Questions & Answers for 2015 AEP AGENTS & AGENCIES

Transcription

1 Region 25 MedicareBlue Rx (Revised 10/1/14) Questions & Answers for 2015 AEP AGENTS & AGENCIES Contents 1. MedicareBlue Rx General Plan Questions and 2015 Plan Changes CVS Caremark Questions Pharmacy Network Questions Formulary Questions Mail Order Questions General Questions About Low-Income Subsidies (LIS) Changes in the Coverage Gap Enrollment Period and Premium Changes Background Information for Agents MedicareBlue Rx Low-Income Subsidy Amounts Senior Health Insurance Plan (SHIP) Information by State

2 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES 1.1. Where is the service area for the plan? The service area for the plan is a seven-state region in the Upper Midwest and Northern Plains consisting of Iowa, Minnesota, Montana, Nebraska, North Dakota, South Dakota and Wyoming. The beneficiary s permanent residence must be in the service area to be eligible for MedicareBlue Rx Who can join the plan? MedicareBlue Rx is a stand-alone Part D Plan available to all Medicare beneficiaries who permanently reside in the seven-state region service area (see Q&A 1.1.) and who are entitled to Medicare Part A and/or enrolled in Medicare Part B. Beneficiaries can also join MedicareBlue Rx if they are enrolled in a Medicare Supplement plan like those offered by local Blue Cross and Blue Shield plans in the region. If a beneficiary is enrolled in an MA coordinated care (HMO or PPO) plan or an MA PFFS plan that includes Medicare prescription drug coverage, he or she may not enroll in a PDP unless he or she disenrolls from the HMO, PPO or MA PFFS plan. If a beneficiary is enrolled in a private-fee-for-service plan (PFFS) that does not provide Medicare prescription drug coverage, or an MA Medical Savings Account (MSA) plan, he or she may enroll in a PDP. A beneficiary may also enroll in a PDP if he or she is enrolled in an 1876 Cost plan. Note: Group MedicareBlue Rx beneficiaries do not need to reside in the service area to join a group plan. These beneficiaries should contact whoever answers benefit questions about their plan for more information. 2

3 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES 1.3. What types of changes are occurring in MedicareBlue Rx for 2015? 1.4. Can you give me an overview of the plan? MedicareBlue Rx will offer three plan options in 2015: Value Plus, Standard and Premier. CVS Caremark 1 will be the new Pharmacy Benefit Manager. CVS Caremark will replace Prime Therapeutics 2 as the firm that manages the pharmacy network and the drug formulary (list of covered drugs). The premiums for Standard and Premier are increasing. However, the new Value Plus plan option has a lower premium than the other two plan options. The Standard deductible is increasing from $160 to $320. All three plan options will have a 5-tier structure including the four current tiers for generic and brand name drugs and a new tier for high-cost specialty drugs. The copay and coinsurance amounts for most tiers are decreasing. However, some drugs may move to a different tier as a result of the annual formulary change. Monthly supplies are changing from 31 days to 30 days to align with the industry (with the exception of prescriptions filled at long-term care pharmacies). See table that follows plan option Highlights of MedicareBlue Rx plan changes for 2015 Value Plus There is a new plan option called Value Plus for The monthly premium will be $ This plan is designed to appeal to individuals who are newly eligible for Medicare. Even though they may not have significant prescription drug costs today, we want to encourage them to enroll in coverage now to avoid paying the late enrollment penalty later. This plan option has a $160 annual deductible. Within the pharmacy network, some pharmacies offer preferred cost sharing and some pharmacies offer standard cost sharing. Members will often pay less when they fill prescriptions at preferred pharmacies, including CVS/pharmacy, Hy-Vee, White Drug, Wal-Mart and others. (Note: See Q&A 3.5. for more on how preferred and standard cost sharing works for this plan option.) 1 CVS/caremark is an independent company providing pharmacy benefit management services. 2 Prime Therapeutics, LLC, is an independent company providing pharmacy benefit management services. 3

4 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES Value Plus (cont.) The Value Plus plan option has five drug tiers. Here are the cost-sharing amounts at pharmacies that offer preferred cost sharing (30-day supplies): Tier 1: Preferred Generic drugs $0 copay Tier 2: Non-Preferred Generic drugs $6 copay Tier 3: Preferred Brand drugs $35 copay Tier 4: Non-Preferred Brand drugs 50% coinsurance Tier 5: Specialty drugs 29% coinsurance Cost sharing at pharmacies that offer standard cost sharing (30-day supplies): Tier 1: Preferred Generic drugs $5 copay Tier 2: Non-Preferred Generic drugs $12 copay Tier 3: Preferred Brand drugs $45 copay Tier 4: Non-Preferred Brand drugs 50% coinsurance Tier 5: Specialty drugs 29% coinsurance Once members pay $2,960 in 2015, they have reached the coverage gap. They will pay no more than 45 percent of the plan s costs for brandname drugs and 65 percent of the plan s costs for generic drugs. Standard Monthly premium will increase from $41.90 to $ The deductible is increasing from $160 to $320, but all copays are decreasing. There is a new Tier 5 for Specialty drugs. Here are the costsharing amounts for all tiers (30-day supplies): Tier 1: Preferred Generic drugs $0 copay Tier 2: Non-Preferred Generic drugs $6 copay Tier 3: Preferred Brand drugs $22 copay Tier 4: Non-Preferred Brand drugs $95 copay Tier 5: Specialty drugs 25% coinsurance The Standard Plan has a smaller formulary of covered drugs than the other two plan options. The formulary includes drugs to treat all types of conditions, but includes fewer drugs of each type. Once members pay $2,960 in 2015, they have reached the coverage gap. They will pay no more than 45 percent of the plan s costs for brandname drugs and 65 percent of the plan s costs for generic drugs. 4

