Your Medicare Prescription Drug Coverage as a Member of HealthSelect Medicare Rx provided through Employees Retirement System of Texas (ERS)

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1 P.O Bx 52424, Phenix, AZ January 1, 2015 December 31, 2015 Evidence f Cverage: Yur Medicare Prescriptin Drug Cverage as a Member f HealthSelect Medicare Rx prvided thrugh Emplyees Retirement System f Texas (ERS) This bklet gives yu the details abut yur Medicare prescriptin drug cverage frm January 1, 2015 December 31, It explains hw t get cverage fr the prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. This plan, prvided thrugh ERS, is managed by SilverScript Insurance Cmpany. (When this Evidence f Cverage says we, us, r ur, it means SilverScript Insurance Cmpany. When it says plan r ur plan, it means HealthSelect Medicare Rx.) HealthSelect Medicare Rx is an Emplyer Prescriptin Drug Plan prvided by ERS and administered by SilverScript Insurance Cmpany. This plan is ffered by SilverScript Insurance Cmpany, which has a cntract with Medicare. Enrllment in HealthSelect Medicare Rx depends n SilverScript Insurance Cmpany s cntract renewal with Medicare. This infrmatin is available fr free in ther languages. Please cntact ur SilverScript Custmer Care number tll free at (855) (TTY 711) fr additinal infrmatin. Hurs are 24 hurs a day, 7 days a week. SilverScript Custmer Care als has free language interpreter services available fr nn-english speakers. Esta infrmación está dispnible gratuitamente en trs idimas. Cmuníquese cn nuestr Servici al Miembr, al (855) (TTY 711) para btener infrmación adicinal. Estams dispnibles las 24 hras del dia, ls 7 dias de la semana. El Servici al Miembr también tiene servicis gratuits de interpretación dispnibles para persnas que n hablan inglés. This infrmatin is available in different frmats, including Braille, large print and audi frmats. Please call SilverScript Custmer Care if yu need plan infrmatin in anther frmat. SilverScript benefits, premium (if yu are paying a prtin f the premium), deductible, and/r cpays may change n January 1, The SilverScript frmulary and pharmacy netwrk may change during the plan year. Yu will receive advance ntice f any frmulary changes that wuld result in a higher cst. If yu are receiving Extra Help frm Medicare, yu will be ntified f any changes t yur Lw Incme Subsidy Status that affect yur cpays. Y0080_52002_EOC_CLT.ERS_2015_9476_2570_801 Frm CMS ANOC/EOC OMB Apprval (Apprved 03/2014)

2 Table f Cntents 2015 Evidence f Cverage Table f Cntents This list f chapters and page numbers is yur starting pint. Fr mre help in finding infrmatin yu need, g t the first page f a chapter. Yu will find a detailed list f tpics at the beginning f each chapter. Chapter 1. Getting started as a member... 1 Explains what it means t be in the HealthSelect Medicare Rx prescriptin drug plan and hw t use this bklet. Tells abut materials we will send yu, yur plan premium, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces Tells yu hw t get in tuch with ur plan (HealthSelect Medicare Rx) and with ther rganizatins, including Medicare, the State Health Insurance Assistance Prgram (SHIP), the Quality Imprvement Organizatin, Scial Security, Medicaid (the state health insurance prgram fr peple with lw incmes), prgrams that help peple pay fr their prescriptin drugs, and the Railrad Retirement Bard. Chapter 3. Using the plan s cverage fr yur Part D prescriptin drugs Explains rules yu need t fllw when yu get yur Part D drugs. Tells hw t use the plan s List f Cvered Drugs (Frmulary) t find ut which drugs are cvered. Tells which kinds f drugs are nt cvered. Explains several kinds f restrictins that apply t yur cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins. Chapter 4. What yu pay fr yur Part D prescriptin drugs Tells abut the fur stages f drug cverage (Deductible Stage, Initial Cverage Perid, Cverage Gap Stage, Catastrphic Cverage Stage MOOP Stage) and hw these stages affect what yu pay fr yur drugs. Explains the three cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr cpay as yur share f the cst fr a drug in each cstsharing tier. Tells abut the late enrllment penalty. Chapter 5. Asking the plan t pay its share f the csts fr cvered drugs Explains when and hw t send a bill t HealthSelect Medicare Rx when yu want t ask the plan t pay yu back fr its share f the cst fr yur cvered drugs.

3 Table f Cntents Chapter 6. Yur rights and respnsibilities Explains the rights and respnsibilities yu have as a member f ur plan. Tells what yu can d if yu think yur rights are nt being respected. Chapter 7. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Tells yu step-by-step what t d if yu are having prblems r cncerns as a member f ur plan. Explains hw t ask fr cverage decisins and make appeals if yu are having truble getting the prescriptin drugs yu think are cvered by ur plan. This includes asking us t make exceptins t the rules and/r extra restrictins n yur cverage. Explains hw t make cmplaints abut quality f care, waiting times, custmer service, and ther cncerns. Chapter 8. Ending yur membership in the plan Explains when and hw yu can end yur membership in the plan. Explains situatins in which the plan is required t end yur membership. Chapter 9. Legal ntices Includes ntices abut gverning law and abut nn-discriminatin. Chapter 10. Definitins f imprtant wrds Explains key terms used in this bklet.

