SiverScript Choice (PDP) offered by SiverScript Insurance Company Annua Notice of Changes for 2019 You are currenty enroed as a member of SiverScript Choice (PDP). Next year, there wi be some changes to the pan s costs and benefits. This booket tes about the changes. You have from October 15 unti December 7 to make changes to your Medicare coverage for next year. What to do now 1. ASK: Which changes appy to you Check the changes to our benefits and costs to see if they affect you. It s important to review your coverage now to make sure it wi meet your needs next year. Do the changes affect the services you use? Look in Section 1 for information about benefit and cost changes for our pan. Check the changes in the booket to our prescription drug coverage to see if they affect you. Wi your drugs be covered? Are your drugs in a different tier, with different cost sharing? Do any of your drugs have new restrictions, such as needing approva from us before you fi your prescription? Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy? Review the 2019 Drug List and ook in Section 1.3 for information about changes to our drug coverage. Your drug costs may have risen since ast year. Tak to your doctor about ower cost aternatives that may be avaiabe for you; this may save you in annua out-of-pocket costs throughout the year. To get additiona information on drug prices visit https://go.medicare.gov/drugprices. These dashboards highight which manufacturers have been increasing their prices and aso show other year-to-year drug price information. Keep in mind that your pan benefits wi determine exacty how much your own drug costs may change. Y0080_52002_ANOC_2019_M 9110_068 Accepted OMB Approva 0938-1051 (Pending OMB Approva) ANOC-9110-19
Think about your overa heath care costs. How much wi you spend out-of-pocket for the services and prescription drugs you use reguary? How much wi you spend on your premium and deductibes? How do your tota pan costs compare to other Medicare coverage options? Think about whether you are happy with our pan. 2. COMPARE: Learn about other pan choices Check coverage and costs of pans in your area. Use the personaized search feature on the Medicare Pan Finder at https://www.medicare.gov website. Cick Find heath & drug pans. Review the ist in the back of your Medicare & You handbook. Look in Section 3.2 to earn more about your choices. Once you narrow your choice to a preferred pan, confirm your costs and coverage on the pan s website. 3. CHOOSE: Decide whether you want to change your pan If you want to keep SiverScript Choice (PDP), you don t need to do anything. You wi stay in SiverScript Choice (PDP). To change to a different pan that may better meet your needs, you can switch pans between October 15 and December 7. 4. ENROLL: To change pans, join a pan between October 15 and December 7, 2018 If you don t join another pan by December 7, 2018, you wi stay in SiverScript Choice (PDP). If you join another pan by December 7, 2018, your new coverage wi start on January 1, 2019. Additiona Resources This document is avaiabe for free in Spanish. ATENCIN: Si usted haba espao, tenemos servicios de asistencia ing!stica disponibes para usted sin costo aguno. Lame a 1-866-235-5660 (TTY: 711). Pease contact our Customer Care number at 1-866-235-5660 for additiona information. (TTY users shoud ca 711.) Hours are 24 hours a day, 7 days a week. This information is avaiabe in a different format, incuding Braie and arge print. Pease ca Customer Care if you need pan information in another format. The formuary and/or pharmacy network may change at any time. You wi receive notice when necessary. About SiverScript Choice (PDP) SiverScript is a Prescription Drug Pan with a Medicare contract offered by SiverScript Insurance Company. Enroment in SiverScript depends on contract renewa. When this booket says we, us, or our, it means SiverScript Insurance Company. When it says pan or our pan, it means SiverScript Choice (PDP).
