing less than a mnth s supply f a drug that is new fr yu (fr example, when yu are trying a medicatin fr the first time that is knwn t have serius side effects). If yu dctr agrees, yu will nt have t pay fr the full mnth s supply fr certain drugs n a new prescriptin. The amunt yu pay when yu get less than a full mnth s supply fr a new drug that is nrmally taken daily will depend n whether yu are respnsible fr paying cinsurance (a percentage f the ttal cst) r a cpayment (a set amunt depending n tier placement). Daily cst-sharing allws yu t make sure a drug wrks fr yu befre yu have t pay fr an entire mnth s supply. If yu are respnsible fr cinsurance, yu pay a percentage f the ttal cst f the drug. Yu pay the same percentage regardless f whether the prescriptin is fr a full mnth s supply r fr SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE

22 fewer days. Hwever, because the entire drug cst will be lwer if yu get less than a full mnth s supply, the amunt yu pay will be less. If yu are respnsible fr a cpayment fr the drug, yur cpay will be based n the number f days f the drug that yu receive. We will calculate the amunt yu pay per day fr yur drug (the daily cst-sharing rate) and multiply it by the number f days f the drug yu receive. Here s an example: Let s say the cpay fr yur drug fr a full mnth s supply (a 30-day supply) is $30. This means that the amunt yu pay per day fr yur drug is $1. If yu receive a 7 days supply f the drug, yur payment will be $1 per day multiplied by 7 days, fr a ttal payment f $7. Yu shuld nt have t pay mre per day just because yu begin with less than a mnth s supply. Let s g back t the example abve. Let s say yu and yur dctr agree that the drug is wrking well and that yu shuld cntinue taking the drug after yur 7 days supply runs ut. If yu receive a secnd prescriptin fr the rest f the mnth, r 23 days mre f the drug, yu will still pay $1 per day, r $23. Yur ttal cst fr the mnth will be $7 fr yur first prescriptin and $23 fr yur secnd prescriptin, fr a ttal f $30 the same as yur cpay wuld be fr a full mnth s supply. Can the frmulary change? We and/r Medicare may add r remve drugs frm the frmulary during the year. If the drug is cvered by Medicare, it will be cvered by SFEHACL. Drug manufacturers cnstantly change, discntinue and/r add new drugs. Changes in the frmulary may affect which drugs are cvered and hw much yu will pay when filling yur prescriptin. If we remve drugs frm the frmulary, add prir authrizatins, quantity limits, any ther restrictins, r mve a drug t a higher cst-sharing tier, and yu are taking the drug affected by the change, we will ntify yu f the change at least 60 days befre the date that the change becmes effective. If we dn't ntify yu f the change in advance, we will give yu up t a 60-day supply (depending n the number f refills left n yur prescriptin) f the drug when yu request a refill f the drug. Hwever, if a drug is remved frm ur frmulary because the drug has been recalled frm the market, r the manufacturer stps making the drug, we will nt give 60 days ntice befre remving the drug frm the frmulary. Instead, we will remve the drug frm ur frmulary immediately and ntify members abut the change as sn as pssible. What if yur drug is nt n the frmulary? Mst Part D drugs are n the SFEHACL frmulary. If Medicare Part D cvers yur drug, it is usually included in ur frmulary. Yu can cntact Custmer Service at t be sure if a drug is cvered. If Custmer Service cnfirms that Medicare Part D des nt cver yur drug, yu have three ptins: Yu can ask yur dctr if yu can switch t anther drug that is cvered by Medicare. If yu wuld like t give yur dctr a list f cvered drugs that are used t treat similar medical cnditins, please shw him/her yur Frmulary bk. Yu can ask us t make an exceptin t cver yur drug nly if it is a Medicare-cvered Part D drug, and all f thse are already n ur plan frmulary. Yu can pay ut-f-pcket fr the drug and request that ur plan reimburse yu by requesting a frmulary exceptin if the drug is cvered by Medicare Part D. Since Mst Part D drugs are n the SFEHACL frmulary, this wuld rarely apply. This des nt bligate ur plan t reimburse yu if the exceptin request is nt apprved. See Sectin 5 fr mre infrmatin n hw t request an appeal. 16 SFEHACL MEDICARE PART D PLAN BENEFIT GUIDE 2017