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

Transcription

1 UPREHS PRIME MEDICARE PART D PRESCRIPTION DRUG PLAN (EMPLOYER PDP) BENEFIT GUIDE Yur Medicare Prescriptin Drug cverage as a Member f the UPREHS Prime Medicare Part D Plan 2016 A $9 cpayment gets yu a 90-day supply f any Tier 1 Generic drug frm the Dept Drug Mail Pharmacy while yu are in yur Initial Cverage benefit stage. This Benefit Guide gives the details abut yur UPREHS Medicare Part D Prescriptin Drug cverage frm January 1, 2016 thrugh December 31, This bk may therwise be knwn as yur Evidence f Cverage (EOC). It is an imprtant legal dcument. Please keep it in a safe place. Benefits, frmulary, pharmacy netwrk, premiums, deductible, and/r cpayments/cinsurance may change n January 1, UPREHS Custmer Service Fr help r infrmatin, please call Custmer Service Mnday thrugh Friday frm 7:30 am t 3:30 pm Muntain Time at Calls t this number are free TTY/TDD Call the natinal number 711 Website: E7316EOC2016

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3 Table f Cntents INTRODUCTION 1 The UPREHS Prime Medicare Plan is a Medicare Part D Prescriptin Drug Plan...1 This Benefit Guide explains hw t get yur Medicare Prescriptin Drug cverage thrugh ur Plan...1 IMPORTANT PHONE NUMBERS AND RESOURCES 2 Hw t cntact the UPREHS Custmer Service...2 Medicare...2 State Health Insurance Assistance Prgram (SHIP) Free Help...2 Quality Imprvement Organizatin (QIO)...3 Scial Security Administratin...3 Railrad Retirement Bard...3 State Pharmacy Assistance Prgram...3 Medicaid...4 Medicare s Extra Help Prgram...4 SECTION 1 PLAN BASICS 5 What is the UPREHS Prime Medicare Prescriptin Drug Plan?...5 Overview f Medicare Prescriptin Drug cverage...5 Hw ther insurance wrks with ur plan...5 If yu have Medicare and Medicaid...6 If yu are a member f a State Pharmacy Assistance Prgram (SPAP)...6 If yu have cverage frm an AIDS Drug Assistance Prgram (ADAP)...6 Help us keep yur membership recrd up-t-date...6 What is the gegraphic service area fr ur Plan?...6 Use yur UPREHS ID Card fr prescriptins instead f yur Medicare card...7 Using plan pharmacies t get yur prescriptin drugs cvered by us...7 Hw d I fill a prescriptin at a retail netwrk pharmacy?...7 Finding a retail netwrk pharmacy...8 What if yur retail netwrk pharmacy is n lnger in ur plan?...8 Filling prescriptins thrugh the Dept Drug Mail Pharmacy?...8 Getting new prescriptins frm the Dept Drug Mail Pharmacy...8 Using ur Website fr refills...9 Use the Dept Drug Mail Pharmacy...9 Getting yur passwrd t use the UPREHS Website...9 Ordering yur refills n the UPREHS Website...10 Order refills at Dept Drug Mail Pharmacy by telephne...10 Filling prescriptins utside the netwrk...11 Hw d I submit a request fr payment?...11 Hme Infusin Pharmacies...12 Lng-term Care Pharmacies...12 Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies...12 What yu pay fr vaccinatins cvered by Part D...12 SECTION 2 PLAN PREMIUM 14 Hw much is yur mnthly plan premium and hw d yu pay it?...14 What happens if yu dn t pay yur plan premiums, r dn t pay them n time?...14 Yu have t cntinue t pay yur Part A and/r Part B premiums...15 Can yur plan premiums change during the year?...15 In sme situatins yur plan premium culd be less...15 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016 I