SiverScript Choice (PDP) Annua Notice of Changes for 2019 1 Summary of Important Costs for 2019 The tabe beow compares the 2018 costs and 2019 costs for SiverScript Choice (PDP) in severa important areas. Pease note this is ony a summary of changes. It is important to read the rest of this Annua Notice of Changes and review the encosed Evidence of Coverage to see if other benefit or cost changes affect you. Cost 2018 (this year) 2019 (next year) Monthy pan premium* $53.30 $49.50 *Your premium may be higher or ower than this amount. See Section 1.1 for detais. Part D prescription drug coverage (See Section 1.3 for detais.) Deductibe: $405 Copayment/Coinsurance during the Initia Coverage Stage: Standard Cost-sharing (One-month suppy): Drug Tier 1: $1.00 Drug Tier 2: $4.00 Drug Tier 3: 17% Drug Tier 4: 36% Drug Tier 5: 25% Deductibe: $415 Copayment/Coinsurance during the Initia Coverage Stage: Standard Cost-sharing (One-month suppy): Drug Tier 1: $1.00 Drug Tier 2: $4.00 Drug Tier 3: 18% Drug Tier 4: 37% Drug Tier 5: 25%
SiverScript Choice (PDP) Annua Notice of Changes for 2019 2 Annua Notice of Changes for 2019 Tabe of Contents Summary of Important Costs for 2019...1 SECTION 1 Changes to Benefits and Costs for Next Year...3 Section 1.1 Changes to the Monthy Premium...3 Section 1.2 Changes to the Pharmacy Network...3 Section 1.3 Changes to Part D Prescription Drug Coverage...3 SECTION 2 Administrative Changes...7 SECTION 3 Deciding Which Pan to Choose...7 Section 3.1 If You Want to Stay in SiverScript Choice (PDP)...7 Section 3.2 If You Want to Change Pans...7 SECTION 4 Deadine for Changing Pans...8 SECTION 5 Programs That Offer Free Counseing about Medicare...8 SECTION 6 Programs That Hep Pay for Prescription Drugs...9 SECTION 7 Questions?...9 Section 7.1 Getting Hep from SiverScript Choice (PDP)...9 Section 7.2 Getting Hep from Medicare...10
SiverScript Choice (PDP) Annua Notice of Changes for 2019 3 SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 Changes to the Monthy Premium Cost 2018 (this year) 2019 (next year) Monthy premium (You must aso continue to pay your Medicare Part B premium uness it is paid for you by Medicaid.) $53.30 $49.50 Your monthy pan premium wi be more if you are required to pay a ifetime Part D ate enroment penaty for going without other drug coverage that is at east as good as Medicare drug coverage (aso referred to as creditabe coverage ) for 63 days or more. If you have a higher income, you may have to pay an additiona amount each month directy to the government for your Medicare prescription drug coverage. Your monthy premium wi be ess if you are receiving Extra Hep with your prescription drug costs. Section 1.2 Changes to the Pharmacy Network Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug pans have a network of pharmacies. In most cases, your prescriptions are covered ony if they are fied at one of our network pharmacies. There are changes to our network of pharmacies for next year. We incuded a copy of our Pharmacy Directory in the enveope with this booket. An updated Pharmacy Directory is ocated on our website at www.siverscript.com. You may aso ca Customer Care for updated provider information or to ask us to mai you a Pharmacy Directory. Pease review the 2019 Pharmacy Directory to see which pharmacies are in our network. Section 1.3 Changes to Part D Prescription Drug Coverage Changes to Our Drug List Our ist of covered drugs is caed a Formuary or Drug List. A copy of our Drug List is in this enveope. The Drug List we incuded in this enveope incudes many but not a of the drugs that we wi cover next year. If you don t see your drug on this ist, it might sti be covered. You can get the compete Drug List by caing Customer Care (see the back cover) or visiting our website (www.siverscript.com). We made changes to our Drug List, incuding changes to the drugs we cover and changes to the restrictions that appy to our coverage for certain drugs. Review the Drug List to make sure your drugs wi be covered next year and to see if there wi be any restrictions. If you are affected by a change in drug coverage, you can: Work with your doctor (or other prescriber) and ask the pan to make an exception to cover the drug. We encourage current members to ask for an exception before next year. o To earn what you must do to ask for an exception, see Chapter 7 of your Evidence of Coverage (What to do if you have a probem or compaint (coverage decisions, appeas, compaints)) or ca Customer Care. Work with your doctor (or other prescriber) to find a different drug that we cover. You can ca Customer Care to ask for a ist of covered drugs that treat the same medica condition.
