UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE

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1 UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE Your Medicare Prescription Drug coverage as a Member of the UPREHS Prime Medicare Part D Plan 2015 A $9 copayment gets you a 90-day supply of any Tier 1 Generic drug from the Depot Drug Mail Pharmacy while you are in your Initial Coverage benefit stage. This Benefit Guide gives the details about your UPREHS Medicare Part D Prescription Drug coverage from January 1, 2015 through December 31, This book may otherwise be known as your Evidence of Coverage (EOC). It is an important legal document. Please keep it in a safe place. Benefits, formulary, pharmacy network, premiums, deductible, and/or copayments/coinsurance may change on January 1, UPREHS Customer Service For help or information, please call Customer Service Monday through Friday from 7:30 am to 3:30 pm Mountain Time at Calls to this number are free TTY/TDD Call the national number 711 Website: E7316EOC2015

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3 Table of Contents 2015 UPREHS PART D PLAN SUMMARY OF BENEFITS AT A GLANCE UPREHS Prime Medicare Plan Prescription Copayments...2 Medicare Coverage Gap Discount Program...2 INTRODUCTION 4 Welcome to the UPREHS Prime Medicare Part D Prescription Drug Plan!...4 The UPREHS Prime Medicare Plan is a Medicare Part D Prescription Drug Plan...4 This Benefit Guide explains how to get your Medicare Prescription Drug coverage through our Plan...4 IMPORTANT PHONE NUMBERS AND RESOURCES 5 How to contact the UPREHS Customer Service...5 Medicare...5 State Health Insurance Assistance Program Free Help...6 Quality Improvement Organization (QIO)...6 Social Security Administration...6 Railroad Retirement Board...6 State Pharmacy Assistance Program...7 Medicaid...7 Medicare s Extra Help Program...7 What if you have coverage from an AIDS Drug Assistance Program (ADAP)?...8 Medicare Coverage Gap Discount Program...8 Do you have Group Insurance or other Health Insurance from an employer?...8 SECTION 1 PLAN BASICS 9 What is the UPREHS Prime Medicare Prescription Drug Plan?...9 Overview of Medicare Prescription Drug coverage...9 How other insurance works with our plan...9 If you have Medicare and Medicaid...10 If you are a member of a State Pharmacy Assistance Program (SPAP)...10 Help us keep your membership record up-to-date...10 What is the geographic service area for our Plan?...10 Use your UPREHS Health Insurance and Rx ID Card for prescriptions instead of your Medicare card...11 Using plan pharmacies to get your prescription drugs covered by us...11 How do I fill a prescription at a standard cost-sharing network retail pharmacy?...11 Finding a standard cost-sharing network retail pharmacy...12 What if your standard cost-sharing network retail pharmacy is no longer in our plan?...12 How do I fill a prescription through the Depot Drug Pharmacies?...12 Getting new prescriptions from the preferred cost-sharing Depot Drug Mail Pharmacy...12 Using our Website for preferred cost-sharing refills...13 Use the preferred cost-sharing Depot Drug Mail Pharmacy...13 Preferred cost-sharing refills by mail...13 Preferred cost-sharing refills by telephone...14 Getting your password to use the UPREHS Website...14 Ordering your preferred cost-sharing refills on the UPREHS Website...14 Filling prescriptions outside the network...15 How do I submit a request for payment?...15 Home Infusion Pharmacies...16 Long-term Care Pharmacies...16 Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Pharmacies...16 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015 I

4 What you pay for vaccinations covered by Part D...17 SECTION 2 PLAN PREMIUM 19 How much is your monthly plan premium and how do you pay it?...19 What happens if you don t pay your plan premiums, or don t pay them on time?...19 You have to continue to pay your Part A and/or Part B premiums...20 Can your plan premiums change during the year?...20 In some situations your plan premium could be less...20 In some situations your plan premium could be more...20 What is the late enrollment penalty?...20 Who pays an extra Part D amount because of income?...21 SECTION 3 PRESCRIPTION DRUG COVERAGE 22 What is a formulary?...22 How do you find out what drugs are on our formulary?...22 What are drug tiers? Copayment chart for 30-day drug supplies...23 Sometimes you can get less than a full month s supply...23 Can the formulary change?...24 What if your drug is not on the formulary?...24 If there are extra rules that apply to the drug you take...25 Temporary (or transition) drug supplies...25 What types of drugs does Medicare or UPREHS not cover?...26 There are restrictions on coverage for some drugs...27 Programs on drug safety...27 Program to help members manage their medications...28 Does your enrollment in our Plan affect the drugs covered under Medicare Part A or Part B?...28 How much do you pay for drugs covered by our Plan?...28 Deductible...29 Initial Coverage Benefit Stage...29 Out-of-pocket Stage (Coverage Gap) before you qualify for Catastrophic Coverage...29 Catastrophic Coverage...30 How is your out-of-pocket cost calculated?...30 Who can pay for your prescription drugs, and how do these payments apply to your out-of-pocket costs?...30 Explanation of Benefits...31 How does your prescription drug coverage work if you go to a hospital or skilled nursing facility?...31 SECTION 4 MAKING COMPLAINTS 32 Problems that are handled by the complaint process...32 Complaints related to the timeliness of our actions on coverage decisions and appeals...33 Step-by-step process for making a complaint...33 Step 1 for making complaints...33 Step 2 for making complaints...34 For quality of care problems, you may also complain to the QIO...34 SECTION 5 WHAT TO DO IF YOU HAVE A PROBLEM AND NEED A COVERAGE DECISION, OR APPEAL 35 Introduction...35 Is your problem or concern about your benefits or coverage?...35 Legal Terms...35 You can get help from government organizations that are not connected with us...35 Asking for coverage decisions and making appeals explanation...36 II UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