4 In sme situatins yur plan premium culd be mre...15 What is the late enrllment penalty?...15 Wh pays an extra Part D amunt because f incme?...16 SECTION 3 PRESCRIPTION DRUG COVERAGE 17 What is a frmulary?...17 Hw d yu find ut which drugs are n ur frmulary?...17 What are drug tiers? Prescriptin Cpayment Amunts...18 Smetimes yu can get less than a full mnth s supply...18 Can the frmulary change?...19 What if yur drug is nt n the frmulary?...19 If there are extra rules that apply t the drug yu take...20 Temprary (r transitin) drug supplies...20 What types f drugs des Medicare and/r UPREHS nt cver?...21 There are restrictins n cverage fr sme drugs...22 Prgrams n drug safety...22 Medicatin Therapy Management Prgram t help members manage their medicatins...23 Des yur enrllment in ur Plan affect the drugs cvered under Medicare Part A r Part B?...23 Hw much d yu pay fr drugs cvered by ur Plan in the different benefit levels?...23 Annual Deductible...24 Initial Cverage Benefit Level...24 Out-f-pcket Level (Cverage Gap) befre yu qualify fr Catastrphic Cverage...24 Catastrphic Cverage Level...25 Hw are yur ut-f-pcket csts calculated?...25 Wh can pay fr yur prescriptin drugs, and hw d these payments apply t yur ut-f-pcket csts?...25 Explanatin f Benefits...26 Hw des yur prescriptin drug cverage wrk if yu g t a hspital r skilled nursing facility?...26 SECTION 4 MAKING COMPLAINTS 27 Prblems that are handled by the cmplaint prcess...27 Cmplaints abut ur timeliness n cverage decisins and appeals...28 Step-by-step prcess fr making a cmplaint...28 Step 1 fr making cmplaints...28 Step 2 fr making cmplaints...29 Fr quality f care prblems, yu may als cmplain t the QIO...29 SECTION 5 HOW TO GET A COVERAGE DECISION OR AN APPEAL 30 Is yur prblem r cncern abut yur benefits r cverage?...30 Legal terms...30 Hw t get help when yu are asking fr a cverage decisin (exceptin) r making an appeal...30 What is an exceptin (cverage decisin)?...31 Imprtant things t knw abut asking fr exceptins (cverage decisins)...32 Step-by-Step instructins t ask fr a cverage decisin r an exceptin...32 Step 1 fr Cverage Decisins and Exceptins...32 Step 2 fr Cverage Decisins and Exceptins...34 Step 3 fr Cverage Decisins and Exceptins...35 Making an appeal...35 Step-by-Step instructins t make an Appeal...35 Step 1 t make a Level 1 Appeal...35 Step 2 t make a Level 1 Appeal...36 II UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

5 Step 3 t make a Level 1 Appeal...37 Step-by-step instructins t make a Level 2 Appeal...37 Step 1 t make a Level 2 Appeal...37 Step 2 t make a Level 2 Appeal...37 Step 3 t make a Level 2 Appeal...38 Taking yur appeal t Level 3 and beynd...39 Level 3 Appeal...39 Level 4 Appeal...39 Level 5 Appeal...40 SECTION 6 ENDING YOUR MEMBERSHIP IN THE UPREHS MEDICARE PLANS 41 When can yu end yur membership in UPREHS?...41 What is disenrllment?...41 Yu can end yur membership during the Annual Enrllment Perid...41 In certain situatins, yu can end yur membership during a Special Enrllment Perid...42 T get mre infrmatin abut when yu can end yur membership...43 Hw d yu end yur membership in UPREHS?...43 Yu must keep getting yur prescriptins thrugh ur plan until yur membership ends...44 UPREHS must end yur membership in ur Medicare plans under certain situatins...44 We cannt ask yu t leave ur plan because f yur health...45 Yu have the right t make a cmplaint if we ask yu t leave ur plan...45 SECTION 7 YOUR RIGHTS, RESPONSIBILITIES AND PROTECTIONS 46 Abut yur rights, respnsibilities and prtectins...46 Yur right t be treated with fairness and respect...46 We must ensure that yu get timely access t yur cvered drugs...46 We must prtect the privacy f yur persnal health infrmatin...46 Yur right t get infrmatin abut ur plan, pharmacies and yur cvered drugs...47 We must supprt yur right t make decisins abut yur care...48 Yur right t make cmplaints and t ask us t recnsider decisins we have made...48 What can yu d if yu think yu are being treated unfairly r yur rights are nt being respected?...49 Hw t get mre infrmatin abut yur rights...49 Yu have sme respnsibilities as a member f the UPREHS Medicare Plans...49 SECTION 8 LEGAL NOTICES 51 Ntice abut gverning law...51 Ntice abut nndiscriminatin...51 Ntice abut Medicare Secndary Payer subrgatin rights...51 Infrmatin required by the Emplyee Retirement Incme Security Act f 1974 (ERISA)...51 SECTION 9 DEFINITIONS OF IMPORTANT WORDS USED IN THIS BENEFIT GUIDE (EVIDENCE OF COVERAGE) 53 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016 III