5 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES Premier Monthly premium will increase from $ to $ The plan will continue to have no deductible. All copays are decreasing and there is a new Tier 5 for Specialty drugs. Beginning in 2015, some Preferred Brand drugs will be covered with a copay in the coverage gap. Here are the cost-sharing amounts for all tiers (30-day supplies): Tier 1: Preferred Generic drugs $1 copay Tier 2: Non-Preferred Generic drugs $3 copay Tier 3: Preferred Brand drugs $24 copay Tier 4: Non-Preferred Brand drugs 50% coinsurance Tier 5: Specialty drugs 33% coinsurance Once members pay $2,960 in 2015, they have reached the coverage gap. Premier members will pay a $1 copay for Tier 1: Preferred Generic drugs, a $3 copay for Tier 2: Non-Preferred Generic drugs and a $24 copay for some Tier 3: Preferred Brand drugs in the coverage gap. They will also pay no more than 45 percent of the plan s costs for brand-name drugs and 65 percent of the plan s costs for generic drugs. Catastrophic Coverage Medicare sets the amounts for catastrophic coverage each year. These amounts are changing in Once an individual has paid $4,700 in out-of-pocket prescription drug costs, they will pay the greater of 5 percent coinsurance OR a $2.65 copay for generic drugs and a $6.60 copay for all other covered drugs Why does the plan change each year? 1.6. Why is the premium for the Premier plan option increasing so significantly in 2015? 1.7. How does the plan differentiate itself in the marketplace? We set prices for our plans based on the claims we expect. Each year, Medicare requires us to review our claims and set prices for the following year based on each plan s actual claims for the previous year. If claims are higher or lower than expected, we must change the plan premiums or adjust the benefits for the following year. Benefit enhancements, including the addition of some Tier 3 drugs, and a decrease in copay amounts are the main drivers in the premium increase for the Premier plan option. Also having some impact on premiums is the overall drug trend that includes new high cost drugs. BCBS has worked with Medicare for many years. We know what it takes to work with government processes and succeed. All three MedicareBlue Rx plan options have features that beneficiaries may find attractive for different reasons, including low premium, $0 copays, no deductible, extra gap coverage, etc. 5

6 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES Members can appreciate how easy the plans are to use. All three plans have the same pharmacy network that includes the major chains across the United States and many independent pharmacies. The cost-sharing structure of the plans is set up so members can easily budget their prescription drug expenses What s the best way to determine the most suitable plan for an individual? Selecting the most suitable plan that best meets a person s personal situation depends on several factors: premium amounts, deductible amounts, drugs covered and cost-sharing amounts. Enrollees and potential enrollees can use the 2015 Plan Selector Tool that will be available on on October 1. Although this tool will look and function differently from our current tool, it will calculate the enrollee s financial liability for each of our plan options and provide the same type of information to help individuals choose the plan that s best for them. Other factors to consider are the enrollee s comfort level with the cost sharing. Some beneficiaries prefer a lower premium plan with a deductible. Others may want coverage right away without a deductible and be willing to pay a higher premium for it. The choice is theirs. Members who may want to change options this year can call our Medicare Solutions specialists at for help with the Plan Selector Tool. Representatives are available seven days a week, from 8 a.m. to 8 p.m., Central and Mountain Times. TTY hearing impaired users can call 711. Agents of record information will not be changed if a member uses the call center to switch plan options this fall. Members with Internet access can use the drug cost calculator on the Plan Selector Tool by going to This comparison tool will be available starting October 1, See the separate announcement about updates to the tool for You may choose to meet directly with your enrolled members to help them compare plans. Using the online cost calculator will help to facilitate your discussion with them. 6