5 How to get help when you are asking for a coverage decision or making an appeal...36 How to ask for a coverage decision or make an appeal...37 Part D coverage decisions and appeals...37 Which of these situations are you in?...38 What is an exception?...38 Important things to know about asking for exceptions...39 Step-by-Step instructions to ask for a coverage decision including an exception...39 Step 1 for Coverage Decisions and Exceptions...39 Step 2 for Coverage Decisions and Exceptions...41 Step 3 for Coverage Decisions and Exceptions...42 Step-by-Step instructions to make a Level 1 Appeal...42 Step 1 to make a Level 1 Appeal...42 Step 2 to make a Level 1 Appeal...43 Step 3 to make a Level 1 Appeal...43 Step-by-step instructions to make a Level 2 Appeal...44 Step 1 to make a Level 2 Appeal...44 Step 2 to make a Level 2 Appeal...44 Step 3 to make a Level 2 Appeal...45 Taking your appeal to Level 3 and beyond...45 Level 3 Appeal...46 Level 4 Appeal...46 Level 5 Appeal...46 SECTION 6 ENDING YOUR MEMBERSHIP IN THE UPREHS MEDICARE PLANS 47 When can you end your membership in UPREHS?...47 What is disenrollment?...47 Usually, you can end your membership during the Annual Enrollment Period...47 In certain situations, you can end your membership during a Special Enrollment Period...48 Where can you get more information about when you can end your membership?...49 How do you end your membership in UPREHS?...49 Until your membership ends, you must keep getting your prescriptions through our plan...50 UPREHS must end your membership in our Medicare plans under certain situations...50 If you move out of our plan s service area...51 We cannot ask you to leave our plan because of your health...51 You have the right to make a complaint if we ask you to leave our plan...51 SECTION 7 YOUR RIGHTS AND RESPONSIBILITIES 52 About your rights and protections...52 Your right to be treated with fairness and respect...52 We must ensure that you get timely access to your covered drugs...52 We must protect the privacy of your personal health information...52 Your right to get information about our plan, pharmacies and your covered drugs...53 We must support your right to make decisions about your care...54 Your right to make complaints and to ask us to reconsider decisions we have made...54 What can you do if you think you are being treated unfairly or your rights are not being respected?...55 How to get more information about your rights...55 You have some responsibilities as a member of the UPREHS Medicare Plans...55 SECTION 8 LEGAL NOTICES 57 Notice about governing law...57 Notice about nondiscrimination...57 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015 III

6 Notice about Medicare Secondary Payer subrogation rights...57 Information required by the Employee Retirement Income Security Act of 1974 (ERISA)...57 SECTION 9 DEFINITIONS OF IMPORTANT WORDS USED IN THIS BENEFIT GUIDE (EVIDENCE OF COVERAGE) 59 IV UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