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7 Intrductin Yu are enrlled in the UPREHS Prime Medicare Prescriptin Drug plan. We are pleased that yu ve chsen t allw UPREHS t be yur Part D Plan. The UPREHS Prime Medicare Plan is a Medicare Part D Prescriptin Drug Plan UPREHS is cntracted with the Centers fr Medicare & Medicaid Service (CMS) as an Emplyee Grup Waiver Plan (EGWP) direct cntract Medicare Part D Prescriptin Drug Plan. Medicare must apprve the UPREHS Plan each year. Fr current UPREHS Medicare members, yu were autmatically enrlled in ur Plan s that UPREHS can cntinue t prvide yur prescriptin drug benefits. New plan members must enrll when they becme eligible fr and enrlled in Medicare Parts A and B. The service area fr this plan is natinal including all states in Cntinental America, Alaska, Hawaii and Puert Ric Territry. If yu mve ut f ur service area, please cntact Custmer Service. This Benefit Guide is part f ur cntract with yu abut hw UPREHS cvers yur care. Other parts f this cntract include yur enrllment frm, the Frmulary (list f cvered drugs) 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 mnths in which yu are enrlled in UPREHS starting January 1, 2016 thrugh December 31, Thrughut the remainder f this Benefit Guide, we may als refer t the UPREHS Prime Medicare Plan as plan, we, us, r ur plan. This Benefit Guide explains hw t get yur Medicare Prescriptin Drug cverage thrugh ur Plan This Benefit Guide, tgether with (yur enrllment frm fr new enrllees), riders, and amendments that we may send t yu, is ur cntract with yu. It explains yur rights, benefits, and respnsibilities as a member f ur Plan. It als explains ur respnsibilities t yu. The infrmatin in this Benefit Guide is in effect fr the time perid frm January 1, 2016 thrugh December 31, Medicare must apprve ur plan each year. This Benefit Guide gives yu the details, including: What is and what is nt cvered in ur Plan. Hw t get yur prescriptins filled, including sme rules yu must fllw. What yu will have t pay fr yur prescriptins. What t d if yu are unhappy abut smething related t getting yur prescriptins filled. Hw t leave ur Plan, including yur chices fr cntinuing Medicare Prescriptin Drug cverage. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

8 Imprtant phne numbers and resurces Hw t cntact the UPREHS Custmer Service If yu have any questins r cncerns, please call r write t Custmer Service. We will be happy t help yu. Our Custmer Service hurs are 7:30 am t 3:30 pm, Muntain Time, Mnday thrugh Friday. CALL: Calls t this number are free. TTY/TDD calls use the natinal access number, 711. FAX: help@uphealth.cm WEBSITE: WRITE: UPREHS, PO Bx , Salt Lake City, Utah OR VISIT: UPREHS, 1040 Nrth 2200 West Suite 200, Salt Lake City, UT MAIL NEW PRESCRIPTIONS: UPREHS, PO Bx , Salt Lake City, Utah PART D DRUG APPEALS OR COVERAGE DECISIONS: Call Catamaran tll free at r fax t them at Please use these numbers fr the fllwing: Medicare When yu want t cntact us fr a cverage decisin 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. When yu want t make an appeal abut yur Part D prescriptin drugs. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu want t send a request t ask us t pay fr ur share f the cst f a drug yu have received. The cverage decisin prcess includes determining requests that ask us t pay fr ur share f the csts f a drug that yu have received. This may ccur n Part D cvered vaccinatins, hspital take-hme-drugs, r ut-f-netwrk pharmacy purchases. CALL Medicare, r calls t this number are free and available 24 hurs a day, 7 days a week (TTY/TDD ) WEBSITE Use a cmputer t lk at the fficial gvernment Website fr Medicare infrmatin. This Website gives yu up-t-date infrmatin abut Medicare and current issues. It includes Medicare publicatins yu can print directly frm yur cmputer. It has tls t help yu cmpare Medicare Health Plans and Prescriptin Drug Plans in yur area. Yu can als search the Helpful Cntacts Sectin fr the Medicare cntacts in yur state. If yu d nt have a cmputer, yur lcal library r senir center may be able t help yu visit this Website using their cmputer. State Health Insurance Assistance Prgram (SHIP) Free Help State Health Insurance Assistance Prgram r SHIP is a gvernment prgram with trained cunselrs in every state. Cunselrs give free health insurance infrmatin and help t peple with Medicare. SHIPs have different names depending n which state they are in. Yur SHIP can explain yur Medicare rights and prtectins, help yu make cmplaints abut care r treatment, and help straighten ut prblems 2 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