7 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES 1.9. Do members need to complete a form if they want to change to a different MedicareBlue Rx plan option? When can members make a change? What happens if members don t select a new option? Will members get a new ID card for 2015? I ve heard about Medicare plans having star ratings. What is the MedicareBlue Rx star rating? Yes. Medicare requires that members complete a change form, either paper, online or by phone, to change to a different option. We cannot automatically move members from one plan option to another without the member completing a form. Members can change plan options during the annual enrollment period (AEP), October 15 to December 7, Changes made during that time take effect January 1, Changes at other times of the year are allowed only if an individual is eligible for a Special Enrollment Period as a result of an event such as moving into a new service area, moving into or out of a long-term care facility or becoming eligible for Extra Help. If Standard or Premier members don t make a change, they will automatically continue in their current plan option. Both of these plan options have benefit and premium changes for Yes. All members will receive new member ID cards for 2015 in December The new card will include the information the pharmacy will need to process claims correctly in Until December 31, 2014, members should continue using their old (current) card. Each year, Medicare rates how plans perform in different categories such as detecting and preventing illness, ratings from patients, patient safety and customer service. The star rating system is designed to provide consumers with additional information to help them choose among the Medicare plans offered in their area. In 2014, MedicareBlue Rx received a four-star rating, the highest rating of any prescription drug plan in the region. Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next. Members who have access to the Internet may use the tools on and select Find health & drug plans. They will have to enter their ZIP Code to compare the plan ratings for MedicareBlue Rx and other Medicare plans in their area. 7

8 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES Individuals can enroll in a 5-star plan at any time during the year. They can enroll for the first time or change from another plan in which they are enrolled. The 2015 ratings will be announced in October When will 2015 plan ratings be available? How do the Marketplaces/Exchanges introduced in each state affect Medicare beneficiaries? If a beneficiary already has health coverage through an employer or union, can they still join MedicareBlue Rx? If a beneficiary has coverage under a Medicare Advantage plan, can they still join MedicareBlue Rx? We expect the 2015 plan ratings for MedicareBlue Rx to be released sometime in October. Once they are released, we have 21 days to replace all 2014 plan ratings in the 2015 pre-enrollment kits. If you order a quantity of kits, be aware that you will have to replace the 2014 plan ratings with the 2015 version within 21 days, too. Available since 2014, the Marketplace is a new way for uninsured individuals to purchase individual health insurance. The policies sold through the Marketplace are not necessarily intended for people eligible for Medicare. Individuals eligible for Medicare can continue to participate in Medicare and buy Medicare Advantage, Prescription Drug and Medicare Supplement policies directly from insurance companies as they do today. Beneficiaries should be aware that they could lose their employer or union health coverage if they join MedicareBlue Rx. They should be advised to read their employer or union communications. If they have questions, they should visit their employer s website, or contact the office listed in their communications. If there isn t information on whom to contact, their employer s benefits administrator or the office that answers questions about their coverage can help. Beneficiaries may already have prescription drug coverage from a Medicare Advantage plan that will meet their needs. By joining MedicareBlue Rx, their membership in their Medicare Advantage plan may end. This will affect both their doctor and hospital coverage and their prescription drug coverage. They should be advised to read the information that their Medicare Advantage plan sends them and if they have questions, they should contact their Medicare Advantage plan. 8

9 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES When should beneficiaries expect to receive plan materials? What materials will they receive? Current members received their Annual Notice of Changes and Evidence of Coverage, as well as a new pharmacy directory and formulary, by September 30, This information will be about the MedicareBlue Rx Standard plan and the MedicareBlue Rx Premier plan. Beginning October 1, 2014, you can begin to discuss the new MedicareBlue Rx Value Plus plan with them as well so members can understand the changes and decide which would be better suited to their needs. Other beneficiaries, such as non-members, who request information about any of the plan options, will receive a pre-enrollment package within 7 to 10 days of their request. The package includes plan benefit information and numbers they can call to reach a Medicare Solutions specialist if they have additional questions. It also contains an application and postage-paid envelope should they choose to enroll by mail. Once a beneficiary s enrollment request is approved, member materials are mailed. These materials include a confirmation letter, member ID card and Welcome Kit. The confirmation letter issued by the plan notifies the beneficiary of CMS response and must be mailed within 10 days of CMS notice to MedicareBlue Rx. This letter includes the member s ID card. The Welcome Kit also will arrive within 10 days after CMS confirms the enrollment and includes: Welcome letter Member Handbook Evidence of Coverage booklet Formulary Pharmacy directory Electronic Funds Transfer (EFT) form and return envelope Privacy Practices Notice Authorization to Release Information (ARI) form Authorization of Representative (AOR) form CVS Caremark Mail Order information A fraud, waste and abuse flyer 9

10 1. MEDICAREBLUE RX GENERAL PLAN QUESTIONS AND 2015 PLAN CHANGES Can a new member sign up for Electronic Funds Transfer (EFT) at the time he/she enrolls? Members can now choose EFT as a payment option on the paper enrollment form. This option is not available with online or phone enrollments since the plan needs a voided check to process EFT. The form will be in preenrollment kits and can be mailed back with the enrollment application or separately. 10

