welcome Welcome to the Blue Shield of California Medicare Rx Plan (PDP) an employer group/union-sponsored Medicare Part D plan for eligible retirees. This plan provides you access to enhanced Medicare prescription drug coverage. Keep this guide handy for quick reference about your prescription drug benefits. S2468_13_346B 10232013 University of California Medicare PPO with Prescription Drug blueshieldca.com/med_formulary
Blue Shield of California Medicare Rx Plan employer group/union prescription drug benefit quick reference guide What s inside 1. How your Blue Shield of California Medicare Rx Plan works 2. Which ID card to use for prescription drugs 3. Where to fill prescriptions via network pharmacies and mail service 4. When to get prior authorization 5. Learning about the formulary 1 Quick reference guide
Understanding your prescription drug coverage Your Blue Shield of California Medicare Rx Plan is a combination of the prescription drug coverage offered through a typical employer group/union health plan, plus the prescription drug coverage offered by Medicare. It s a pharmacy benefit that works much like the prescription coverage you ve used in the past. However, the formulary (list of drugs) is different from the formulary you ve used in the past, so please be sure to review your new plan formulary for the drugs you are currently taking. A new ID card You will receive a separate Blue Shield of California Medicare Rx Plan ID card to use when filling prescriptions. It looks like this: Member John Doe Membership No. XEAJ1234567801 Plan Blue Shield of California Medicare Rx Plan (PDP) Card issued MM/DD/YY RxBin 012353 RxPCN 03510000 RxGrp MRD300 Issuer 80840 CMS S2468-004 sample Your ID card is personalized just for you. It will have your name, your ID number, and the date your card was issued. Be sure to keep your new pharmacy ID card in your wallet, and use your Blue Shield of California Medicare Rx Plan ID card when you fill prescriptions. It s particularly important for you to show your new card the FIRST time you fill a prescription with this new plan so that your pharmacy can update your records and your claims can be processed correctly. Show your Blue Shield medical ID card when you go to the doctor, and for all other healthcare services. Use your Blue Shield of California Medicare Rx Plan ID card when you fill prescriptions. Key facts about your Medicare prescription drug coverage Your former employer group/union works with Blue Shield to determine the benefits and cost-sharing amounts for Medicare prescription drug coverage. The benefit summary below lists the cost-sharing amounts that apply to you. You can also check the Blue Shield of California Medicare Rx Plan Evidence of Coverage (EOC) included in this welcome kit, or call Member Services at the number on the back of your ID card. Quick reference guide 1
Benefit highlights 2014 Pharmacy benefits Tier 1 Preferred Generic Drugs 30-day supply/network preferred or other network pharmacy or select UC Medical Center pharmacy 90-day supply/network preferred pharmacy or select UC Medical Center pharmacy or through mail service 90-day supply/other network pharmacy Tier 2 Preferred Brand Drugs 30-day supply/network preferred or other network pharmacy or select UC Medical Center pharmacy 90-day supply/network preferred pharmacy or select UC Medical Center pharmacy or through mail service 90-day supply/other network pharmacy Tier 3 Non-Preferred Brand Drugs 30-day supply/network preferred or other network pharmacy or select UC Medical Center pharmacy 90-day supply/network preferred pharmacy or select UC Medical Center pharmacy or through mail service 90-day supply/other network pharmacy You pay: $10 copay $20 copay $30 copay $30 copay $60 copay $90 copay $45 copay $90 copay $135 copay No coverage gap! With Blue Shield of California Medicare Rx Plan, you have no gap in coverage or donut hole. Instead, you simply pay the cost-sharing amounts listed in the chart. 2 Quick reference guide
Benefit highlights Pharmacy benefits Tier 4 Injectable Drugs 30-day supply/network preferred or other network pharmacy or select UC Medical Center pharmacy 90-day supply/network preferred or select UC Medical Center pharmacy or through mail service 90-day supply/other network pharmacy Tier 5 Specialty Tier Drugs 30-day supply/network preferred or other network pharmacy or select UC Medical Center pharmacy 90-day supply/preferred or select UC Medical Center pharmacy or through mail service 90-day supply/other network pharmacy You pay: $30 copay $60 copay $90 copay $30 copay $60 copay $90 copay Important: For brand drugs that have a generic equivalent, you pay the difference in cost between the generic and brand drug plus a Tier 1 copay. Please see Chapter 4 of your Evidence of Coverage for more information on what you pay for diabetic supplies, sexual dysfunction drugs, and transgender drugs. Quick reference guide 3