4 Chapter 1: Getting started as a member 1 Chapter 1. Getting started as a member SECTION 1 Intrductin... 3 Sectin 1.1 Yu are enrlled in HealthSelect Medicare Rx, which is a Medicare Prescriptin Drug Plan. 3 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 3 Sectin 1.3 What des this Chapter tell yu?... 3 Sectin 1.4 What if yu are new t HealthSelect Medicare Rx?... 3 Sectin 1.5 Legal infrmatin abut the Evidence f Cverage 4 SECTION 2 What makes yu eligible t be a plan member?... 4 Sectin 2.1 Yur eligibility requirements 4 Sectin 2.2 What are Medicare Part A and Medicare Part B?... 4 Sectin 2.3 Here is the plan service area fr HealthSelect Medicare Rx. 5 SECTION 3 What ther materials will yu get frm us?... 5 Sectin 3.1 Yur plan membership card Use it t get all cvered prescriptin drugs 5 Sectin 3.2 The Pharmacy Directry: Yur guide t pharmacies in ur netwrk 6 Sectin 3.3 The plan s List f Cvered Drugs (Frmulary). 6 Sectin 3.4 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs.. 6 SECTION 4 Yur mnthly premium fr HealthSelect Medicare Rx... 7 Sectin 4.1 Hw much is yur plan premium?... 7 Sectin 4.2 Can we change yur mnthly plan premium during the year?... 8 SECTION 5 Please keep yur plan membership recrd up t date... 8 Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu 8 SECTION 6 We prtect the privacy f yur persnal health infrmatin... 9 Sectin 6.1 We make sure that yur health infrmatin is prtected 9

5 Chapter 1: Getting started as a member 2 SECTION 7 Hw ther insurance wrks with ur plan Sectin 7.1 Which plan pays first when yu have ther insurance?... 10

6 Chapter 1: Getting started as a member 3 SECTION 1 Sectin 1.1 Intrductin Yu are enrlled in HealthSelect Medicare Rx, which is a Medicare Prescriptin Drug Plan Yu are cvered by Medicare fr yur health care cverage, either thrugh Original Medicare r thrugh a Medicare Advantage plan, and yu have chsen t get yur Medicare prescriptin drug cverage thrugh ur plan, HealthSelect Medicare Rx. There are different types f Medicare plans. HealthSelect Medicare Rx is a Medicare prescriptin drug plan (PDP). Like all Medicare plans, this Medicare prescriptin drug plan is apprved by Medicare and run by a private cmpany. Sectin 1.2 What is the Evidence f Cverage bklet abut? This Evidence f Cverage bklet tells yu hw t get yur Medicare prescriptin drug cverage thrugh ur plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the plan. This plan, HealthSelect Medicare Rx prvided thrugh ERS, is ffered by SilverScript Insurance Cmpany. (When this Evidence f Cverage says we, us, r ur, it means SilverScript Insurance Cmpany. When it says plan r ur plan, it means HealthSelect Medicare Rx.) The wrd cverage and cvered drugs refers t the prescriptin drug cverage available t yu as a member f HealthSelect Medicare Rx. Sectin 1.3 What des this Chapter tell yu? Lk thrugh Chapter 1 f this Evidence f Cverage t learn: What makes yu eligible t be a plan member? What is yur plan s service area? What materials will yu get frm us? What is yur plan premium and hw can yu pay it? Hw d yu keep the infrmatin in yur membership recrd up t date? Sectin 1.4 What if yu are new t HealthSelect Medicare Rx? If yu are a new member, then it s imprtant fr yu t learn what the plan s rules are and what cverage is available t yu. We encurage yu t set aside sme time t lk thrugh this Evidence f Cverage bklet. If yu are cnfused r cncerned r just have a questin, please cntact SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet).

7 Chapter 1: Getting started as a member 4 Sectin 1.5 Legal infrmatin abut the Evidence f Cverage It s part f ur cntract with yu This Evidence f Cverage is part f ur cntract with yu abut hw HealthSelect Medicare Rx cvers yur care. Other parts f this cntract include the List f Cvered Drugs (Frmulary), and any ntices yu receive frm us abut changes t yur cverage r cnditins that affect yur cverage. These ntices are smetimes called riders r amendments. The cntract is in effect fr the mnths in which yu are enrlled in HealthSelect Medicare Rx between January 1, 2015 and December 31, Each year, Medicare allws us t make changes t the plans that we ffer. This means we can change the csts and benefits f HealthSelect Medicare Rx after December 31, We can als chse t stp ffering the plan, r t ffer it in a different service area, after December 31, Medicare must apprve ur plan each year Medicare (the Centers fr Medicare & Medicaid Services) must apprve HealthSelect Medicare Rx each year. Yu can cntinue t get Medicare cverage as a member f ur plan as lng as we chse t cntinue t ffer the plan and Medicare renews its apprval f the plan. SECTION 2 Sectin 2.1 What makes yu eligible t be a plan member? Yur eligibility requirements Yu are eligible fr membership in ur plan as lng as: ERS has determined that yu are eligible fr this plan Yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu have Medicare Part A r Medicare Part B (r yu have bth Part A and Part B) Sectin 2.2 What are Medicare Part A and Medicare Part B? When yu first signed up fr Medicare, yu received infrmatin abut what services are cvered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cver services prvided by hspitals (fr inpatient services, skilled nursing facilities r hme health agencies). Medicare Part B is fr mst ther medical services (such as physician s services and ther utpatient services) and certain items (such as durable medical equipment and supplies).