11 2. CVS CAREMARK QUESTIONS 2.1. Why are the plans moving to CVS Caremark as the Pharmacy Benefit Manager? The plan s Pharmacy Benefit Manager (PBM) provides important services including managing the pharmacy network and drug formulary (list of covered drugs). Plans typically review their PBM every few years to make sure they are getting the best service and pricing available. As one of the largest independent prescription drug management companies in the country, CVS Caremark offers a wide range of services for Part D plans, including a rigorous Medication Therapy Management program and a mail order program to help members meet their prescription drug needs Will current members need to re-enroll as a result of the change to CVS Caremark? 2.3. Will members need to get new prescriptions from their doctors as a result of this change? 2.4. How will members access their prescription drug information with CVS Caremark? 2.5. Why are prescriptions changing from 31-day to 30-day supplies? No. Coverage for 2015 will continue automatically in the member s current plan unless the member makes a change. If members have refills remaining on their prescriptions on December 31, 2014, those refills will be transferred to CVS Caremark, so members won t need to request a new prescription from their doctor. (Note: See Q&A 5.4. for how this applies to members who use mail order prescription services.) Members will be able to set up an account at where they can review their claims history, order prescriptions by mail and check on the status of mail orders. Members can also call CVS Caremark at to set up an account and access their prescription drug information. (Note: See Q&A for more on how members can access 2014 and 2015 claims information. Also see Q&As 5.4. through 5.6. for details on setting up an account with CVS Caremark.) 30-day supplies are becoming the industry norm and this change aligns the plans with that. It also helps when we have to calculate a daily supply rate in certain instances since it divides more evenly than 31 days. Note: To meet CMS requirements, long-term care pharmacies will continue to fill 31-day prescriptions. 11

12 2. CVS CAREMARK QUESTIONS 2.6. What happens if a prescription is written for 31 days or 34 days? 2.7. What if a prescription is written for less than 30 days? 2.8. What additional services does CVS Caremark provide? If the member wants to receive the extra amount above a 30-day supply, he or she would have to pay two copays or the additional coinsurance amount since the copays/ coinsurance is not pro-rated for the extra number of days. If the member s prescription is written for 31 or 34 days, the member can talk with their pharmacist or doctor about changing it to a 30-day supply. If the cost sharing is a copay, the amount the member pays will be based on the number of days for which the prescription is written. For example, if the cost of a 30- day supply is $30, the cost of the drug is $1 per day. If the member receives a 7-day supply, he/she will pay $7. If the cost sharing is coinsurance, the member will pay the same percentage regardless of whether the prescription is for a full month supply or fewer days. However, because the cost will be lower for less than a full months supply, the coinsurance amount will also be less. In February 2015, members will receive a CVS Caremark ExtraCare Health Card that they can use to receive a 20% discount on regularly priced CVS/pharmacy brand health-related products. Each member will receive two key tags that they and their family members can use to save money on products such as non-prescription allergy and pain medications, cough and cold products, vitamins, first aid supplies and skin care products. Another service that CVS Caremark offers is its automatic mail order refill service, ReadyFill at Mail. (Note: See Q&A 5.7. for more information on ReadyFill at Mail.) 12

13 2. CVS CAREMARK QUESTIONS 2.9. How long will members be able to access Prime Therapeutics formulary and pharmacy search tools? How long will the MyPrime.com website be available? How long will members be able to submit 2014 claims to Prime Therapeutics? Prime Therapeutics 2014 formulary and pharmacy search tools will be turned off December 31, Members can enroll in MedicareBlue Rx plans until November 30, 2014, and use the current formulary and pharmacy search tools for 2014 drugs and pharmacies. Beginning October 1, 2014, formulary and pharmacy searches and drug cost calculations for 2015 will be done in a similar way but using new CVS Caremark tools on If members want to check the formulary or search for a pharmacy in 2015, they should use the 2015 tools that will be available on on October 1. Information about 2014 claims will be available on the MyPrime.com website for one year, until December 31, Members will be able to review their claims history for the past 12 months on the MyPrime.com website. There will be a link to MyPrime.com from throughout Members claims history for 2014 will not be transferred to the new Caremark.com website. While most claims are processed at the pharmacy in real time, members who need to submit claim forms for 2014 claims will be able to submit those claims for payment for three years (through the end of 2017). 13

14 3. PHARMACY NETWORK QUESTIONS 3.1. How does the change to CVS Caremark change the pharmacy network? 3.2. Are there any pharmacies that are currently in the network that will not be in the network for 2015? 3.3 Will members be notified if their current pharmacy will no longer be in the network for 2015? 3.4. Can members still get 90-day supplies at certain retail pharmacies? Nationwide, the pharmacy network will include about 4,000 more pharmacies, for a total of 68,000 pharmacies. All of the major pharmacy chains such as CVS/pharmacy, Walgreens, Wal-Mart, Target, and Costco are still in the network. Many local and regional pharmacies such as Hy-Vee, White Drug, Albertsons and Osco are also in the network. Almost all of the pharmacies that are currently in the network will continue to be in the network for There are fewer than 100 pharmacies that members have used recently that are not currently in the network. CVS Caremark is attempting to contract with those pharmacies to add them to the network. This process can take several months and we hope to have it completed by the end of The pharmacy directory members will receive this fall is current as of August 1, 2014 so there could be additional pharmacies in the network by January 1, For the most up-to-date information, always check the online pharmacy search tool or call the Broker Help Desk. Yes. If a pharmacy that a member has used in 2014 is no longer going to be in the network in 2015, the member will receive a notification letter with that information by November 1. Yes. Members will be able to get 90-day supplies at CVS/pharmacy locations and certain other pharmacies. Those pharmacies will be identified as EDS (extended day supply) in the pharmacy directory. 14