Catastrophic coverage stage If your annual True Out-Of-Pocket (TrOOP) costs reach $4,550, you qualify for catastrophic coverage. At this point, you will pay nothing for covered Part D prescription drugs. TrOOP costs are prescription drug expenses that you must pay because Medicare Part D does not cover them, or they are not paid by your former employer group/union (typically copays and any deductibles, if applicable). It s important to note that any drugs or services that are covered under Medicare Part B, and any Part D drugs not covered by Medicare, but covered as part of additional coverage offered by your former employer group/union, do not count toward your TrOOP total. Because this is a Medicare Part D plan, Blue Shield of California Medicare Rx Plan is required to track and notify you of your Part D drug costs, the amount you pay out-of-pocket, and your current coverage level or stage. For each month that you obtain prescription drugs, you will be mailed an Explanation of Benefits (EOB) that outlines this information. This is for tracking purposes only. The EOB is not a bill. 4 Quick reference guide
Filling prescriptions Here are how-to tips to get the most from your Medicare prescription drug plan. You have the choice to fill prescriptions at a retail network pharmacy, an other network pharmacy, at select UC Medical Center pharmacies, or through Blue Shield s convenient mail service. Network pharmacies Blue Shield of California Medicare Rx Plan s pharmacy network includes all major drugstore chains and most independent pharmacies throughout California. The plan has preferred pharmacies and other network pharmacies. Preferred pharmacies are pharmacies where the plan has negotiated a lower cost-sharing for our members for covered drugs than at other network pharmacies. For example, you can obtain a 90-day supply of covered drugs for the amount of only two 30-day copays when you visit one of our preferred pharmacies. They include: Albertsons, Osco, and Sav-on* CVS* Safeway/Vons* Locating a network pharmacy is easy: Check the Blue Shield online directory at blueshieldca.com/med_pharmacy; Check the pharmacy directory that is included in this welcome kit packet; or Call the Member Services number on your Blue Shield of California Medicare Rx Plan ID card or on the back of this guide. Out-of-network pharmacies Prescription drugs are usually not covered at out-of-network pharmacies except in special circumstances: If you become ill while traveling and there is no network pharmacy nearby If you are prescribed medication as a result of urgent or emergency care Some employer group/union sponsored plans allow you to use out-of-network pharmacies to fill your covered prescriptions at a higher cost-sharing to you. See the Benefits Rider that came with your EOC to see if this applies to your plan. Blue Shield of California Medicare Rx Plan does not pay for any prescriptions that are filled by pharmacies outside of the United States and its territories, even for a medical emergency. Check your Pharmacy Directory or EOC for more detailed information about filling prescriptions outside the network. Mail service pharmacy Blue Shield of California Medicare Rx Plan provides access to pharmacy mail service which provides you the convenience of receiving up to a 90-day supply of covered maintenance drugs delivered to your home or office, with no charge for shipping. To receive medications from PrimeMail (our prescription drug mail service vendor), you must first register online, by phone, or by mail. Once you are registered, PrimeMail will need your prescription, which can be sent electronically or by phone, fax, or mail. * Accepts e-prescribing. Maintenance drugs are those prescribed to treat chronic or long-term health conditions such as asthma, diabetes, high blood pressure, or high cholesterol, and are taken on a regular basis to maintain health. Quick reference guide 5
For more information, go to blueshieldca.com, click on Pharmacy, then choose Mail service pharmacy. Or call PrimeMail at (866) 346-7200. [TTY: (866) 346-7197]. Please allow 10 to 14 days to receive your covered maintenance medications through mail service. Once your prescription is on file with our mail service, please allow five to eight days to receive refills of your covered medications. Select UC Medical Center pharmacies You can obtain a 90-day supply of covered drugs for the amount of only two 30-day copays when you visit select UC Medical Center pharmacies. Please contact your benefits administrator for a list of participating pharmacies. Knowing when to get prior authorization Some drugs require prior authorization by Blue Shield before the prescription can be filled. Prior authorization ensures that the drug is covered under Blue Shield of California Medicare Rx Plan and that it is safe and effective for you. Here are two ways to find out if any prescription drugs you currently take require prior authorization: 1. Search the Blue Shield of California Medicare Rx Plan formulary for your specific drug (see the Learning about the formulary section). If you see PA in the Requirements/ Limits column, you or your physician/ prescriber must obtain prior authorization from Blue Shield Pharmacy Services. 2. Call the Member Services number listed on your Blue Shield of California Medicare Rx Plan ID card or on the back of this guide. Your physician/prescriber can contact Blue Shield Pharmacy Services at (800) 535-9481 [TTY: (888) 239-6482] weekdays from 8:30 a.m. to 5 p.m., to request a prior authorization. 6 Quick reference guide