SiverScript Choice (PDP) Annua Notice of Changes for 2019 4 In some situations, we are required to cover a temporary suppy of a non-formuary drug in the first 90 days of the pan year or the first 90 days of membership to avoid a gap in therapy. For 2019, members in ong term care (LTC) faciities wi now receive a temporary suppy that is the same amount of temporary days suppy provided in a other cases: 31 days of medication rather than the amount provided in 2018 (102 days of medication). (To earn more about when you can get a temporary suppy and how to ask for one, see Chapter 3, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary suppy of a drug, you shoud tak with your doctor to decide what to do when your temporary suppy runs out. You can either switch to a different drug covered by the pan or ask the pan to make an exception for you and cover your current drug. If you previousy received a prior authorization (PA) for a drug that is being removed from the formuary in 2019, that drug wi no onger be covered even if your PA extends into 2019 or beyond. Pease review your copy of the 2019 formuary to determine which drugs are covered in 2019. A copy of the formuary is aso avaiabe onine at www.siverscript.com. If you are currenty taking a drug for which you have received a formuary exception, pease refer to the etter sent to you which granted the exception to see whether the exception continues beyond the 2018 pan year. If it states your formuary exception wi expire in or at the end of 2018, you wi need to submit a new exception request for the drug for 2019 if its formuary status has not changed. You may review the 2019 comprehensive formuary on our website at www.siverscript.com to see whether the changes to it impact your drug. Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are aowed by Medicare rues. Starting in 2019, we may immediatey remove a brand name drug on our Drug List if, at the same time, we repace it with a new generic drug on the same or ower cost sharing tier and with the same or fewer restrictions. Aso, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediatey move it to a different cost-sharing tier or add new restrictions. This means if you are taking the brand name drug that is being repaced by the new generic (or the tier or restriction on the brand name drug changes), you wi no onger aways get notice of the change 60 days before we make it or get a 60-day refi of your brand name drug at a network pharmacy. If you are taking the brand name drug, you wi sti get information on the specific change we made, but it may arrive after the change is made. Aso, starting in 2019, before we make other changes during the year to our Drug List that require us to provide you with advance notice if you are taking a drug, we wi provide you with notice 30, rather than 60, days before we make the change. Or we wi give you a 30-day, rather than a 60-day, refi of your brand name drug at a network pharmacy. When we make these changes to the Drug List during the year, you can sti work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We wi aso continue to update our onine Drug List as schedued and provide other required information to refect drug changes. (To earn more about the changes we may make to the Drug List, see Chapter 3, Section 6 of the Evidence of Coverage.)
SiverScript Choice (PDP) Annua Notice of Changes for 2019 5 Changes to Prescription Drug Costs Note: If you are in a program that heps pay for your drugs ( Extra Hep ), the information about costs for Part D prescription drugs may not appy to you. We have incuded a separate insert, caed the Evidence of Coverage Rider for Peope Who Get Extra Hep Paying for Prescription Drugs (aso caed the Low Income Subsidy Rider or the LIS Rider ), which tes you about your drug costs. If you receive Extra Hep and didn t receive this insert with this packet, pease ca Customer Care and ask for the LIS Rider. Phone numbers for Customer Care are in Section 7.1 of this booket. There are four drug payment stages. How much you pay for a Part D drug depends on which drug payment stage you are in. (You can ook in Chapter 4, Section 2 of your Evidence of Coverage for more information about the stages.) The information beow shows the changes for next year to the first two stages the Yeary Deductibe Stage and the Initia Coverage Stage. (Most members do not reach the other two stages the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, ook at Chapter 4, Sections 6 and 7, in the encosed Evidence of Coverage.) Changes to the Deductibe Stage Stage 2018 (this year) 2019 (next year) Stage 1: Yeary Deductibe Stage The deductibe is $405. The deductibe is $415. During this stage, you pay the fu cost of your Part D drugs unti you have reached the yeary deductibe.
SiverScript Choice (PDP) Annua Notice of Changes for 2019 6 Changes to Your Cost-sharing in the Initia Coverage Stage To earn how copayments and coinsurance work, ook at Chapter 4, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage. Stage Stage 2: Initia Coverage Stage Once you pay the yeary deductibe, you move to the Initia Coverage Stage. During this stage, the pan pays its share of the cost of your drugs and you pay your share of the cost. The costs in this row are for a one-month (30-day) suppy when you fi your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a ong-term suppy or for mai-order prescriptions, ook in Chapter 4, Section 5 of your Evidence of Coverage. We changed the tier for some of the drugs on our Drug List. To see if your drugs wi be in a different tier, ook them up on the Drug List. 2018 (this year) Your cost for a one-month suppy fied at a network pharmacy with standard cost-sharing: Tier 1 Preferred Generic: You pay $1.00 per prescription. Tier 2 Generic: You pay $4.00 per prescription. Tier 3 Preferred Brand: You pay 17% of the tota cost. Tier 4 Non-Preferred Drug: You pay 36% of the tota cost. Tier 5 Speciaty Tier: You pay 25% of the tota cost. Once your tota drug costs have reached $3,750, you wi move to the next stage (the Coverage Gap Stage). 2019 (next year) Your cost for a one-month suppy fied at a network pharmacy with standard cost-sharing: Tier 1 Preferred Generic: You pay $1.00 per prescription. Tier 2 Generic: You pay $4.00 per prescription. Tier 3 Preferred Brand: You pay 18% of the tota cost. Tier 4 Non-Preferred Drug: You pay 37% of the tota cost. Tier 5 Speciaty Tier: You pay 25% of the tota cost. Once your tota drug costs have reached $3,820, you wi move to the next stage (the Coverage Gap Stage).