15 3. PHARMACY NETWORK QUESTIONS 3.5. What does it mean when a pharmacy offers preferred cost sharing or standard cost sharing within the network? All three MedicareBlue Rx plan options have the same overall pharmacy network of more than 68,000 pharmacies nationwide. For the MedicareBlue Rx Value Plus plan option only, within the participating pharmacy network, there are some pharmacies that offer preferred cost sharing. The plan has negotiated lower cost-sharing amounts for prescription drugs at these pharmacies. That means members will often pay less for prescription drugs when they fill them at a pharmacy that offers preferred cost sharing. Value Plus members can go to a pharmacy that offers standard cost sharing, which is still a network pharmacy, but they will often pay more for their prescription drugs. Pharmacies with preferred cost sharing for the Value Plus option: More than 1,600 in the 7-state region and more than 30,000 nationwide, including CVS/pharmacy, Wal-Mart, White Drug and Hy-Vee. A breakdown of preferred pharmacies by state as of 9/1/2014 is: o Iowa: 465 o Minnesota: 471 o Montana: 149 o Nebraska: 273 o North Dakota: 92 o South Dakota: 129 o Wyoming: 64 Pharmacies with standard cost sharing: All other network pharmacies. There are more than 3,200 in the 7-state region and more than 68,000 nationwide. Members who do not live near a pharmacy that offers preferred cost sharing can take advantage of the preferred pricing by filling prescriptions through the plan s mail order service. (Note: See section 5. Mail Order for more information on mail order.) Note: Preferred and standard cost sharing is new terminology this year from the Centers for Medicare & Medicaid Services (CMS) to describe plans with preferred pharmacies in their networks. You will see those terms in all pre-enrollment and member materials. Following is the complete list of preferred pharmacies (for the Value Plus plan option): 15

16 3. PHARMACY NETWORK QUESTIONS CVS/pharmacy AccessHealth SuperValu/Albertsons Wal-Mart Thrifty White Hy-Vee Good Neighbor LeaderNet APNS PPOK Medicine Shoppe/Medicap Kinney Drugs Discount Drug Mart Bartell Drug Navarro Discount Pharmacies Kroger 3.6. Why does only the Value Plus plan option have preferred pharmacies? 3.7. How do members access the national network when traveling? Offering preferred cost sharing at certain pharmacies is one way to manage prescription drug costs. It allows members who have convenient access to preferred pharmacies to choose a less expensive plan option. Preferred pharmacies were included in the Value Plus option as part of the design and pricing process as this new plan was being developed. It s possible that preferred pharmacies could be added to the other two plan options in the future. However, premiums and cost sharing would need to be reviewed for those options before making this change. Members can locate a network pharmacy anywhere in the U.S. by calling Customer Service. They can fill prescriptions at any network pharmacy nationwide by showing their ID card. 16

17 4. FORMULARY QUESTIONS 4.1. How is the formulary changing for 2015? 4.2. Do all three plan options have the same formulary? 4.3. Why are there two different formularies this year? 4.4. How are the two formularies different? 4.5. If there is a formulary change related to a drug a current member is taking, will the member be notified? The formulary is a list of all covered drugs. The formulary changes each year as new drugs become available, as generic versions of brand-name drugs become available, as different drugs become recognized as the recommended treatment for a condition, or as drugs are recalled. Even though there are new formularies this year because of the change to CVS Caremark, the number of changes for 2015 is similar to the amount of changes that typically happen from one year to the next. No. The Value Plus and Premier plan options have the same formulary. The Standard plan option has a different formulary that includes fewer drugs than the formulary for the other two plan options. The Standard plan option has a different formulary with fewer drugs than the other two plan options. Having a smaller formulary is one way to help manage costs within a plan. Having two formularies allows members to choose the plan that best meets their needs based on the drugs they currently take. The formulary for the Value Plus and Premier plan options includes generic drugs in Tiers 1 and 2, brandname drugs in Tiers 3 and 4 and both generic and brand-name drugs in Tier 5. The Standard plan option has a different formulary that includes drugs to treat all types of conditions, but includes fewer drugs of each type. The Standard formulary has generic drugs in Tier 1 and both generic and brand-name drugs in Tiers 2 through 5. Members who are taking a drug that is being removed from the 2015 formulary or who take a drug with new utilization review requirements for 2015 will receive a letter explaining the change in November. We ll provide more details about these mailings in Agent/Broker Alerts this fall. 17