Learning about the formulary Your Blue Shield of California Medicare Rx Plan includes a Medicare-approved formulary. This is the list of covered drugs. And it s more extensive than what s usually offered through a typical employer group/union health plan. Depending on the type of drugs you take, you may see some differences between our formulary and others you ve seen or used. These differences reflect Medicare requirements and/or are based on safety concerns and effectiveness for specific age categories. Check the Blue Shield of California Medicare Rx Plan Formulary online It s easy to review all the drugs that are covered under your plan. To find out which ones are available through mail service, have quantity limits, or require a first-line therapy or prior authorization: Go to blueshieldca.com/med_formulary Choose PDP Formulary (Employer Group Only) No Internet access? No problem. We ve included a copy of the formulary in this welcome kit, or, just call us at (888) 239-6469 [TTY: (888) 239-6482] to request a copy of the formulary. Additional drugs Blue Shield of California Medicare Rx Plan covers Blue Shield of California Medicare Rx Plan covers more drugs than required by Medicare. In fact, not all Medicare Part D plans cover the drugs we do. With Blue Shield of California Medicare Rx Plan, you have coverage for: Cough and cold drugs generic prescription products are covered Vitamin and mineral products When the formulary changes We will send you a printed formulary every year to reflect the coming year s changes. In addition, we update our formularies monthly on our website. See the Check the Blue Shield of California Medicare Rx Plan Formulary online section above for instructions. In addition, Medicare can change the list of covered Medicare Part D drugs at any time. If drugs are ever removed from the Blue Shield of California Medicare Rx Plan Formulary, or if a prior authorization becomes required, or if there is a change to the quantity limits or step therapy restrictions, you will be notified of the change 60 days before it takes effect if you currently take that drug. Checking the formulary before you fill a prescription is the best way to know whether or not the drugs are covered. Quick reference guide 7
You may also verify if a particular drug is on our formulary by calling the Member Services number on your Blue Shield of California Medicare Rx Plan ID card or on the back of this guide. Financial help from Medicare People with limited incomes may qualify for Extra Help, a program to help pay for their prescription drug costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call (877) 486-2048, 24 hours a day, seven days a week; The Social Security Office at (800) 772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call (877) 486-2048; or Your State Medicaid Office. 8 Quick reference guide
Have a question? Need help? Give us a call. For prescription drug benefits Our Member Services team is available 7 a.m. to 8 p.m., seven days a week from October 1 through February 14. However, after February 14, your call will be handled by our automated phone system on weekends and holidays. All calls to these numbers are toll-free. Phone: (888) 239-6469 TTY: (888) 239-6482 (This number requires special telephone equipment.) You can also write to us at: Blue Shield of California Medicare Rx Plan P.O. Box 927 Woodland Hills, CA 91365 For prior authorization requests If you are prescribed a drug that requires prior authorization, have your physician/ prescriber contact Blue Shield Pharmacy Services at (800) 535-9481 [TTY: (888) 239-6482], weekdays, 8:30 a.m. to 5 p.m. For medical benefits When you have questions or need help with your medical benefits, you can call the number listed on your medical plan ID card. For general questions and information about Medicare Part D, visit the Medicare website at www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours a day/7 days a week. TTY users should call (877) 486-2048. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Blue Shield of California is a PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. An independent member of the Blue Shield Association PDP00046-UC-COB (10/13)