7 2015 UPREHS Part D Plan Summary of Benefits at a Glance A $9 copayment gets you a 90-day supply of any Tier 1 Generic drug from the Depot Drug Mail Pharmacy while you are in your Initial Coverage benefit stage. For questions please contact UPREHS Customer Service at , Monday through Friday, 7:30 AM to 3:30 PM Mountain Time. TTY/TDD users call the national number 711. Use the Depot Drug Mail Pharmacy whenever possible! NOTE: Federally qualified low-income members have lower, or no copayments and premiums may be less. If you are receiving Extra Help, you will receive additional information. Drug costs can fluctuate daily so they may not be the same amount on each prescription you fill. Part D Benefits Premiums for Medicare Part D, HCPP & Medicare Secondary Plans are Combined $320 Part D Deductible UPREHS pays this for you! $2,960 Initial Coverage Amount, or Initial Coverage Benefit Stage Out of Pocket Benefit Stage until you reach $4,700 TrOOP (True out of pocket spend amount) 35% Generic Drug Discount paid by UPREHS in the Coverage Gap Increased for % Brand Name Drug Discount in the Coverage Gap for 2015 Increased for 2015 Catastrophic Coverage Benefit Stage Quantities of Drugs Supplied UPREHS Prime Medicare Part D Plan Benefits Description An Enhanced Plan $230 is your combined monthly premium covering ALL of your UPREHS Medicare Plans. There is no change for 2015.You must still pay your Medicare Part B Premium. You pay NO DEDUCTIBLE! $320 is paid for you by UPREHS! No first-dollar costs to you except for drug copayments. You receive $2,960 in drug benefits during your Initial Coverage Stage. You pay only your copayment in this stage. Medicare determines this amount. This is the same as Medicare s standard amount. After you use your $2,960 for drug costs in the Initial Coverage Stage, you pay 100% of the drug cost (less discounts) until your yearly out of pocket drug costs reach $4,700. All copayments in the Initial Coverage Stage and Part D drugs you pay for in the Coverage Gap apply to the $4,700. This is the same as Medicare s standard amount. UPREHS pays 35% of the cost of a Generic Drug when you are in the Coverage Gap out-of-pocket benefit stage until your yearly outof-pocket drug costs reach $4,700. You pay 65% of drug cost. The discount is given when you fill your prescription. You do not get out-of-pocket spending credit for the 35% paid by UPREHS. Your Brand Name drug discount in the Coverage Gap is 55% on most brand drugs. Many manufacturers continue the 50% discount. UPREHS pays an additional 5% of the cost for a total discount of 55%. Discounts are given when you fill your prescription. You get credit for 95% of the cost of the drug against your TrOOP (out-ofpocket spending). You do not get credit for the 5% paid for you by UPREHS. After you spend $4,700 out-of-pocket, you will enter the Catastrophic Coverage benefit stage and all Medicare Part D drug copayments are $2.65 for generic, $6.60 for brand name drugs, or 5% of the cost of the drug, whichever is greater. Remember, a $9 copayment gets you a 90-day supply of any Tier 1 Generic drug from the Depot Drug Mail Pharmacy while you are in your Initial Coverage benefit stage! 30-day supplies or less are available from standard cost-sharing pharmacies. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

8 Part D Benefits Part D Drugs Requiring Cost- Utilization Limits, and Step Therapy Formulary Mental Health Part D Drugs Part D and Part B Diabetic Supplies Home Infusion Therapy Part D Drugs UPREHS Prime Medicare Part D Plan Benefits Description An Enhanced Plan Your Formulary includes all Part D drugs with very few of these limitations. UPREHS applies NO Step Therapy, and NO Cost- Utilization Limits not required by Medicare. Your Formulary includes all Part D drugs! You are not limited to only certain Part D drugs as you would be with many plans. If you need a Part D drug, UPREHS covers it! You don t have to appeal to get a Part D drug. See your 2015 Formulary Book. All Part D drugs are covered in your Formulary! If Medicare covers the drug, it is available to you under your UPREHS plan. The Depot Drug Pharmacies provide up to 90-day supplies of many Part B and most D diabetic supplies to save you money. Contact UPREHS Customer Service for help and coordination UPREHS Prime Medicare Plan Prescription Copayments Day Copayment Amounts for Part D Drugs Depot Drug Mail & Walk-In Pharmacies Preferred Cost-Sharing $$$ Your Best Money Saver 30, 60 or 90-Day Supplies Available National Retail Pharmacy Network Includes Briova and Other Specialty Pharmacies Standard Cost-Sharing 30-Day or less Supply Only Tier 1 Generic Drugs 30-Day Tier 2 Brand Preferred 30-Day $3 $15 $15 $30 Tier 3 Brand Standard costsharing 30-Day Higher of $75 or 33% of drug cost Higher of $90 or 33% of drug cost Tier 4 Specialty & High Cost Drugs 30-Day Not Supplied 33% of drug cost 30- day or less supply only Note: Out-of-Network Pharmacy - Emergency Only We refund you the UPREHS cost for the Part D drug minus your Retail tier copayment amount. You pay any charges above our cost. If you are in the Coverage gap and the generic and brand name discounts were not applied from the pharmacy, you will not be reimbursed for the discount amounts. Non-Part D drugs are not covered. If the actual cost plus dispensing fee for a prescription is less than the Tier copayment amount for that drug, you will pay the actual cost plus dispensing fee, not the copayment! Some drugs would cost you less under this rule so make sure that you use your UPREHS ID card! Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program provides manufacturer discounts on most brand name drugs to Part D enrollees who have reached the coverage gap and are not already receiving Extra Help. A 55% discount on the negotiated price (excluding the dispensing fee and vaccine administration fee, if any) 2 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