9 with Medicare bills. Yur SHIP has infrmatin abut Medicare Prescriptin Drug Plans, Medicare Health Plans, and abut Medigap (Medicare supplement insurance) plicies. CALL Medicare at t find the SHIP in yur state WEBSITE t find the SHIP in yur state Quality Imprvement Organizatin (QIO) Quality Imprvement Organizatin (QIO) is a grup f dctrs and health prfessinals in yur state wh review medical care and handle certain types f cmplaints frm patients with Medicare. A QIO is paid by the Federal gvernment t check n and help imprve the care given t Medicare patients. There is a QIO in each state. Medicare cmplaints they review include thse abut quality f care, and patients wh think the cverage fr their hspital stay, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility services are ending t sn. Yu can find cntact infrmatin fr the QIO in yur state by calling Medicare at Scial Security Administratin The Scial Security Administratin 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 at TTY/TDD users shuld call Calls t these numbers are free and are available 7:00 AM t 7:00 pm, Mnday thrugh Friday. Yu can als visit Scial Security is als respnsible fr determining wh has t pay an extra amunt fr their Part D drug 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. Railrad Retirement Bard Mst UPREHS members receive their Medicare benefits thrugh 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. Yu can call yur lcal Railrad Retirement Bard ffice r (calls t this number are free) frm 9:00 AM t 3:30 PM, Mnday thrugh Friday. TTY/TDD users shuld call Yu can als visit State Pharmacy Assistance Prgram Many states have State Pharmacy Assistance Prgrams (SPAP s). SPAP s are State-funded prgrams that prvide financial assistance fr prescriptin drugs t lw-incme and medically needy senir citizens and individuals with disabilities. Each state has different rules t prvide drug cverage t its members. Sme SPAP s will help pay fr the premiums, deductibles, and/r cpayments fr thse wh qualify. Please cntact the SPAP in yur state t determine what benefits may be available t yu. Yu can find the SPAP in yur area by calling Medicare at UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

10 Medicaid A jint Federal and state prgram that helps with medical csts fr sme peple with lw incmes and limited 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. T find ut mre abut Medicaid and its prgrams, cntact yur specific state Medicaid ffice. Yu can find yur state Medicaid ffice by calling Medicare at 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 stck, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium and prescriptin cpayments. 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 and csts. T see if yu qualify fr getting Extra Help, call: MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call ; r Yur state Medicaid Office. If yu believe yu have qualified fr Extra Help and yu believe that yu are paying an incrrect cstsharing 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 c-payment level, r, if yu already have the evidence, t prvide this evidence t us. UPREHS will apply an adjusted cst sharing amunt using Best Available Evidence (BAE) that yu prvide prir t Medicare s ntificatin t us. BAE wuld be a ntice frm yur state Medicaid ffice r Medicare presented t the pharmacy, r faxed t ur Custmer Service. When we receive the evidence frm yu r Medicare shwing yur cpayment level, we will update ur system s that yu can pay the crrect cpayment when yu get yur next prescriptin at the pharmacy. If yu verpay yur cpayment, we will reimburse yu. We will frward a check t yu in the amunt f yur verpayment. Please cntact Custmer Service if yu have questins. 4 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