8 Chapter 1: Getting started as a member 5 Sectin 2.3 Here is the plan service area fr HealthSelect Medicare Rx Althugh Medicare is a Federal prgram, HealthSelect Medicare Rx is available nly t individuals wh live in ur plan service area. T remain a member f ur plan, yu must live in the United States and its territries. Please nte: If yu use a Pst Office Bx, yu will need t prvide prf that yu live in ur service area. If yu plan t mve ut f the service area, please cntact SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). When yu mve, yu will have a Special Enrllment Perid that will allw yu t enrll in a Medicare health r drug plan that is available in yur new lcatin. It is als imprtant that yu call Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. SECTION 3 Sectin 3.1 What ther materials will yu get frm us? Yur plan membership card Use it t get all cvered prescriptin drugs While yu are a member f ur plan, yu must use yur membership card fr ur plan fr prescriptin drugs yu get at netwrk pharmacies. Here s a sample membership card t shw yu what yurs will lk like: Please carry yur card with yu at all times and remember t shw yur card when yu get cvered drugs. If yur plan membership card is damaged, lst, r stlen, call SilverScript Custmer Care right away and we will send yu a new card. (Phne numbers fr SilverScript Custmer Care are printed n the back cver f this bklet.) Yu may need t use yur existing medical r yur red, white, and blue Medicare card t get cvered medical care and services under Original Medicare.

9 Chapter 1: Getting started as a member 6 Sectin 3.2 The Pharmacy Directry: Yur guide t pharmacies in ur netwrk What are netwrk pharmacies? Our Pharmacy Directry gives yu a cmplete list f ur netwrk pharmacies that means all f the pharmacies that have agreed t fill cvered prescriptins fr ur plan members. Why d yu need t knw abut netwrk pharmacies? Yu can use the Pharmacy Directry t find the netwrk pharmacy yu want t use. Yu shuld use a netwrk pharmacy t receive plan benefits. Yur cst may be greater if yu use an ut-fnetwrk pharmacy t fill yur prescriptins. If yu dn t have the Pharmacy Directry, yu can get a cpy frm SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). At any time, yu can call SilverScript Custmer Care t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur website at Sectin 3.3 The plan s List f Cvered Drugs (Frmulary) The plan has a List f Cvered Drugs (Frmulary). We call it the Drug List fr shrt. It tells which Part D prescriptin drugs are cvered by HealthSelect Medicare Rx. The drugs n this list are selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the HealthSelect Medicare Rx Drug List. The Drug List als tells yu if there are any rules that restrict cverage fr yur drugs. We will send yu a cpy f the Drug List. The Drug List we send t yu includes infrmatin fr the cvered drugs that are mst cmmnly used by ur members. Hwever, we cver additinal drugs that are nt included in the printed Drug List. If ne f yur drugs is nt listed in the Drug List, yu shuld visit ur website r cntact SilverScript Custmer Care t find ut if we cver it. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website ( r call SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). Sectin 3.4 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs When yu use yur Part D prescriptin drug benefits, we will send yu a summary reprt t help yu understand and keep track f payments fr yur Part D prescriptin drugs. This summary reprt is called the Part D Explanatin f Benefits (r the Part D EOB ). The Part D Explanatin f Benefits tells yu the ttal amunt yu, r thers n yur behalf, have spent n yur Part D prescriptin drugs and the ttal amunt we have paid fr each f yur Part D prescriptin drugs during the mnth. Chapter 4 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Part D Explanatin f Benefits and hw it can help yu keep track f yur drug cverage.

