SecurityBlue HMO. Link to Specific Guidance Regarding Exceptions and Appeals

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1 SecurityBlue HMO Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality Assurance Policies and Procedures Link to Specific Guidance Regarding Exceptions and Appeals

2 SecurityBlue HMO: Conditions and Limitations Access Requirements SecurityBlue HMO contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. SecurityBlue HMO has a large national network of more than 58,000 pharmacies, including chain and independent drug stores. Network Limitations Enrollees must use network pharmacies or the SecurityBlue HMO mail order pharmacy service to receive covered Part D drugs except under emergency or non-routine circumstances. When obtaining prescriptions from pharmacies outside the network, the coverage by SecurityBlue HMO may be less. In the event that you use a pharmacy outside of SecurityBlue HMO s national pharmacy network, you may need to pay for the drug in full and submit a claim to SecurityBlue HMO for reimbursement. Eligible out-of-network claims will be paid at the rate the drug would have been paid for if you had purchased the drug from a SecurityBlue HMO network pharmacy. You will be responsible for the difference between the amount SecurityBlue HMO would have paid a network pharmacy and the price you paid, in addition to your applicable copayment or coinsurance. Formulary SecurityBlue HMO uses a formulary. A formulary is a list of covered drugs selected by SecurityBlue HMO in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified in writing at least 60 days before the change is made, except in the case the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market.. SecurityBlue HMO, as with all Medicare prescription drug plans, covers drugs that are listed on a formulary. SecurityBlue HMO covers all Part D drugs allowed by Medicare. You and your prescribing physician may ask for coverage of a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher level of payment. Brand Drugs vs. Generic Drugs When a generic version of a brand name drug is available, our network pharmacies must provide you with the generic version. However, if your doctor has told us the medical reason that the generic drug will not work for you, then we will cover the brand name drug. Your share of the cost may be greater for the brand name drug.

3 Days Supply Prescriptions for 1-34 days will require the same copayment as a 34-day supply and any prescriptions beyond 34 days (35-90 days) will be charged the same copayment as a 90- day supply. Prescriptions obtained at a retail pharmacy for days may have a higher copayment than those received through the SecurityBlue HMO mail order pharmacy service. Eligibility Restrictions Anyone who is entitled to Medicare Part A benefits and enrolled in Medicare Part B is eligible to enroll in a Medicare Advantage plan. However, if you are already enrolled in a Medicare Advantage plan such as an HMO or PPO and then enroll in a SecurityBlue HMO plan, you will be disenrolled from your Medicare Advantage plan. You must also live in the SecurityBlue HMO service area and not be enrolled in any other Medicareapproved prescription drug plan. Individuals with Medicare may enroll in a prescription drug plan during specific times of the year. You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, contact: MEDICARE ( ) 24 hours a day, seven days a week. TTY/TDD users call , on the Web. The Social Security Administration at (TTY/TDD users call ), between 7 a.m. and 7 p.m., Monday through Friday, on the Web. Your state Medicaid office SecurityBlue HMO: Potential for Contract Termination All Medicare Advantage Plan Sponsors agree to offer the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a sponsor decides not to continue, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for choosing other Medicare Advantage and Medicare prescription drug coverage in your area. SecurityBlue HMO: Disenrollment Rights and Instructions Voluntary Disenrollment During the Annual Election Period (November 15 through December 31), anyone with Medicare will have an opportunity to switch from one way of getting Medicare to another. From January 1 through March 31, anyone with Medicare has another chance to make one change in the way they get Medicare. With this chance, you are limited in the type of plan you may join. If you have Medicare prescription drug coverage when making your change, you will only be able to join a Medicare Advantage plan that offers