11 Sectin 1 Plan Basics What is the UPREHS Prime Medicare Prescriptin Drug Plan? UPREHS is cntracted with the Centers fr Medicare & Medicaid Service (CMS) as an Emplyer Grup Waiver Plan (EGWP) direct cntract Medicare Part D Prescriptin Drug Plan. Medicare must apprve ur cntract each year. As an EGWP, ur membership is available nly t Unin Pacific Railrad r affiliated Railrad Medicare retires, and their spuse/widw/widwer. CMS des nt require an EGWP t perfrm sme f the cntractual requirements that apply t fr-prfit Part D plans because f ur membership restrictins. UPREHS was funded slely t serve yu - ur members. Current UPREHS Medicare members have been autmatically enrlled in ur Plan s that UPREHS can cntinue t prvide yur prescriptin drug benefits while yu receive Medicare benefits. Yu are getting yur Medicare Prescriptin Drug cverage thrugh UPREHS. This Benefit Guide explains yur benefits, what yu have t pay, and the rules yu must fllw t get yur prescriptin drugs cvered. Overview f Medicare Prescriptin Drug cverage Medicare Prescriptin Drug cverage is insurance that helps pay fr yur prescriptin drugs, vaccines, bilgicals, and sme supplies nt cvered by Medicare Part B. We will generally cver the drugs listed in ur frmulary as lng as the drug is medically necessary, the prescriptin is filled at a plan pharmacy, Medicare Part D cvers it, and ther cverage rules are fllwed. We d nt pay fr drugs under Medicare Part D that are cvered by Medicare Part B. As a member, all yu have t d is cntinue t pay yur Part B premium and yur UPREHS mnthly premium and cpayments. The amunt f the mnthly premium is nt affected by yur health status r hw many prescriptins yu need. If yu have limited incme and resurces, yu may get Extra Help frm Medicare t pay yur premium and cpayments s that yu get yur prescriptin drugs fr little r n cst. Please call the Scial Security Administratin at t learn mre abut Extra Help. Hw ther insurance wrks with ur plan If yu have any ther prescriptin drug cverage in additin t ur plan, yu are required t tell us. Please call Custmer Service t let us knw. We are required t fllw rules set by Medicare t make sure that yu are using all f yur benefits in cmbinatin when yu get yur cvered drugs frm ur plan. This is called crdinatin f benefits because it invlves crdinating the drug benefits yu get frm ur plan with any ther drug benefits available t yu. We ll help yu with it. Medicare law requires us t cllect this infrmatin frm yu when yu r yur spuse enrlls in the UPREHS Medicare Plans, r when ther insurance becmes invlved. 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 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

12 Veterans Administratin. Medicare Part D des nt crdinate with prescriptins supplied by the VA. Either the VA pays, r Medicare Part D pays, but nt bth. 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 UPREHS, yur dctr, hspital, and pharmacy. 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. The infrmatin yu prvide helps us calculate hw much yu and thers have paid fr yur drugs. In additin, if yu lse r get additinal prescriptin drug cverage, please call Custmer Service at t update yur membership recrds. If yu have Medicare and Medicaid Medicare, nt Medicaid, will pay fr mst f yur prescriptin drugs. Yu will cntinue t get yur health cverage under bth Medicare and Medicaid as lng as yu still qualify fr Medicaid benefits. If yu are a member f a State Pharmacy Assistance Prgram (SPAP) If yu are currently enrlled in a SPAP, yu may get help paying yur premiums, and/r cpayments. Please cntact yur SPAP t determine what benefits are available t yu. Please see the Intrductin Sectin f this bk fr mre infrmatin. If yu have cverage frm an AIDS Drug Assistance Prgram (ADAP) The AIDS Drug Assistance Prgram (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access t life-saving HIV medicatins. Medicare Part D prescriptin drugs that are als cvered by ADAP qualify fr prescriptin cst-sharing assistance. Nte: T be eligible fr the ADAP perating in yur State, individuals must meet certain criteria, including prf f State residence and HIV status, lw incme as defined by the State, and uninsured/under-insured status. Fr infrmatin n eligibility criteria, cvered drugs, r hw t enrll in the prgram, please call Medicare at Help us keep yur membership recrd up-t-date We have a file f infrmatin abut yu as a plan member. Pharmacists use this membership recrd t knw what drugs are cvered fr yu. The membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage and ther infrmatin. Please help us keep yur membership recrd up-t-date by letting Custmer Service knw right away if there are any changes in yur name, address, r phne number, r if yu g int a nursing hme. Als, tell Custmer Service abut any changes in prescriptin drug cverage yu have frm ther surces, such as frm Medicaid, frm a current r different emplyer, r yur spuse s current r frmer emplyer. Yu shuld tell Custmer Service abut any changes in cverage due t claims filed under liability insurance, such as wrkers cmpensatin claims r claims against anther driver in an autmbile accident. What is the gegraphic service area fr ur Plan? UPREHS is a Natinal Medicare Prescriptin Drug Plan and includes all states and Alaska, Hawaii, and the territry f Puert Ric. We cannt pay fr any prescriptins that are filled by pharmacies utside f the United States, even fr a medical emergency. 6 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