10 Chapter 1: Getting started as a member 7 A Part D Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). SECTION 4 Yur mnthly premium fr HealthSelect Medicare Rx Sectin 4.1 Hw much is yur plan premium? Please cntact ERS fr mre infrmatin abut the premium fr this plan. In additin, yu must cntinue t pay yur Medicare Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). If yu pay a premium, 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. Chapter 2, Sectin 7 tells mre abut these prgrams. If yu qualify, enrlling in the prgram might lwer yur mnthly plan premium, if yu pay a prtin f yur premium. If yu are already enrlled in Extra Help and getting help frm ne f these prgrams the infrmatin abut premiums in this Evidence f Cverage may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call SilverScript Custmer Care and ask fr the LIS Rider. (Phne numbers fr SilverScript Custmer Care are printed n the back cver f this bklet.) If yu pay a premium, in sme situatins, yur plan premium culd be mre In sme situatins, yur plan premium culd be mre than the amunt listed. These situatins are described belw. 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. In that case, their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. ERS has elected t pay fr yur late enrllment penalty n yur plan. Hwever, if yu jin anther plan yur late enrllment penalty may nt be cvered and yu may be respnsible fr paying yur late enrllment penalty. Many members are required t pay ther Medicare premiums In additin t paying the mnthly plan premium, many members are required t pay ther Medicare premiums. Sme plan members (thse wh aren t eligible fr premium-free Part A) pay a premium fr Medicare Part A. And mst plan members pay a premium fr Medicare Part B.

11 Chapter 1: Getting started as a member 8 Sme peple pay an extra amunt fr Part D because f their yearly incme, this is knwn as Incme Related Mnthly Adjustment Amunts, als knwn as IRMAA. If yur incme is $85,000 r abve fr an individual (r married individuals filing separately) r $170,000 r abve fr married cuples, yu must pay an extra amunt directly t the gvernment (nt the Medicare plan) 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 the plan and lse prescriptin drug cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be. Fr mre infrmatin abut Part D premiums based n incme, g t Chapter 4, Sectin 10 f this bklet. Yu can als visit n the web r call (800) MEDICARE ((800) ), 24 hurs a day, 7 days a week. TTY users shuld call (877) Or yu may call Scial Security at (800) , 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call (800) Yur cpy f Medicare & Yu 2015 gives infrmatin abut the Medicare premiums in the sectin called 2015 Medicare Csts. This explains hw the Medicare Part B and Part D premiums differ fr peple with different incmes. Everyne with Medicare receives a cpy f Medicare & Yu 2015 each year in the fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy f Medicare & Yu 2015 frm the Medicare website ( Or, yu can rder a printed cpy by phne at (800) MEDICARE ((800) ), 24 hurs a day, 7 days a week. TTY users call (877) Sectin 4.2 Can we change yur mnthly plan premium during the year? N. We are nt allwed t change the amunt we charge fr the plan s mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu at least 15 days prir t January 1. ERS establishes the base premium rate. Hwever, in sme cases the part f the premium that yu have t pay (if yu are paying any prtin f yur premium) can change during the year. This happens if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year. If a member qualifies fr Extra Help with their prescriptin drug csts, the Extra Help prgram will pay part f the member s mnthly plan premium. S a member wh becmes eligible fr Extra Help during the year wuld begin t pay less twards their mnthly premium. And a member wh lses their eligibility during the year will need t start paying their full mnthly premium, if applicable. Yu can find ut mre abut the Extra Help prgram in Chapter 2, Sectin 7. SECTION 5 Sectin 5.1 Please keep yur plan membership recrd up t date Hw t help make sure that we have accurate infrmatin abut yu Yur membership recrd has infrmatin frm ERS enrllment file, including yur address and telephne number. It shws yur specific plan cverage.

12 Chapter 1: Getting started as a member 9 The pharmacists in the plan s netwrk need t have crrect infrmatin abut yu. These netwrk prviders use yur membership recrd t knw what drugs are cvered and the cst-sharing amunts fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. Let us knw abut these changes: Changes t yur name, yur address, r yur phne number Changes in any ther medical r drug insurance cverage yu have (such as frm yur emplyer, yur spuse s emplyer, wrkers cmpensatin, r Medicaid) If yu have any liability claims, such as claims frm an autmbile accident If yu have been admitted t a nursing hme If yur designated respnsible party (such as a caregiver) changes If any f this infrmatin changes, please let us knw by calling SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). It is als imprtant t cntact Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. Read ver the infrmatin we send yu abut any ther insurance cverage yu have Medicare requires that we cllect infrmatin frm yu abut any ther medical r drug insurance cverage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. (Fr mre infrmatin abut hw ur cverage wrks when yu have ther insurance, see Sectin 7 in this chapter.) Once each year, we will send yu a letter that lists any ther medical r drug insurance cverage that we knw abut. Please read ver this infrmatin carefully. If it is crrect, yu dn t need t d anything. If the infrmatin is incrrect, r if yu have ther cverage that is nt listed, please call SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). SECTION 6 Sectin 6.1 We prtect the privacy f yur persnal health infrmatin We make sure that yur health infrmatin is prtected Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Fr mre infrmatin abut hw we prtect yur persnal health infrmatin, please g t Chapter 6, Sectin 1.4 f this bklet.