SiverScript Choice (PDP) Annua Notice of Changes for 2019 7 Changes to the Coverage Gap and Catastrophic Coverage Stages The other two drug coverage stages the Coverage Gap Stage and the Catastrophic Coverage Stage are for peope with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, ook at Chapter 4, Sections 6 and 7, in your Evidence of Coverage. SECTION 2 Administrative Changes Process 2018 (this year) 2019 (next year) The due date of your monthy premium is changing. The number of days in a one-month suppy, the cumuative maximum suppy and the emergency suppy from a ong-term care pharmacy is changing. Currenty your monthy premiums are due on the 15th day of the month for the month of coverage. A one month suppy from a ong-term care pharmacy is 34 days with a cumuative maximum of 102 days. The ong-term care emergency suppy is 34 days. Effective January 1, 2019, a premiums wi be due on the 1st day of the month for the month of coverage. A one month suppy from a ong-term care pharmacy is 31 days with a cumuative maximum of 31 days. The ong-term care emergency suppy is 31 days. SECTION 3 Deciding Which Pan to Choose Section 3.1 If You Want to Stay in SiverScript Choice (PDP) To stay in our pan, you don t need to do anything. If you do not sign up for a different pan by December 7, you wi automaticay stay enroed as a member of our pan for 2019. Section 3.2 If You Want to Change Pans We hope to keep you as a member next year, but if you want to change for 2019, foow these steps: Step 1: Learn about and compare your choices You can join a different Medicare prescription drug pan, OR You can change to a Medicare heath pan. Some Medicare heath pans aso incude Part D prescription drug coverage, OR You can keep your current Medicare heath coverage and drop your Medicare prescription drug coverage. To earn more about Origina Medicare and the different types of Medicare pans, read Medicare & You 2019, ca your State Heath Insurance Assistance Program (see Section 5), or ca Medicare (see Section 7.2). You can aso find information about pans in your area by using the Medicare Pan Finder on the Medicare website. Go to https://www.medicare.gov and cick Find heath & drug pans. Here, you can find information about costs, coverage, and quaity ratings for Medicare pans. Step 2: Change your coverage To change to a different Medicare prescription drug pan, enro in the new pan. You wi automaticay be disenroed from SiverScript Choice (PDP).
SiverScript Choice (PDP) Annua Notice of Changes for 2019 8 To change to a Medicare heath pan, enro in the new pan. Depending on which type of pan you choose, you may automaticay be disenroed from SiverScript Choice (PDP). o You wi automaticay be disenroed from SiverScript Choice (PDP) if you enro in any Medicare heath pan that incudes Part D prescription drug coverage. You wi aso automaticay be disenroed if you join a Medicare HMO or Medicare PPO, even if that pan does not incude prescription drug coverage. o If you choose a Private Fee-For-Service pan without Part D drug coverage, a Medicare Medica Savings Account pan, or a Medicare Cost Pan, you can enro in that new pan and keep SiverScript Choice (PDP) for your drug coverage. Enroing in one of these pan types wi not automaticay disenro you from SiverScript Choice (PDP). If you are enroing in this pan type and want to eave our pan, you must ask to be disenroed from SiverScript Choice (PDP). To ask to be disenroed, you must send us a written request or contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week (TTY users shoud ca 1-877-486-2048). To change to Origina Medicare without a prescription drug pan, you must either: o Send us a written request to disenro. Contact Customer Care if you need more information on how to do this (phone numbers are in Section 7.1 of this booket). o or Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenroed. TTY users shoud ca 1-877-486-2048. SECTION 4 Deadine for Changing Pans If you want to change to a different prescription drug pan or to a Medicare heath pan for next year, you can do it from October 15 unti December 7. The change wi take effect on January 1, 2019. Are there other times of the year to make a change? In certain situations, changes are aso aowed at other times of the year. For exampe, peope with Medicaid, those who get Extra Hep paying for their drugs, those who have or are eaving empoyer coverage, and those who move out of the service area may be aowed to make a change at other times of the year. For more information, see Chapter 8, Section 2.2 of the Evidence of Coverage. Note: If you re in a drug management program, you may not be abe to change pans. SECTION 5 Programs That Offer Free Counseing about Medicare The State Heath Insurance Assistance Program (SHIP) is a government program with trained counseors in every state. Contact information for the SHIP in your state can be found in the Appendix of your Evidence of Coverage. A SHIP is independent (not connected with any insurance company or heath pan). It is a state program that gets money from the Federa government to give free oca heath insurance counseing to peope with Medicare. SHIP counseors can hep you with your Medicare questions or probems. They can hep you understand your Medicare pan choices and answer questions about switching pans. You wi find contact information for the SHIP in your state in the Appendix of your Evidence of Coverage.