9 is available for those brand name drugs from manufacturers that have agreed to pay the discount. Medicare does not cover brand name drugs unless the manufacturer agrees to the discount. Many manufacturers continue the 50% discount. UPREHS pays an additional 5% of the cost for a total discount of 55%. You do not get credit for the 5% paid for you by UPREHS. If you reach the coverage gap, we will automatically apply the discount when your pharmacy bills you for your prescription and your receipt will show any discount provided. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and the discounted amount helps to move you through the coverage gap. You also receive some coverage for generic drugs. When you reach the coverage gap, UPREHS pays 35% of the price for your generic drugs and you pay the remaining 65%. The coverage for generic drugs works differently than the 55% discount for brand name drugs. For generic drugs, the amount paid by the plan (35%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is included as part of the cost of the drug. If you have any questions about the availability of discounts for the drugs you are taking or about the Medicare Coverage Gap Discount Program in general, please contact Customer Service (phone numbers are on the front cover of this book). If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program that provides coverage for Part D drugs (other than Extra Help), you still get the 55% discount on covered brand name drugs. The 55% discount is applied to the price of the drug before any SPAP or other coverage. If you get Extra Help, you already get coverage for your prescription drug costs during the coverage gap so these discounts do not apply to you. If you think that you have reached the coverage gap and did not get a discount when you paid for your brand name drug, call Customer Service. If we don t agree that you are owed a discount, you can appeal. You can get help filing an appeal from your State Health Insurance Assistance Program (SHIP)) or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

10 Introduction Welcome to the UPREHS Prime Medicare Part D Prescription Drug Plan! You are enrolled in the UPREHS Prime Medicare Prescription Drug plan. We are pleased that you ve chosen to allow UPREHS to be your Part D Plan. The UPREHS Prime Medicare Plan is a Medicare Part D Prescription Drug Plan UPREHS is contracted with the Centers for Medicare & Medicaid Service (CMS) as an Employee Group Waiver Plan (EGWP) direct contract Medicare Part D Prescription Drug Plan. Medicare must approve the UPREHS Plan each year. For current UPREHS Medicare members, you were automatically enrolled in our Plan so that UPREHS can continue to provide your prescription drug benefits. New plan members are enrolled when they become eligible for and enrolled in Medicare Parts A and B. The service area for this plan is national including all state in Continental America, Alaska, Hawaii and Puerto Rico Territory. If you move out of our service area, please contact Customer Service. This Benefit Guide is part of our contract with you about how UPREHS covers your care. Other parts of this contract include your enrollment form, the Formulary (list of covered drugs) and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for months in which you are enrolled in UPREHS starting January 1, 2015 through December 31, Throughout the remainder of this Benefit Guide, we may also refer to the UPREHS Prime Medicare Plan as plan, we, us, or our plan. This Benefit Guide explains how to get your Medicare Prescription Drug coverage through our Plan This Benefit Guide, together with (your enrollment form for new enrollees), riders, and amendments that we may send to you, is our contract with you. It explains your rights, benefits, and responsibilities as a member of our Plan. It also explains our responsibilities to you. The information in this Benefit Guide is in effect for the time period from January 1, 2015 through December 31, Medicare must approve our plan each year. This Benefit Guide gives you the details, including: What is and what is not covered in our Plan. How to get your prescriptions filled, including some rules you must follow. What you will have to pay for your prescriptions. What to do if you are unhappy about something related to getting your prescriptions filled. How to leave our Plan, including your choices for continuing Medicare Prescription Drug coverage. 4 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

11 Important phone numbers and resources How to contact the UPREHS Customer Service If you have any questions or concerns, please call or write to Customer Service. We will be happy to help you. Our Customer Service hours are 7:30 am to 3:30 pm, Mountain Time, Monday through Friday. CALL TTY/TDD , this number is also on the cover of this Benefit Guide for easy reference. Calls to this number are free. Please use 711, the national access number. FAX WRITE UPREHS, PO Box , Salt Lake City, UT WEBSITE IN PERSON 1040 North 2200 West Suite 200, Salt Lake City, Utah PART D DRUG APPEALS OR COVERAGE DECISIONS Call Catamaran toll free at or fax to them at PLEASE USE THE ABOVE CONTACT INFORMATION FOR THE FOLLOWING: When you want to contact us for a coverage decision about your Part D prescription drugs. A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your Part D prescription drugs. When you want to make an appeal about your Part D prescription drugs. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you want to make a complaint about your Part D prescription drugs. You can make a complaint about us or one of our network pharmacies, including a complaint about the quality of your care. This type of complaint does not involve a coverage or payment dispute. If your problem is about our coverage or payment, refer to the text above about making an appeal. When you want to send a request to ask us to pay for our share of the cost of a drug you have received. The coverage decision process includes determining requests that ask us to pay for our share of the costs of a drug that you have received. This may occur on Part D covered vaccinations, hospital take-home-drugs, or out-of-network pharmacy purchases. Medicare CALL Medicare, or calls to this number are free and available 24 hours a day, 7 days a week (TTY/TDD ) WEBSITE Medicare is the Federal health insurance program for people 65 years of age or older, some people under age 65 with disabilities, and people with End Stage Renal Disease, sometimes referred to as ESRD (permanent kidney failure requiring dialysis or a kidney transplant). CMS is the Federal agency in charge of the Medicare program. CMS stands for Centers for Medicare & Medicaid Service. CMS contracts with and regulates Medicare Prescription Drug Plans (including our Plan). UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