4 Medicare Part D or you will have to go to Original Medicare and join a prescription drug plan. If you do not have Medicare prescription drug coverage when making this change, you will only be able to join a Medicare Advantage plan that does not offer Medicare Part D or go to Original Medicare. Generally, you cannot make any other changes during the year unless you qualify for a Special Election Period. If you wish to leave SecurityBlue HMO, you will need to submit a written and signed disenrollment request to SecurityBlue HMO. You may also call MEDICARE. Medicare Customer Service Representatives are available 24 hours a day, seven days a week. TTY/TDD users should call Until your disenrollment is effective, you must continue getting your health care through SecurityBlue HMO. Involuntary Disenrollment SecurityBlue HMO may end your coverage for any of the following reasons: You lose your entitlement to Medicare Part A hospital insurance and / or fail to pay your Medicare Part B medical insurance SecurityBlue HMO is no longer contracting with Medicare or leaves your service area You permanently move out of the SecurityBlue HMO service area and do not voluntarily disenroll You fail to pay your SecurityBlue HMO premium You engage in disruptive behavior, provided fraudulent information when you enrolled or knowingly permitted abuse or misuse of your enrollment card Please consult the SecurityBlue HMO Evidence of Coverage for complete information on disenrollment rights. SecurityBlue HMO: Coverage Decisions, Part D Exceptions, Prior Authorizations, Appeals and Grievances Coverage Decisions A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. We make a coverage decision for you whenever you go to a doctor for medical care. You can also contact the Plan and ask for a coverage decision. For example, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. If a drug is not covered in the way you would like it to be covered, you can ask the Plan to make an exception. An exception is a type of coverage decision. Similar to other types of coverage decisions, if we turn down your request for an exception, you can appeal our decision. Click on the Link to Specific Guidance Regarding Exceptions and Appeals for information about how to request a Coverage Decision. Exceptions Members of SecurityBlue HMO and their prescribing physicians may ask for coverage of a non-preferred Part D drug at the preferred cost-sharing level. This is a request for a tiering exception. This would lower the copayment amount you must pay for your drug. You cannot ask that a Part D drug on the specialty tier be covered at a higher

5 level of payment. A member s prescribing physician may either contact SecurityBlue HMO directly to request an exception or provide supporting information to SecurityBlue HMO if the request is made by the member. Generally, a request will be approved only if the alternative drugs included in the formulary would not be as effective in treating a condition and/or would result in adverse medical effects. Generally, the Plan must make a decision as expeditiously as the member s health requires, but no later than 72 hours of receiving supporting information from the member s physician for a standard request. If applying the standard timeframe (72 hours) for making the determination seriously jeopardizes the life or health of the member or the member s ability to regain maximum function, an expedited review can be requested. In this instance, the Plan must make a decision as expeditiously as the member s health requires, but no later than 24 hours of receiving supporting information from the member s physician. Prior Authorizations In addition to the exception process addressed above, SecurityBlue HMO requires you to get prior authorization for certain drugs. Even if a drug is on SecurityBlue HMO s formulary, it may still require prior authorization. This means that you will need to get approval from SecurityBlue HMO before you fill your prescription for a drug that requires prior authorization. If you don t obtain approval, SecurityBlue HMO may not cover the drug. Appeals and Grievances Members of SecurityBlue HMO, their physicians, or authorized representatives acting on the member s behalf may request an appeal of an adverse coverage determination made by SecurityBlue HMO. Examples of reasons an appeal may be filed include: the member believes he or she was denied benefits that the member is entitled to receive, the member believes there has been a delay in providing or approving the drug coverage, or the member disagrees with the amount of cost sharing he or she is required to pay. A request for a Standard Appeal may be made orally or in writing to SecurityBlue HMO. SecurityBlue HMO is required to notify the member in writing of its decision as quickly as the member's health condition requires, but no later than 7 calendar days from the date SecurityBlue HMO receives the request for the Standard Appeal. Members of SecurityBlue HMO and their prescribing physicians may request that an appeal be Expedited for situations in which applying the Standard Appeal process may seriously jeopardize the member's health, life or ability to regain maximum function. (This would not include requests for payment of drugs already furnished.) A request for an Expedited Appeal can be made orally or in writing. SecurityBlue HMO is required to notify the member and the prescribing physician of its decision as quickly as the member's health condition requires, but no later than 72 hours after receiving the request. Members of SecurityBlue HMO may file a Grievance, either orally or in writing, expressing dissatisfaction with the operations, activities or behavior of SecurityBlue HMO or with the quality of care or service received from a SecurityBlue HMO provider. SecurityBlue HMO is required to respond to the member's Grievance as quickly as the