SiverScript Choice (PDP) Annua Notice of Changes for 2019 9 SECTION 6 Programs That Hep Pay for Prescription Drugs You may quaify for hep paying for prescription drugs. Beow we ist different kinds of hep: Extra Hep from Medicare. Peope with imited incomes may quaify for Extra Hep to pay for their prescription drug costs. If you quaify, Medicare coud pay up to 75% or more of your drug costs incuding monthy prescription drug premiums, annua deductibes, and coinsurance. Additionay, those who quaify wi not have a coverage gap or ate enroment penaty. Many peope are eigibe and don t even know it. To see if you quaify, ca: o 1-800-MEDICARE (1-800-633-4227). TTY users shoud ca 1-877-486-2048, 24 hours a day, 7 days a week; o The Socia Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users shoud ca 1-800-325-0778 (appications); or o Your State Medicaid Office (appications). Hep from your state s pharmaceutica assistance program. State Pharmaceutica Assistance Programs hep peope pay for prescription drugs based on their financia need, age, or medica condition. To earn more about the program, check with your State Heath Insurance Assistance Program (the name and phone numbers for this organization are in the Appendix of your Evidence of Coverage). Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) heps ensure that ADAP-eigibe individuas iving with HIV/AIDS have access to ife-saving HIV medications. Individuas must meet certain criteria, incuding proof of State residence and HIV status, ow income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are aso covered by ADAP quaify for prescription cost-sharing assistance through the ADAP in your state. For information on eigibiity criteria, covered drugs, or how to enro in the program, pease ca the ADAP in your state. Contact information for the ADAP in your state is in the Appendix of your Evidence of Coverage. SECTION 7 Questions? Section 7.1 Getting Hep from SiverScript Choice (PDP) Questions? We re here to hep. Pease ca Customer Care at 1-866-235-5660. (TTY ony, ca 711.) We are avaiabe for phone cas 24 hours a day, 7 days a week. Cas to these numbers are free. Read your 2019 Evidence of Coverage (it has detais about next year s benefits and costs) This Annua Notice of Changes gives you a summary of changes in your benefits and costs for 2019. For detais, ook in the 2019 Evidence of Coverage for SiverScript Choice (PDP). The Evidence of Coverage is the ega, detaied description of your pan benefits. It expains your rights and the rues you need to foow to get covered services and prescription drugs. A copy of the Evidence of Coverage is incuded in this enveope. Visit our Website You can aso visit our website at www.siverscript.com. As a reminder, our website has the most up-to-date information about our pharmacy network (Pharmacy Directory) and our ist of covered drugs (Formuary/Drug List).
SiverScript Choice (PDP) Annua Notice of Changes for 2019 10 Section 7.2 Getting Hep from Medicare To get information directy from Medicare: Ca 1-800-MEDICARE (1-800-633-4227) You can ca 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users shoud ca 1-877-486-2048. Visit the Medicare Website You can visit the Medicare website (https://www.medicare.gov). It has information about cost, coverage, and quaity ratings to hep you compare Medicare prescription drug pans. You can find information about pans avaiabe in your area by using the Medicare Pan Finder on the Medicare website. (To view the information about pans, go to https://www.medicare.gov and cick on Find heath & drug pans. ) Read Medicare & You 2019 You can read the Medicare & You 2019 Handbook. Every year in the fa, this booket is maied to peope with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequenty asked questions about Medicare. If you don t have a copy of this booket, you can get it at the Medicare website (https://www.medicare.gov) or by caing 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users shoud ca 1-877-486-2048.