13 Use yur UPREHS ID Card fr prescriptins instead f yur Medicare card As a member f ur plan, ne card des it fr yu! Yu have a cmbined UPREHS Health Insurance and Rx ID card. Use yur UPREHS ID card t btain prescriptins (nt yur Medicare card). Yu will need bth yur Medicare (red, white and blue card) and UPREHS ID cards fr yur medical services. During the time yu are a plan member and using plan benefits, yu must use yur UPREHS ID card. This ID card prtects yur privacy by using a UPREHS unique ID number that we use t identify yu. Yur UPREHS number is NOT yur Scial Security number r yur Medicare Part A and B number. Yu must use the UPREHS ID number n yur card t identify yurself when btaining prescriptins thrugh all pharmacies, when cntacting UPREHS Custmer Service, and when btaining yur persnal infrmatin frm the UPREHS Website. Please carry yur UPREHS ID card with yu at all times. If yur membership card is ever damaged, lst, r stlen, call UPREHS Custmer Service at right away and we will send yu a new card. Using plan pharmacies t get yur prescriptin drugs cvered by us What are netwrk pharmacies? Use Dept Drug Pharmacies t get yur 90-day prescriptin drug supplies. What is the Dept Drug Mail Pharmacy? Dept Drug Mail Pharmacy prvides prescriptins in supplies. Yu need t btain 90-day supplies f all Tier 1 generic drugs when using the Dept Drug Mail Pharmacy. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. Yu may cntinue t btain a 30, 60 r 90-day supply f Tier 2, 3 r 4 prescriptin drugs frm Dept Drug Mail Pharmacy. Dept Drug pharmacies have lw cpayments because UPREHS wns them. They were established slely t serve ur members. Our savings are returned t yu in the frm f lwer cpayments and expanded pharmacy benefits. What is a retail netwrk pharmacy? This is a pharmacy at which yu can get prescriptins that yu want in less than 90-day supplies. Cpayments at these pharmacies are higher than thse at Dept Drugs pharmacies. We call them retail netwrk pharmacies because they are under cntract with ur plan. They are still a netwrk pharmacy, but their price fr cvered prescriptin drugs is mre than UPREHS pays. That is the reasn that yur cpayments are higher if yu use a retail netwrk pharmacy. What are cvered drugs? All Medicare Part D cvered drugs are included in ur frmulary. A cvered drug is the general term we use t mean all f the utpatient prescriptin drugs that are cvered by ur plan and Medicare Part D. Hw d I fill a prescriptin at a retail netwrk pharmacy? T fill yur prescriptin at a retail netwrk pharmacy, yu must shw yur UPREHS ID card. If yu d nt have yur ID card with yu when yu fill yur prescriptin, yu may have t pay the full cst f the prescriptin (rather than paying just yur cpayment). If this happens, yu can ask us t reimburse yu fr ur share f the cst by submitting yur prescriptin receipt t us alng with a cmpleted UPREHS Prescriptin Claim Frm fund n the UPREHS website at r by calling Custmer Service at T learn hw t submit a paper claim, please refer t the paper claims prcess described at the end f this Sectin. If yu must use a retail netwrk pharmacy, ask yur physician fr tw (2) prescriptins, a ne-mnth supply t be filled at yur lcal pharmacy and a lng-term prescriptin t be filled in 90-day supplies thrugh the Dept Drug Mail Pharmacy per the instructins in this Sectin. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