12 Use a computer to look at the official government Website for Medicare information. This Website gives you up-to-date information about Medicare and current issues. It includes Medicare publications you can print directly from your computer. It has tools to help you compare Medicare Health Plans and Prescription Drug Plans in your area. You can also search the Helpful Contacts section for the Medicare contacts in your state. If you do not have a computer, your local library or senior center may be able to help you visit this Website using their computer. State Health Insurance Assistance Program Free Help State Health Insurance Assistance Program or SHIP is a government program with trained counselors in every state. Counselors give free health insurance information and help to people with Medicare. SHIPs have different names depending on which state they are in. Your SHIP can explain your Medicare rights and protections, help you make complaints about care or treatment, and help straighten out problems with Medicare bills. Your SHIP has information about Medicare Prescription Drug Plans, Medicare Health Plans, and about Medigap (Medicare supplement insurance) policies. CALL Medicare at to find the SHIP in your state WEBSITE to find the SHIP in your state Quality Improvement Organization (QIO) Quality Improvement Organization (QIO) is a group of doctors and health professionals in your state who review medical care and handle certain types of complaints from patients with Medicare. A QIO is paid by the Federal government to check on and help improve the care given to Medicare patients. There is a QIO in each state. Medicare complaints they review include those about quality of care, and patients who think the coverage for their hospital stay, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility services are ending too soon. You can find contact information for the QIO in your state by calling Medicare at Social Security Administration The Social Security Administration is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens who are 65 or older, or who have a disability or End Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security at TTY/TDD users should call Calls to these numbers are free and are available 7:00 AM to 7:00 pm, Monday through Friday. You can also visit Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for a reconsideration. Railroad Retirement Board Most UPREHS members receive their Medicare benefits through the Railroad Retirement Board. The Railroad Retirement Board is an independent Federal agency that administers comprehensive benefit programs for the nation s railroad workers and their families. You can call your local Railroad Retirement Board office or (calls to this number are free) from 9:00 AM to 3:30 PM, Monday through Friday. TTY/TDD users should call You can also visit 6 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

13 State Pharmacy Assistance Program Many states have State Pharmacy Assistance Programs (SPAP s). SPAP s are State-funded programs that provide financial assistance for prescription drugs to low-income and medically needy senior citizens and individuals with disabilities. Each state has different rules to provide drug coverage to its members. Some SPAP s will help pay for the premiums, deductibles, and/or copayments for those who qualify. Please contact the SPAP in your state to determine what benefits may be available to you. You can find the SPAP in your area by calling Medicare at Medicaid A joint Federal and state program that helps with medical costs for some people with low incomes and limited resources. Some people with Medicare are also eligible for Medicaid. In addition there are programs offered through Medicaid that help people with Medicare pay their Medicare costs, such as their Medicare premiums. These Medicare Savings Programs help people with limited income and resources save money each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). (Some people with QMB are also eligible for full Medicaid benefits (QMB). Specified Low-Income Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Some people with SLMB are also eligible for full Medicaid benefits (SLMB). Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Working Individuals (QDWI): Helps pay Part A premiums. To find out more about Medicaid and its programs, contact your specific state Medicaid office. You can find your state Medicaid office by calling Medicare at Medicare s Extra Help Program Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stock, but not your home or car. If you qualify, you get help paying for any Medicare drug plan s monthly premium and prescription copayments. This Extra Help also counts toward your out-of-pocket costs. People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don t need to apply. Medicare mails a letter to people who automatically qualify for Extra Help. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call: MEDICARE ( ). TTY users should call , 24 hours a day, 7 days a week; The Social Security Office at , between 7 am to 7 pm, Monday through Friday. TTY users should call ; or Your state Medicaid Office. If you believe you have qualified for Extra Help and you believe that you are paying an incorrect costsharing amount when you get your prescription at a pharmacy, our plan has established a process that allows you to either request assistance in obtaining evidence of your proper co-payment level, or, if you already have the evidence, to provide this evidence to us. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

14 UPREHS will apply an adjusted cost sharing amount using Best Available Evidence (BAE) that you provide prior to Medicare s notification to us. BAE would be a notice from your state Medicaid office or Medicare presented to the pharmacy, or faxed to our Customer Service. When we receive the evidence showing your copayment level from Medicare or from you, we will update our system so that you can pay the correct copayment when you get your next prescription at the pharmacy. If you overpay your copayment, we will reimburse you. Either we will forward a check to you in the amount of your overpayment or we will offset future copayments. Please contact Customer Service if you have questions. What if you have coverage from an AIDS Drug Assistance Program (ADAP)? What is the AIDS Drug Assistance Program (ADAP)? The AIDS Drug Assistance Program (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance Note: To be eligible for the ADAP operating in your State, individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Coverage Gap Discount Program The Medicare Coverage Gap Discount Program is available nationwide. Please go to Page 3 for more detailed information about your benefits during the coverage gap. The Medicare Coverage Gap Discount Program provides manufacturer discounts on most Medicare Part D brand name drugs to Part D members who have reached the coverage gap and are not already receiving Extra Help. Do you have Group Insurance or other Health Insurance from an employer? If you have other prescription drug coverage through your (or your spouse s) employer or retiree group, please contact that group s benefits administrator. The benefits administrator can help you determine how your current prescription drug coverage will work with our plan. You may also call MEDICARE ( ; TTY: ) with questions related to your Medicare coverage. 8 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