13 Chapter 1: Getting started as a member 10 SECTION 7 Sectin 7.1 Hw ther insurance wrks with ur plan Which plan pays first when yu have ther insurance? When yu have ther insurance (like ther emplyer grup health cverage), there are rules set by Medicare that decide whether ur plan r yur ther insurance pays first. The insurance that pays first is called the primary payer and pays up t the limits f its cverage. The ne that pays secnd, called the secndary payer, nly pays if there are csts left uncvered by the primary cverage. The secndary payer may nt pay all f the uncvered csts. These rules apply fr emplyer grup health plan cverage: If yu have retiree cverage, Medicare pays first. If yur grup health plan cverage is based n yur r a family member s current emplyment, wh pays first depends n yur age, the number f peple emplyed by yur emplyer, and whether yu have Medicare based n age, disability, r End-Stage Renal Disease (ESRD): If yu re under 65 and disabled and yu r yur family member is still wrking, yur plan pays first if the emplyer has 100 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 100 emplyees. If yu re ver 65 and yu r yur spuse is still wrking, the plan pays first if the emplyer has 20 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 20 emplyees. 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 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. If yu have questins abut wh pays first, r yu need t update yur ther insurance infrmatin, call SilverScript Custmer Care (phne numbers are printed n the back cver f this bklet). 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.

14 Chapter 2: Imprtant phne numbers and resurces 11 Chapter 2. Imprtant phne numbers and resurces SECTION 1 SECTION 2 SECTION 3 SECTION 4 HealthSelect Medicare Rx cntacts (hw t cntact us, including hw t reach SilverScript Custmer Care) Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) SECTION 5 Scial Security SECTION 6 SECTION 7 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Infrmatin abut prgrams t help peple pay fr their prescriptin drugs SECTION 8 Hw t cntact the Railrad Retirement Bard SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer?... 21

15 Chapter 2: Imprtant phne numbers and resurces 12 SECTION 1 HealthSelect Medicare Rx cntacts (hw t cntact us, including hw t reach SilverScript Custmer Care) Hw t cntact SilverScript Custmer Care Fr assistance with claims, billing r member card questins, please call r write t SilverScript Custmer Care. We will be happy t help yu. SilverScript Custmer Care Cntact Infrmatin CALL (855) Calls t this number are free. 24 hurs a day, 7 days a week. SilverScript Custmer Care als has free language interpreter services available fr nn-english speakers. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. 24 hurs a day, 7 days a week. FAX (888) WRITE WEBSITE SilverScript Insurance Cmpany P.O. Bx Phenix, AZ Hw t cntact us when yu are asking fr a cverage decisin r making an appeal 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. Fr mre infrmatin n asking fr cverage decisins abut yur Part D prescriptin drugs, see Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). An appeal is a frmal way f asking us t review and change a cverage decisin we have made. Fr mre infrmatin n making an appeal abut yur Part D prescriptin drugs, see Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Yu may call us if yu have questins abut ur cverage decisin r appeals prcesses.

16 Chapter 2: Imprtant phne numbers and resurces 13 Cverage Decisins and Appeals fr Part D Prescriptin Drugs Cntact Infrmatin CALL (866) Calls t this number are free. 24 hurs a day, 7 days a week. TTY (866) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. 24 hurs a day, 7 days a week. FAX (855) WRITE WEBSITE SilverScript Insurance Cmpany Prescriptin Drug Plans Cverage Decisins and Appeals Department P.O. Bx 52000, MC 109 Phenix, AZ Hw t cntact us when yu are making a cmplaint abut ur Part D prescriptin drugs Yu can make a cmplaint abut us r ne f ur netwrk pharmacies, including a cmplaint abut the quality f care. This type f cmplaint des nt invlve cverage r payment disputes. (If yur prblem is abut the plan s cverage r payment, yu shuld lk at the sectin abve abut making an appeal.) Fr mre infrmatin n making a cmplaint abut yur Part D prescriptin drugs, see Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Cmplaints abut Part D prescriptin drugs Cntact Infrmatin CALL (866) Calls t this number are free. 24 hurs a day, 7 days a week. TTY (866) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. 24 hurs a day, 7 days a week. FAX (866) WRITE SilverScript Insurance Cmpany Prescriptin Drug Plans

17 Chapter 2: Imprtant phne numbers and resurces 14 Grievance Department P.O. Bx 53991, MC 121 Phenix, AZ MEDICARE WEBSITE Yu can submit a cmplaint abut HealthSelect Medicare Rx directly t Medicare. T submit an nline cmplaint t Medicare g t Where t send a request asking us t pay fr ur share f the cst f a drug yu have received The cverage determinatin prcess includes determining requests t pay fr ur share f the csts f a drug that yu have received. Fr mre infrmatin n situatins in which yu may need t ask the plan fr reimbursement r t pay a bill yu have received frm a prvider, see Chapter 5 (Asking us t pay ur share f the csts fr cvered drugs). Please nte: If yu send us a payment request and we deny any part f yur request, yu can appeal ur decisin. See Chapter 7 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)) fr mre infrmatin. Payment Requests Cntact Infrmatin CALL (866) Calls t this number are free. 24 hurs a day, 7 days a week. TTY (866) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. 24 hurs a day, 7 days a week. WRITE WEBSITE SilverScript Insurance Cmpany Prescriptin Drug Plans Medicare Part D Paper Claim P.O. Bx Phenix, AZ