18 4. FORMULARY QUESTIONS 4.6. How is the formulary organized? What do the different drug tiers mean? 4.7. Will drugs be on the same tiers for 2015, except for drugs that have moved to the new Specialty tier? 4.8. How are Specialty drugs covered in 2015? The formulary for each MedicareBlue Rx plan option includes prescription drugs believed to be part of a quality treatment program. MedicareBlue Rx will generally cover the drugs listed in the plans formularies as long as the drug is medically necessary, the prescription is filled at a network pharmacy and other plan rules are followed. The drugs on the plan s formulary are organized into tiers. The current four tiers will continue and there is a new Tier 5 for Specialty drugs. Specialty drugs include expensive drugs taken by a small number of people to treat rare conditions. Each tier has a different costsharing amount in the form of either a copay or coinsurance. The cost-sharing amount depends on which tier the drug is on. Tier 1: Preferred Generic drugs Tier 2: Non-Preferred Generic drugs Tier 3: Preferred Brand drugs Tier 4: Non-Preferred Brand drugs Tier 5: Specialty drugs Formularies change every year. Drugs move from one tier to another, new drugs are added and drugs are removed if generics become available or new drugs are recommended to treat specific conditions. Some drugs are moving to different tiers for For some drugs, this will result in lower costs, while for others it may result in a cost increase. Members should review the 2015 formulary once they receive it to confirm the amount they will pay for their drugs in Specialty drugs are covered in a new Tier 5 for Members will pay coinsurance for Specialty drugs. 18

19 4. FORMULARY QUESTIONS 4.9. If I have members whose drugs are not on the formulary or are in a different tier, and they choose to switch plans in 2015, what do they need to do? If a member switches to a different option within MedicareBlue Rx, any formulary exceptions or drug utilization requirements (prior authorization, quantity limit exceptions and step therapy) met in 2014 will carry over for There is nothing the member needs to do as long as the exception or prior authorization does not expire in If the prior authorization expires in 2014, the member must continue to work with Prime to get it approved. If it expires in 2015, they can get refills up to the expiration date and then will need to go through the process with CVS Caremark. New members who are enrolling in MedicareBlue Rx for the first time, or current members affected by 2015 formulary changes, can submit coverage determinations for exception, prior authorization or other utilization management requests for 2015 starting on December 1, Members can request a coverage determination so that the drug may be covered by their plan beginning January 1,

20 4. FORMULARY QUESTIONS What process do members need to follow to submit requests for prior authorization or exceptions? Either a member or a doctor can submit an exception request, although if the member submits the request, a doctor s statement will most likely be required as well. The doctor must submit a statement indicating that the exception is necessary because none of the drugs on the formulary would be as effective in treating the member s condition or because taking a different drug would have adverse effects for the member. If the exception involves a prior authorization, quantity limit or other limit we have placed on a drug, the doctor s statement must indicate that the prior authorization or limit would not be as effective for treating the condition or would have adverse effects for the member. There are several ways to submit an exception request to CVS Caremark in 2015: Call CVS Caremark at Representatives are available seven days a week, 24/7. TTY users call Fax the request to Physician fax forms are available at or can be requested by phone. Mail the request to this address: CVS Caremark P.O. Box 52000, MC109 Phoenix, AZ Members who need to request an exception during the remainder of 2014 should use this information: Call MedicareBlue Rx Customer Service at Representatives are available seven days a week, from 8 a.m. to 8 p.m., Central and Mountain Times. TTY users call 711. Fax the request to Physician fax forms are available at or can be requested by phone. Mail the request to this address: MedicareBlue Rx Attn: Appeals Department 1305 Corporate Center Dr. Eagan, MN

21 4. FORMULARY QUESTIONS If a member is currently taking a drug that has some type of exception that has already been approved (formulary, prior authorization, step therapy, quantity limit), will the member need to request the exception again from CVS Caremark? If a member is currently taking a drug that has some type of exception (formulary, prior authorization, step therapy, quantity limit), will the member be able to continue taking their current drug while they complete any new approval processes required by CVS Caremark? If a member has already completed the step therapy process to get coverage for a drug, will they need to repeat that process? If a member currently has approval for a drug that requires prior authorization, will they need to complete that process again? If a member currently has a quantity limit exception will they need to submit a new request for that exception? Exceptions are granted for a certain period of time. If the exception doesn t expire until 2015 or later, members can refill their prescriptions up to the expiration date. After that, they will need to complete a new exception request process with CVS Caremark. Any refills remaining on December 31, 2014 for drugs with exceptions will transfer over to CVS Caremark, so members will be able to continue filling those prescriptions in If a member s exception expires between now and the end of 2014, and the member needs a refill, they must work with Prime Therapeutics as they do today to get the exception approved. Yes. In general, previously approved coverage determinations (exception requests) that are not expiring in 2014 will carry over to the new PBM, CVS Caremark. All current members will be eligible for a 30-day transition supply of their current drug during their first 90 days of enrollment while they talk to their doctor to get a new prescription for a covered drug or submit a request for an exception. Network pharmacies will know as of January 1, 2015, whether the person is a member of MedicareBlue Rx and whether there are any restrictions on their prescriptions. The member would only need to repeat the process if their prior authorization expires in In this case, they would need to continue to work with Prime to get approval. If it expires in 2015, they would need to complete the process with CVS Caremark. The member would only need to repeat the process if their prior authorization expires in In this case, they would need to continue to work with Prime to get approval. If it expires in 2015, they would need to complete the process with CVS Caremark. The member would only need to repeat the process if their prior authorization expires in In this case, they would need to continue to work with Prime to get approval. If it expires in 2015, they would need to complete the process with CVS Caremark. 21