15 Section 1 Plan Basics What is the UPREHS Prime Medicare Prescription Drug Plan? UPREHS is contracted with the Centers for Medicare & Medicaid Service (CMS) as an Employer Group Waiver Plan (EGWP) direct contract Medicare Part D Prescription Drug Plan. Medicare must approve our contract each year. As an EGWP, our membership is available only to Union Pacific Railroad or affiliated Railroad Medicare retires, and their spouse/widow/widower. CMS does not require an EGWP to perform some of the contractual requirements that apply to for-profit Part D plans because of our membership restrictions. UPREHS was founded solely to serve you - our members. Current UPREHS Medicare members have been automatically enrolled in our Plan so that UPREHS can continue to provide your prescription drug benefits while you receive Medicare benefits. Now that you are enrolled in the UPREHS Prime Medicare Plan you are getting your Medicare Prescription Drug coverage through UPREHS. This Benefit Guide explains your benefits, what you have to pay, and the rules you must follow to get your prescription drugs covered. Overview of Medicare Prescription Drug coverage Medicare Prescription Drug coverage is insurance that helps pay for your prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a plan pharmacy, Medicare Part D covers it, and other coverage rules are followed. We do not pay for drugs under Medicare Part D that are covered by Medicare Part B. As a member, all you have to do is continue to pay your Part B premium and your UPREHS monthly premium and copayments. The amount of the monthly premium is not affected by your health status or how many prescriptions you need. If you have limited income and resources, you may get Extra Help from Medicare to pay your premium and copayments so that you get your prescription drugs for little or no cost. Please call the Social Security Administration to learn more. How other insurance works with our plan If you have any other prescription drug coverage in addition to our plan, you are required to tell us. Please call Customer Service to let us know. We are required to follow rules set by Medicare to make sure that you are using all of your benefits in combination when you get your covered drugs from our plan. This is called coordination of benefits because it involves coordinating the drug benefits you get from our plan with any other drug benefits available to you. We ll help you with it. Medicare law requires us to collect this information from you when you or your spouse enrolls in the UPREHS Medicare Plans, or when other insurance becomes involved. If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: No-fault insurance (including automobile insurance) Liability (including automobile insurance) Black lung benefits Workers compensation UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

16 Veterans Administration. Medicare Part D does not coordinate with prescriptions supplied by the VA. Either the VA pays, or Medicare Part D pays, but not both. Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time. The information you provide helps us calculate how much you and others have paid for your drugs. In addition, if you lose or get additional prescription drug coverage, please call Customer Service at to update your membership records. If you have Medicare and Medicaid Medicare, not Medicaid, will pay for most of your prescription drugs. You will continue to get your health coverage under both Medicare and Medicaid as long as you still qualify for Medicaid benefits. If you are a member of a State Pharmacy Assistance Program (SPAP) If you are currently enrolled in a SPAP, you may get help paying your premiums, and/or copayments. Please contact your SPAP to determine what benefits are available to you. Please see the Introduction for more information. Help us keep your membership record up-to-date We have a file of information about you as a plan member. Pharmacists use this membership record to know what drugs are covered for you. The membership record has information from your enrollment form, including your address and telephone number. It shows your specific plan coverage and other information. Please help us keep your membership record up-to-date by letting Customer Service know right away if there are any changes in your name, address, or phone number, or if you go into a nursing home. Also, tell Customer Service about any changes in prescription drug coverage you have from other sources, such as from Medicaid or from a current or different former employer, or your spouse s current or former employer. You should tell Customer Service about any changes in coverage due to claims filed under liability insurance, such as workers compensation claims or claims against another driver in an automobile accident. What is the geographic service area for our Plan? UPREHS is a National Medicare Prescription Drug Plan and includes the states of Alaska, Hawaii, and the territory of Puerto Rico. Your UPREHS preferred cost-sharing pharmacies are the Depot Drug Mail Pharmacy, and all Depot Drug Walk-In Pharmacies. You are limited to filling one 30-day supply (or less) per prescription from a UPREHS standard cost-sharing retail pharmacy. Usually, maintenance prescriptions (medication taken longer than 30 days) must be filled through the Depot Drug Pharmacies. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency. 10 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