18 Chapter 2: Imprtant phne numbers and resurces 15 SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) Medicare is the Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with disabilities, and peple with End-Stage Renal Disease (permanent kidney failure requiring dialysis r a kidney transplant). The Federal agency in charge f Medicare is the Centers fr Medicare & Medicaid Services (smetimes called CMS ). This agency cntracts with Medicare Prescriptin Drug Plans, including us. Medicare Cntact Infrmatin CALL (800) MEDICARE, r (800) Calls t this number are free. 24 hurs a day, 7 days a week. TTY (877) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. 24 hurs a day, 7 days a week. WEBSITE This is the fficial gvernment website fr Medicare. It gives yu upt-date infrmatin abut Medicare and current Medicare issues. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print directly frm yur cmputer. Yu can als find Medicare cntacts in yur state. The Medicare website als has detailed infrmatin abut yur Medicare eligibility and enrllment ptins with the fllwing tls: Medicare Eligibility Tl: Prvides Medicare eligibility status infrmatin. Medicare Plan Finder: Prvides persnalized infrmatin abut available Medicare prescriptin drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) plicies in yur area. These tls prvide an estimate f what yur ut-f-pcket csts might be in different Medicare plans. Yu can als use the website t tell Medicare abut any cmplaints yu have abut HealthSelect Medicare Rx. Tell Medicare abut yur cmplaint: Yu can submit abut HealthSelect Medicare Rx directly t Medicare. T submit a cmplaint, g t

19 Chapter 2: Imprtant phne numbers and resurces 16 Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this website using its cmputer. Or, yu can call Medicare and tell them what infrmatin yu are lking fr. They will find the infrmatin n the website, print it ut, and send it t yu. (Yu can call Medicare at (800) MEDICARE ((800) ), 24 hurs a day, 7 days a week. TTY users shuld call (877) ) SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) The State Health Insurance Assistance Prgram (SHIP) is a gvernment prgram with trained cunselrs in every state. Please see the Appendix at the end f this dcument t find the cntact infrmatin fr the SHIP in yur state. SHIPs are independent (nt cnnected with any insurance cmpany r health plan). It is a state prgram that gets mney frm the Federal gvernment t give free lcal health insurance cunseling t peple with Medicare. SHIP cunselrs can help yu with yur Medicare questins r prblems. They can help yu understand yur Medicare rights, help yu make cmplaints abut yur medical care r treatment, and help yu straighten ut prblems with yur Medicare bills. SHIP cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans. SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a Quality Imprvement Organizatin in each state. Please see the Appendix at the end f this dcument t find the cntact infrmatin fr the Quality Imprvement Organizatin in yur state. Quality Imprvement Organizatins have a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Quality Imprvement Organizatin is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact Quality Imprvement Organizatin if yu have a cmplaint abut the quality f care yu have received. Fr example, yu can cntact yur Quality Imprvement

20 Chapter 2: Imprtant phne numbers and resurces 17 Organizatin if yu were given the wrng medicatin r if yu were given medicatins that interact in a negative way. SECTION 5 Scial Security Scial Security 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 r visit yur lcal Scial Security ffice. Scial Security is als respnsible fr determining wh has t pay an extra amunt fr their Part D 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. If yu mve r change yur mailing address, it is imprtant that yu cntact Scial Security t let them knw. Scial Security Cntact Infrmatin CALL (800) Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. Yu can use Scial Security s autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day. TTY (800) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. WEBSITE

21 Chapter 2: Imprtant phne numbers and resurces 18 SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Medicaid is a jint Federal and state gvernment prgram that helps with medical csts fr certain peple with limited incmes and 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: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and ther cst-sharing (like deductibles and cpays). (Sme peple with QMB are als eligible fr full Medicaid benefits (QMB+).) Specified Lw-Incme Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Sme peple with SLMB are als eligible fr full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Wrking Individuals (QDWI): Helps pay Part A premiums. T find ut mre abut Medicaid and its prgrams, cntact the Medicaid Agency in yur state using the cntact infrmatin in the Appendix at the end f this dcument. SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs 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 stcks, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium (if yu are paying a prtin f the premium), annual deductible, and prescriptin cpays. 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 (if yu are paying a prtin f the premium) and csts. T see if yu qualify fr getting Extra Help, call: (800) MEDICARE ((800) ). TTY users shuld call (877) , 24 hurs a day, 7 days a week; The Scial Security Office at (800) , between 7 am and 7 pm, Mnday thrugh Friday. TTY users shuld call (800) (applicatins); r