22 5. MAIL ORDER QUESTIONS 5.1. How is mail order changing for 2015? 5.2. How does the mail order program work? 5.3. What will the cost for 90-day supplies ordered by mail be in 2015? 5.4. If someone is currently filling prescriptions by mail, what do they need to do to switch their mail order prescriptions to CVS Caremark? 5.5. How can a member begin filling prescriptions by mail through CVS Caremark? Mail order services will be provided by CVS Caremark Mail Order Pharmacy rather than Prim *** or Walgreens Mail Service. *** Prim is a mail-service pharmacy owned and operated by Prime Therapeutics, LLC, an independent company providing pharmacy benefit management services. Purchasing drugs by mail can help MedicareBlue Rx members save time and money when they order 90-day extended supplies of maintenance medications. The drugs are usually delivered to their home within days after they order. Prescriptions are available by mail through CVS Caremark Mail Order Pharmacy. Members will receive information on the mail order service in their Welcome Kit when they enroll in the plan. The CVS Caremark Mail Order Pharmacy phone number and website are included in the pharmacy directory. More information can also be found online at For all three plan options, the cost of 90-day supplies by mail will be two times the 30-day copay or the coinsurance percentage. Members will need to call CVS Caremark to set up an account and provide consent to have mail order continue. It will not be automatic. Any prescriptions from members currently using Prim with refills remaining will transfer to CVS Caremark. Walgreens mail order prescriptions are not transferring to CVS Caremark and any members using that service will need to get new prescriptions and submit them to CVS Caremark using a new mail order form. However, the prescriptions cannot be filled until the member calls to set up a mail order account with CVS Caremark that includes address and payment information. Members can call CVS Caremark at any time after December 18, 2014, to set up an account. (Note: See Q&A 5.6. for information on setting up an online account.) Members will need to call CVS Caremark to set up a mail order account. They can call CVS Caremark at any time after December 18, 2014 to set up an account. Once that is done, either the member or his/her doctor can submit a prescription to be filled. 22

23 5. MAIL ORDER QUESTIONS 5.6. Can members order refills online? 5.7. What is ReadyFill at Mail and how does it work? Yes. The online ordering process is moving to CVS Caremark. Members will be able to go to and create an account after January 1, Once in their account, members can order refills or check the status of a current mail order. Mail order forms will be available on and While on the site, members can also sign up for ReadyFill at Mail. ReadyFill at Mail is an automatic mail order refill service offered by CVS Caremark. Members can sign up to have their mail order prescriptions automatically refilled every three months. Members can choose which prescriptions they want ReadyFill to apply to and can add or drop this service at any time. Members participating in ReadyFill will receive a call or message prior to each shipment. They will need to confirm the order and verify that they still want the prescription before it is billed and shipped. 23

24 6. GENERAL QUESTIONS ABOUT LOW-INCOME SUBSIDIES (LIS) 6.1. How does CMS determine the benchmark plans? 6.2. Which plans are the benchmark plans? 6.3. Can you explain what communications CMS sends to LIS beneficiaries and when they will be mailed? Every year, Medicare receives bids from participating Medicare Part D plans for the coming year. From this information, they finalize premiums and set threshold pricing for plans called a benchmark. Some Part D plans fall above the benchmark and some fall below. Generally, Medicare beneficiaries who receive Extra Help (subsidies) for their prescription drug coverage will pay the least amount by enrolling in a benchmark plan. In 2015, MedicareBlue Rx is not a benchmark plan. The national base beneficiary premium for 2015 is $33.13 and the regional benchmark amount for 2015 is $ Check for a listing of Medicare Part D plan sponsors that are benchmark plans in Every fall, CMS reviews eligibility for LIS and notifies a beneficiary if their Extra Help will continue or change, or if they no longer qualify. In addition, CMS reassigns autoassigned LIS beneficiaries with 100 percent premium subsidy to a different PDP if their plan is terminating, increasing above the LIS benchmark premium, or converting to an enhanced benefit plan. Here s a list of the mailings and when they are received by the beneficiary. Early September SSA mails re-determination letters to certain LIS applicants. Mid-September GREY LETTER mailed to those losing deemed status. Mid-October ORANGE LETTER mailed to those deemed for LIS for next year, but copayment will change. Late October BLUE REASSIGNMENT LETTER mailed to those receiving 100 percent subsidies being reassigned to a new LIS benchmark plan. Early November TAN CHOOSERS letter mailed to LIS members that voluntarily enrolled in a plan that is no longer a benchmark plan; makes beneficiary aware of who the new LIS benchmark plans are. Since MedicareBlue Rx Standard is not a benchmark plan in 2015, the mailings will not affect our current LIS membership and eligible beneficiaries will not be autoenrolled in the plan. Current LIS members who chose to belong to the plan will continue in the plan unless they choose a different one this fall. They will pay the 24