17 Use your UPREHS Health Insurance and Rx ID Card for prescriptions instead of your Medicare card As a member of our plan, one card does it for you! You have a combined UPREHS Health Insurance and Rx ID card. Use your UPREHS ID card to obtain prescriptions (not your Medicare card). You will need both your red, white and blue Medicare and UPREHS ID cards for your medical service. During the time you are a plan member and using Plan Service, you must use your UPREHS ID card. This ID card protects your privacy by using a UPREHS unique ID number that we use to identify you. Your UPREHS number is NOT your Social Security number or your Medicare Part A & B number. You must use your number on your card to identify yourself when obtaining prescriptions through the Depot Drug Mail Pharmacy, Depot Drug Walk-In Pharmacies, standard cost-sharing retail network pharmacies, when contacting UPREHS Customer Service, and when obtaining your personal information from the UPREHS Website. Please carry your Plan membership card with you at all times. If your membership card is ever damaged, lost, or stolen, call UPREHS Customer Service right away and we will send you a new card. Using plan pharmacies to get your prescription drugs covered by us What are network pharmacies? With few exceptions, you must use the Depot Drug Pharmacies to get your prescription drugs covered. What is a preferred cost-sharing pharmacy? Our preferred cost-sharing pharmacies are the Depot Drug Mail Pharmacy, and the Depot Drug Walk-In Pharmacies. These pharmacies require preferred cost-sharing copayments. UPREHS owns the Depot Drug Pharmacies that were established solely to serve our members. You must use the Depot Drug Pharmacies for all maintenance prescriptions. Maintenance prescriptions are those taken longer than 30 days. We have negotiated a lower price from the drug manufacturers for covered prescription drugs than the price we pay for your drugs obtained at a standard cost-sharing network retail pharmacy. These savings are returned to you in the form of lower copayments and expanded pharmacy benefits. What is a standard cost-sharing network retail pharmacy? This is a pharmacy at which you can get your first 30-day prescription drug supply (or less) and emergency prescriptions using your drug benefits. These pharmacies require standard copayments. We call them standard costsharing network retail pharmacies because they are under contract with our plan. A standard cost-sharing network retail pharmacy is still a network pharmacy, but their price for covered prescription drugs is more than UPREHS pays. That is the reason that your copayments are higher if you use a standard cost-sharing network retail pharmacy. What are covered drugs? All Medicare Part D covered drugs are included in our formulary. A covered drug is the general term we use to mean all of the outpatient prescription drugs that are covered by our plan and Medicare Part D. How do I fill a prescription at a standard cost-sharing network retail pharmacy? To fill your prescription at a standard cost-sharing network retail pharmacy, you must show your UPREHS ID card. If you do not have your ID card with you when you fill your prescription, you may have to pay the full cost of the prescription (rather than paying just your copayment). If this happens, you can ask us to reimburse you for our share of the cost by submitting your prescription receipt to us along with a completed UPREHS Prescription Claim Form found on the UPREHS website at UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

18 or by calling Customer Service. To learn how to submit a paper claim, please refer to the paper claims process described at the end of this section. If you must use a standard cost-sharing network retail pharmacy, ask your physician to write 2 prescriptions, a one-month supply to be filled at your local pharmacy and a long-term prescription to be filled through the Depot Drug Mail Pharmacy per the instructions in this section. A Depot Drug Walk-In Pharmacy, can place your original prescription on file and you can obtain your refills from the Depot Drug Mail Pharmacy, or the walk-in pharmacy. Finding a standard cost-sharing network retail pharmacy Most local and national chain pharmacies are in our standard cost-sharing pharmacy network. Since our plan is a national plan, all pharmacies cannot be listed in a directory. The pharmacist can tell you if their pharmacy is in network simply by showing them your UPREHS ID card. You can call our Customer Service if you have questions. What if your standard cost-sharing network retail pharmacy is no longer in our plan? Very rarely a pharmacy might leave our network. If this happens, you will need to fill your prescriptions at another standard cost-sharing network retail pharmacy. Please call Customer Service to find another standard cost-sharing network retail pharmacy in your area. How do I fill a prescription through the Depot Drug Pharmacies? There are some maintenance prescription drugs that cannot be sent through the mail. Depot Drug Mail Order does NOT supply those prescriptions. Please refer to your Formulary book and look for the BI (benefit indicator column). Then look for the RO (Retail Only) indicator. UPREHS has determined that it is in the best interest of our members to have these drugs supplied through your local retail network pharmacy and not in the mail. Depot Drug Walk-in Pharmacies DO supply RO drugs. You need to obtain your maintenance prescriptions from the Depot Drug Mail Pharmacy and the Depot Drug Walk-In Pharmacies. Maintenance prescriptions are those that you need to take longer than 30 days. UPREHS supplies your maintenance prescriptions with lower copayments and drug prices, so you get expanded benefit coverage. Getting new prescriptions from the preferred cost-sharing Depot Drug Mail Pharmacy Ordering new prescriptions is easy, and you are not charged shipping costs. Follow these directions to fill new prescriptions: Obtain your written prescription(s) from your doctor. Make certain the number of refills the doctor wants you to have is clearly indicated on your prescription. Your prescription can remain valid for up to one (1) calendar year on most prescriptions, but it cannot be refilled after that time. If you continue to need the medication after the prescription expires, you must get a new prescription from your doctor. Use a separate sheet of paper to show your name and UPREHS ID card number exactly as they appear on your ID card, your shipping address, and your doctor s name and telephone number with the area code. Order a 3-month (90-day) supply for each prescription if possible. Be sure to specify whether you want a 3-month (90-day), or less if there are fewer months left on your prescription. 12 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