22 Chapter 2: Imprtant phne numbers and resurces 19 Yur State Medicaid Office (applicatins). (See Sectin 6 f this chapter fr cntact infrmatin.) If yu believe yu have qualified fr Extra Help and yu believe that yu are paying an incrrect cst-sharing 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 cpay level, r, if yu already have the evidence, t prvide this evidence t us. Dcumentatin frm the state r SSA shwing yur lw-incme subsidy level is the preferred evidence f yur prper cst-sharing level. Please fax yur dcumentatin t us at (866) Please include a phne number where we can cntact yu. If yu cannt prvide the dcumentatin and need assistance r wuld like additinal infrmatin, cntact SilverScript Custmer Care, 24 hurs a day, 7 days a week, tll free at (855) (TTY 711). SilverScript Insurance Cmpany will accept any f the fllwing dcuments as evidence: A cpy f yur Medicaid card which includes yur name and eligibility date during the perid fr which yu believe yu qualified fr Extra Help ; Details f any call yu made t verify yur Medicaid status, including the date a verificatin call was made t the State Medicaid Agency and the name, title and telephne number f the state staff persn wh verified yur Medicaid status during the discrepant perid; A cpy f a state dcument that cnfirms yur active Medicaid status during the discrepant perid; A print ut frm the State electrnic enrllment file shwing yur Medicaid status during the discrepant perid; A screen-print frm the State s Medicaid systems shwing yur Medicaid status during the discrepant perid; Other dcumentatin prvided by the State shwing yur Medicaid status during the discrepant perid; A letter frm the Scial Security Administratin (SSA) shwing that the individual receives Supplemental Security Incme (SSI); r, An Imprtant Infrmatin letter frm SSA cnfirming that the beneficiary is autmatically eligible fr Extra Help. Fr beneficiaries that are institutinalized and qualify fr zer cst-sharing, the fllwing dcuments will be accepted as evidence f yur prper cst-sharing level: A remittance frm the facility shwing Medicaid payment fr a full calendar mnth fr that individual during a mnth after June f the previus calendar year; A cpy f a state dcument that cnfirms Medicaid payment n behalf f the individual t the facility fr a full calendar mnth after June f the previus calendar year; r A screen print frm the State s Medicaid systems shwing that individual s institutinal status based n at least a full calendar mnth stay fr Medicaid payment purpses during a mnth after June f the previus calendar year. When we receive the evidence shwing yur cpay level, we will update ur system s that yu can pay the crrect cpay when yu get yur next prescriptin at the pharmacy.

23 Chapter 2: Imprtant phne numbers and resurces 20 If yu verpay yur cpay, we will reimburse yu. Either we will frward a check t yu in the amunt f yur verpayment r we will ffset future cpays. If the pharmacy hasn t cllected a cpay frm yu and is carrying yur cpay as a debt wed by yu, we may make the payment directly t the pharmacy. If a state paid n yur behalf, we may make payment directly t the state. Please cntact SilverScript Custmer Care if yu have questins (phne numbers are printed n the back cver f this bklet). State Pharmaceutical Assistance Prgrams Many states have State Pharmaceutical Assistance Prgrams that help sme peple pay fr prescriptin drugs based n financial need, age, r medical cnditin. Each state has different rules t prvide drug cverage t its members. These prgrams prvide limited incme and medically needy senirs and individuals with disabilities financial help fr prescriptin drugs. Please see the Appendix at the end f this dcument t find the cntact infrmatin fr the State Pharmaceutical Assistance Prgram in yur state, if applicable. SECTION 8 Hw t cntact 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. If yu have questins regarding yur benefits frm the Railrad Retirement Bard, cntact the agency. If yu receive yur Medicare thrugh the Railrad Retirement Bard, it is imprtant that yu let them knw if yu mve r change yur mailing address. Railrad Retirement Bard Cntact Infrmatin CALL (877) Calls t this number are free. Available 9:00 am t 3:30 pm, Mnday thrugh Friday. If yu have a tuch-tne telephne, recrded infrmatin and autmated services are available 24 hurs a day, including weekends and hlidays. TTY (312) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are nt free. Available 9:00 am t 3:30 pm, Mnday thrugh Friday. WEBSITE

24 Chapter 2: Imprtant phne numbers and resurces 21 SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer? If yu (r yur spuse) get benefits frm yur (r yur spuse s) emplyer r retiree grup ther than ERS as part f this plan, yu may call the emplyer benefits administratr r SilverScript Custmer Care if yu have any questins. Yu can ask abut yur (r yur spuse s) emplyer r retiree health benefits, premiums, r the enrllment perid. (Phne numbers fr SilverScript Custmer Care are printed n the back cver f this bklet.) Yu may als call (800) MEDICARE ((800) ), 24 hurs a day, 7 days a week with questins related t yur Medicare cverage under this plan. TTY users shuld call (877) If yu have ther prescriptin drug cverage thrugh yur (r yur spuse s) emplyer r retiree grup, please cntact that grup s benefits administratr. The benefits administratr can help yu determine hw yur current prescriptin drug cverage will wrk with ur plan.