6 case requires, but no later than 30 days after the date SecurityBlue HMO receives the oral or written Grievance. Please refer to the SecurityBlue HMO Evidence of Coverage for details on the Appeals and Grievance process. Obtaining Data on Exceptions, Appeals and Grievances Members of SecurityBlue HMO can receive a description of the number of Exceptions, Appeals and Grievances received and how these cases were resolved by contacting SecurityBlue HMO by phone or in writing. SecurityBlue HMO: Out-of-Network Part D Coverage Obtaining Out-of-Network Coverage To get a complete description of your prescription drug coverage, including how to have your prescriptions filled, please review the Evidence of Coverage. A network pharmacy is a pharmacy that has agreed to provide prescription drug benefits at negotiated prices for SecurityBlue HMO. In most cases, your prescriptions are covered under SecurityBlue HMO only if they are filled at a network pharmacy or through our mail order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances. The following are a few exceptions when we will pay for a prescription filled at a pharmacy outside of our network. Getting coverage when you travel or are away from the plan s service area If you are traveling within the United States and territories and become ill, lose or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described later. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States and territories, even for a medical emergency. What if I need a prescription because of a medical emergency or because I needed urgent care? We will cover prescriptions that are filled at an out-of-network pharmacy if the prescriptions are related to care for a medical emergency or urgent care. In this situation, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims

7 process described later. Other times you can get your prescription covered if you go to an out-of network pharmacy We will cover your prescription at an out-of-network pharmacy if at least one of the following applies: If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24 hour service. If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail-order pharmacy (such as high-cost and unique drugs). If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and is administered in your doctor s office. If you are evacuated or displaced from your residence due to a State or Federally declared disaster or health emergency. Before you fill your prescription in any of these situations, call Member Service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. If you go to an out-of-network pharmacy, you may be responsible for paying the difference between what we would pay for a prescription filled at an in-network pharmacy and what the out-of-network pharmacy charged for your prescription. To learn how to submit a paper claim, please refer to the paper claims process described next. How do I submit a paper claim? When you go to a network pharmacy your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy because of the reasons listed above, the pharmacy may not be able to submit the claim directly to us and you will have to pay the full cost of your prescription. When you return home, simply submit your claim and your receipt to the following address: SecurityBlue HMO, PO Box 1068 Pittsburgh, PA Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage for more information on coverage determinations. For more information For more detailed information about your SecurityBlue HMO prescription drug coverage, please review the Evidence of Coverage and SecurityBlue HMO s formulary.

8 SecurityBlue HMO: Quality Assurance Policies and Procedures Medication Therapy Management (MTM) Program SecurityBlue HMO offers medication therapy management programs (MTM) at no additional cost for members who have multiple medical conditions, who are taking many prescription drugs, or who have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these MTM programs to help up provide better coverage for our members. We offer an MTM program for members that have 3 of the following conditions bone disease, chronic heart failure, diabetes, dyslipidemia, hypertension. We may contact members who qualify for these programs. These programs are not a benefit to SecurityBlue HMO members. The programs are voluntary and you do not need to pay anything extra to participate. If you are selected to participate, we will send you information about the specific program, including information about how to access the program. For more information on SecurityBlue HMO MTM programs, please review the Evidence of Coverage or contact member service. Prior Authorization SecurityBlue HMO requires you to get prior authorization for certain drugs. This means that you will need to get approval from SecurityBlue HMO before you fill certain prescriptions. If you don t get approval, SecurityBlue HMO may not cover the drug. Our prior authorization policies are in place to ensure the safe and effective use of medications. Quantity Limits For safety purposes, certain drugs are covered in limited amounts per prescription. For example, SecurityBlue HMO provides up to 9 tablets per prescription for the drug Imitrex. Pharmacy Messaging Alert System SecurityBlue HMO has a real-time messaging alert system in place to inform pharmacists of potential drug problems. When a pharmacist, who is dispensing a drug, bills SecurityBlue HMO, the computer system performs a series of clinical checks. These will alert the pharmacist of potential drug to drug interactions, as well as higher or lower doses than are normally prescribed. These alerts serve to increase the quality and safety of pharmacy and patient interactions. Important Information about Plan Performance Ratings The Centers for Medicare and Medicaid Services (CMS) has made information available about our plan s performance ratings, including how it has been rated by plan members and how it compares to similar plans. This information is available for you to view at Specific information about one of our plans may also be requested by calling the phone or TTY number in your enrollment information or on your identification card once you become a member.