19 Depot Drug Mail Pharmacy cannot fill your prescriptions sent to us by your doctor unless we have your specific authorization to do so. You need to call Customer Service to give this authorization when you know the doctor is sending us a new prescription. Without copayment(s), your prescription(s) cannot be filled. You can pay by check or money order payable to the Depot Drug Mail Pharmacy. It is easier for you and UPREHS to pay your copayment with your debit or credit card. That way, you will not need to guess the amount of your copayment. To use your debit or credit card, write down the type of card (MasterCard, Discover, or VISA only) and the entire debit or credit card number and expiration date of your card. Once your card number is on file with Depot Drug Mail Pharmacy, you do not need to send the number each time, but you must specifically authorize us to use your debit or credit card on file for your copayment to fill each prescription. Allow ten (10) working days for mail delivery of your prescriptions. Debit or credit card payment is the most convenient way to pay your prescription copayments when you don t know how much to pay. We tell you how much we applied to your debit or credit card for your copayment on your receipt. Mail the prescription(s), your personal information, and your applicable Tier copayment (or debit or credit card information and your authorization to charge your card) for the prescription(s) to: Depot Drug Mail Pharmacy, PO Box , Salt Lake City, UT We encourage physicians to e-prescribe for you (send electronic prescriptions to NCPDP# ) However, we will still need your permission and instructions to be able to ship your medication. Using our Website for preferred cost-sharing refills UPREHS offers you the convenience of ordering your prescription refills using our Website at You must use your debit or credit card (MasterCard, Discover, or Visa only) for Website ordering. To register on the UPREHS website, follow the instructions below. You can call UPREHS Customer Service at or if you need help. When you fill or refill prescriptions at the Depot Drug Mail Pharmacy, you can receive notifications about your prescription orders. To receive confirmation that Depot Drug has received your order and confirmation about when your order was shipped you must register as a member with your address at (See how under Getting your password to use the UPREHS Website on the next page.) Use the preferred cost-sharing Depot Drug Mail Pharmacy You must use the Depot Drug Mail Pharmacy for mail order prescription service (except for medications provided by a Specialty Drug Pharmacy). Prescription drugs that you get through any other mail order service are not covered. There are three ways to obtain prescription refills from the Depot Drug Mail Pharmacy. Preferred cost-sharing refills by mail Your prescriptions are easy to refill once they are already on file with the Depot Drug Mail Pharmacy. UPREHS urges you to order a 3-month (90-day) supply depending on the number of refill months left on your prescription. You may re-order another 3-month supply in 69 days, or more after your last 3- month refill so that you won t run out of your medication. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

20 A convenient reorder form is included in each prescription sent to you. Simply indicate a three, two, or one-month supply and your method of payment. If you are not using your debit or credit card, include a check or money order for your copayment and mail the form to the address indicated on the form. Preferred cost-sharing refills by telephone Just call the Depot Drug toll-free number, , press 1, and follow the interactive voice response instructions. You must use your debit or credit card (MasterCard, Discover, or VISA only) for copayments to order refills by telephone. To use the telephone refill service: Have your UPREHS ID card; your debit or credit card (MasterCard, Discover, or Visa only) and the prescription number(s) to be refilled ready before you place your call. Call the Depot Drug Mail Pharmacy refill service telephone number toll free at Follow the instructions of the automated pharmacy service line to order your refill(s) and pay the copayment(s) using your debit or credit card. The automated system will tell you the amount to be applied to your card. You may place your automated telephone order any day (including weekends and holidays) between the hours of 4 am and 11 pm, Mountain Time. Getting your password to use the UPREHS Website First, go to our home page at and choose For Members and select Member Login. If you are not yet registered to use our Website, select registration process from the text to get the registration form. Fill in all of the blanks presented. Please use the information shown on your current ID card. When the computer matches this information to your membership file, your registration will be completed. You will receive a Congratulations notice. Your new password will be ed to the address that you used to register. Your website user name will be your Unique Member ID Number as shown on your UPREHS Health Insurance and Rx Card. Your assigned password will be made up of at least six digits including both letters and numbers. Once you receive your computer-assigned password, you will be able to log on and change the password to one that you can easily remember. Ordering your preferred cost-sharing refills on the UPREHS Website Log in with your password. Select the For Members button at the top of the home page and then choose Member Log in. After you are logged in you can select, Order Prescription Refills in the center of the page. From Order Prescription Refills, you can choose the prescription you want to refill; choose the number of months you want to refill and click on Add to Order; check your cost for the prescription and add the prescription to your order. 14 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2015

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