25 Chapter 3: Using the plan s cverage fr yur Part D prescriptin drugs 22 Chapter 3. Using the plan s cverage fr yur Part D prescriptin drugs SECTION 1 Intrductin Sectin 1.1 This chapter describes yur cverage fr Part D drugs. 24 Sectin 1.2 Basic rules fr the plan s Part D drug cverage.. 24 SECTION 2 Fill yur prescriptin at a netwrk pharmacy r thrugh the plan s mail-rder service Sectin 2.1 T have yur prescriptin cvered, use a netwrk pharmacy.. 25 Sectin 2.2 Finding netwrk pharmacies.. 25 Sectin 2.3 Using the plan s mail-rder services. 26 Sectin 2.4 Hw can yu get a lng-term supply f drugs? Sectin 2.5 When can yu use a pharmacy that is nt in the plan s netwrk? SECTION 3 Yur drugs need t be n the plan s Drug List Sectin 3.1 The Drug List tells which Part D drugs are cvered. 28 Sectin 3.2 There are three cst-sharing tiers fr drugs n the Drug List. 29 Sectin 3.3 Hw can yu find ut if a specific drug is n the Drug List? SECTION 4 There are restrictins n cverage fr sme drugs Sectin 4.1 Why d sme drugs have restrictins? Sectin 4.2 What kinds f restrictins? Sectin 4.3 D any f these restrictins apply t yur drugs? SECTION 5 Sectin 5.1 Sectin 5.2 What if ne f yur drugs is nt cvered in the way yu d like it t be cvered? There are things yu can d if yur drug is nt cvered in the way yu d like it t be cvered.. 31 What can yu d if yur drug is nt n the Drug List r if the drug is restricted in sme way?... 32

26 Chapter 3: Using the plan s cverage fr yur Part D prescriptin drugs 23 Sectin 5.3 What can yu d if yur drug is in a cst-sharing tier yu think is t high? SECTION 6 What if yur cverage changes fr ne f yur drugs? Sectin 6.1 The Drug List can change during the year Sectin 6.2 What happens if cverage changes fr a drug yu are taking? SECTION 7 What types f drugs are nt cvered by the plan? Sectin 7.1 Types f drugs we d nt cver. 36 SECTION 8 Shw yur plan membership card when yu fill a prescriptin Sectin 8.1 Shw yur membership card.. 37 Sectin 8.2 What if yu dn t have yur membership card with yu? SECTION 9 Part D drug cverage in special situatins Sectin 9.1 What if yu re in a hspital r a skilled nursing facility fr a stay that is cvered by Original Medicare? Sectin 9.2 What if yu re a resident in a lng-term care facility? Sectin 9.3 What if yu are taking drugs cvered by Original Medicare? Sectin 9.4 Sectin 9.5 What if yu have a Medigap (Medicare Supplement Insurance) plicy with prescriptin drug cverage? What if yu re als getting drug cverage frm an emplyer r retiree grup plan? SECTION 10 Prgrams n drug safety and managing medicatins Sectin 10.1 Prgrams t help members use drugs safely.. 40 Sectin 10.2 Medicatin Therapy Management (MTM) prgram t help members manage their medicatins... 41

27 Chapter 3: Using the plan s cverage fr yur Part D prescriptin drugs 24 Did yu knw there are prgrams t help peple pay fr their drugs? There are prgrams t help peple with limited resurces pay fr their drugs. These include Extra Help and State Pharmaceutical Assistance Prgrams. Fr mre infrmatin, see Chapter 2, Sectin 7. Are yu currently getting help t pay fr yur drugs? If yu are in a prgram that helps pay fr yur drugs, sme infrmatin in this Evidence f Cverage abut the csts fr Part D prescriptin drugs may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call SilverScript Custmer Care and ask fr the LIS Rider. (Phne numbers fr SilverScript Custmer Care are printed n the back cver f this bklet.) SECTION 1 Sectin 1.1 Intrductin This chapter describes yur cverage fr Part D drugs This chapter explains rules fr using yur cverage fr Part D drugs. The next chapter tells what yu pay fr Part D drugs (Chapter 4, What yu pay fr yur Part D prescriptin drugs). In additin t yur cverage fr Part D drugs thrugh ur plan, Original Medicare r yur Medicare Advantage plan (Medicare Part A and Part B) als cvers sme drugs: Medicare Part A cvers drugs yu are given during Medicare-cvered stays in the hspital r in a skilled nursing facility. Medicare Part B als prvides benefits fr sme drugs. Part B drugs include certain chemtherapy drugs, certain drug injectins yu are given during an ffice visit, and drugs yu are given at a dialysis facility. The tw examples f drugs described abve are cvered by Original Medicare. (T find ut mre abut this cverage, see yur Medicare & Yu Handbk.) The medical cverage prvided by yur emplyer grup may cver a supply f these drugs. Sectin 1.2 Basic rules fr the plan s Part D drug cverage The plan will generally cver yur drugs as lng as yu fllw these basic rules: Yu must have a prvider (a dctr r ther prescriber) write yur prescriptin. Effective June 1, 2015, yur prescriber must either accept Medicare r file dcumentatin with CMS shwing that he r she is qualified t write prescriptins. Yu shuld ask yur prescribers the next time yu call r visit if they meet this cnditin.