25 6. GENERAL QUESTIONS ABOUT LOW-INCOME SUBSIDIES (LIS) difference between the benchmark amount and the plan s premium. (Note: See Q&A 6.4., next for more on this.) 6.4. Can an individual enroll in any MedicareBlue Rx plan option if they qualify for Extra Help (low-income subsidies) for prescription drug costs? Yes. Individuals eligible for Extra Help can enroll in any of our prescription drug options, but none of the MedicareBlue Rx plan options are benchmark plans for MedicareBlue Rx Value Plus, Standard and Premier premiums are above the benchmark amount which means LIS members who enroll in any of these plan options will pay the difference between the subsidy and the plan s premium. Members with LIS should not enroll in Premier since they would pay a higher premium for the same benefits they would get by enrolling in Standard. To see what the premium will be based on the amount of Extra Help the member is receiving, refer to the 2015 LIS low-income subsidy table at the end of this document. Note: Although MedicareBlue Rx Value Plus is close to the benchmark premium, it is considered by CMS to be an enhanced plan and therefore will always have a premium, even for LIS individuals. Again, refer to the LIS table at the end of this document to check LIS-related premium amounts Can you explain the Special Enrollment Periods (SEP) that apply to individuals eligible for the LIS? Individuals who qualify for Extra Help with prescription drug costs have a continuous SEP; they may enroll in, disenroll from, or change plan options month to month. If they lose this Extra Help during the year, the opportunity to make a change continues for two months after they are notified that they no longer qualify for Extra Help. If they begin getting Extra Help or the amount of the Extra Help changes, they can change plan options if they are currently enrolled in MedicareBlue Rx. If they are not enrolled, they become eligible to enroll at that time. 25

26 6. GENERAL QUESTIONS ABOUT LOW-INCOME SUBSIDIES (LIS) 6.6. How does Extra Help work? People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75 percent or more of drug costs including monthly prescription drug plan premiums, annual deductibles, copays and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Individuals who qualify for Extra Help with prescription drug costs may enroll in, or disenroll from, a plan at any time. If they lose their Extra Help during the year, the opportunity to make a change continues for two months after they are notified that they no longer qualify for Extra Help. Individuals who are eligible for Extra Help who don t enroll in a prescription drug plan are automatically enrolled in a benchmark prescription drug plan by Medicare. A benchmark plan is a plan that has a monthly plan premium that is below a benchmark amount determined each year by Medicare. Low income individuals enrolled in benchmark plans pay no monthly plan premiums. If a plan s premium increases above the benchmark amount, Medicare will automatically reassign autoassigned individuals who are eligible for Extra Help to a new prescription drug plan available in their area so that they can continue to have no monthly plan premiums. 26

27 6. GENERAL QUESTIONS ABOUT LOW-INCOME SUBSIDIES (LIS) 6.7. What happens if a member no longer qualifies for Extra Help (low income subsidies)? What are their options? 6.8. What are the plan premiums, deductibles and cost-sharing amounts for those qualifying for LIS for each MedicareBlue Rx plan option? Individuals qualify for Extra Help in a variety of ways. They are automatically eligible for Extra Help if they qualify for Medicaid, get help from the state to pay their Medicare Part A or Part B plan premiums or receive Supplemental Security Income (SSI) benefits. If an individual no longer meets one of these requirements, their Extra Help will end unless they apply and qualify again based on their income and assets. If an individual needs to apply, they must provide information about their income and assets each year. If they don t provide the required information or don t meet the eligibility requirements, their Extra Help may be reduced or discontinued. For questions about Extra Help (low-income subsidies) for prescription drug costs, or if an individual needs assistance completing the application, they can: Call the Social Security Administration (SSA) at (TTY users call ) between 7 a.m. and 7 p.m. Monday through Friday. Or, fill out the application online at under the Medicare link. Or, complete the paper application included with the letter they received from Medicare. To get another copy of the application by mail, call MEDICARE ( ). TTY users call Call a State Health Insurance Program (SHIP) local office for free personalized health insurance counseling. See Medicare & You handbook or call MEDICARE ( ) for their telephone number. If a member loses their eligibility for Extra Help, they will have a Special Enrollment Period during which they can switch to a different plan. (Note: For more information, see Q&A 6.5.) LIS rates can be obtained from your local Plan or by calling MedicareBlue Rx Customer Service for assistance as rates are based upon the level of Extra Help a lowincome beneficiary receives. Call Representatives are available seven days a week, from 8 a.m. to 8 p.m., Central and Mountain times. TTY users call 711. The rates are also in the 2015 LIS low-income subsidy table at the end of this document. 27

28 6. GENERAL QUESTIONS ABOUT LOW-INCOME SUBSIDIES (LIS) 6.9. Since we do not have a benchmark premium option, does that mean that no LISqualified members can enroll? Or does it mean that there will not be an option with a premium of zero? Individuals eligible for Extra Help can enroll in any of our MedicareBlue Rx prescription drug options, but it is important that they understand their financial liability for each plan. For additional information about LIS premiums, see Q&A LIS members should call Customer Service at for MedicareBlue Rx to evaluate their personal situation. Representatives are available seven days a week, from 8 a.m. to 8 p.m., Central and Mountain Times. TTY hearing impaired users should call 711. Members may also work with their local SHIP counselors who will be able to help them compare benchmark plans for See the 2015 Senior Health Insurance Plan Information by State list at the end of this document to find your local SHIP. 28