14 Finding a retail netwrk pharmacy Mst lcal and natinal chain pharmacies are in ur retail pharmacy netwrk. Since ur plan is a natinal plan, all pharmacies cannt be listed in a directry. The pharmacist can tell yu if their pharmacy is in netwrk simply by shwing them yur UPREHS ID card. Yu can call ur Custmer Service at if yu have questins. What if yur retail netwrk pharmacy is n lnger in ur plan? Very rarely a pharmacy might leave ur netwrk. If this happens, yu will need t fill yur prescriptins at anther participating retail netwrk pharmacy. Please call Custmer Service at t find anther retail netwrk pharmacy in yur area. Filling prescriptins thrugh the Dept Drug Mail Pharmacy? There are sme maintenance prescriptin drugs that cannt be sent thrugh the mail. Dept Drug Mail Pharmacy des NOT supply thse prescriptins. Please refer t yur Frmulary bk and lk fr the BI (benefit indicatr clumn). Then lk fr the RO (Retail Only) indicatr. UPREHS has determined that it is in the best interest f ur members t have these drugs supplied thrugh yur lcal retail netwrk pharmacy and nt in the mail. Beginning January 1, 2016, Dept Drug Mail Pharmacy can nly ship 90-day supplies f Tier 1 generic prescriptin drugs. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. Yu may cntinue t btain a 30, 60 r 90-day supplies f Tier 2, 3 r 4 prescriptin drugs frm Dept Drug Mail Pharmacy. Getting new prescriptins frm the Dept Drug Mail Pharmacy Ordering new prescriptins is easy, and yu are nt charged shipping csts. UPREHS must fllw Federal Medicare rules when we fill new prescriptins. Fllw these directins t fill new prescriptins: Mst physicians send prescriptins electrnically (e-prescribe) t yur preferred pharmacy. Yur UPREHS ID card includes Dept Drug Mail Pharmacy electrnic prescribing infrmatin. UPREHS must fllw Federal Medicare rules prhibiting autmatically shipping when filling these prescriptins. UPREHS will autmatically fill a 90-day supply f prescriptins csting yu less than $75. Delivery will be delayed and yu will be cntacted fr authrizatin t fill any prescriptins that will cst yu mre than $75. We cannt fill higher cst prescriptins at all withut yur permissin, s be sure t call ur Custmer Service at when yur dctr sends yur new prescriptins electrnically. Dept Drug Mail Pharmacy cannt fill yur prescriptins sent electrnically r faxed t us by yur dctr that will cst yu mre than $75 unless we have yur specific authrizatin t d s. Yu need t call Custmer Service at t give this authrizatin when yu knw the dctr is sending us a new prescriptin. We encurage physicians t e-prescribe fr yu (send electrnic prescriptins t NCPDP # ) Hwever, we will still need yur permissin and instructins t be able t ship yur medicatin. When yu btain a new written prescriptin(s) frm yur dctr, yu can send it t UPREHS with yur instructins. Make certain the number f refills the dctr wants yu t have is clearly indicated n yur prescriptin. Yur prescriptin can remain valid fr up t ne (1) calendar year n mst drugs, but it cannt be refilled after that time. If yu cntinue t need the medicatin after the prescriptin expires, yu must get a new prescriptin frm yur physician. Use a 8 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

15 separate sheet f paper t shw yur name and UPREHS ID card number exactly as they appear n yur ID card, yur shipping address, and yur dctr s name and telephne number with the area cde. Yu need t btain 90-day supplies when using the Dept Drug Mail Pharmacy. If yu need less than a 90-day supply, yu must use a retail netwrk pharmacy. Withut cpayment(s), yur prescriptin(s) cannt be filled. Yu can pay by check r mney rder payable t the Dept Drug Mail Pharmacy. It is easier fr yu and UPREHS t pay yur cpayment with yur debit r credit card. That way, yu will nt need t guess the amunt f yur cpayment. T use yur debit r credit card, write dwn the type f card (MasterCard, Discver, r VISA nly) and the entire debit r credit card number and expiratin date f yur card. Once yur card number is n file with Dept Drug Mail Pharmacy, yu d nt need t send the number each time, but yu must specifically authrize us t use yur debit r credit card n file fr yur cpayment t fill each prescriptin. Allw ten (10) wrking days fr mail delivery f yur prescriptins. Debit r credit card payment is the mst cnvenient way t pay yur prescriptin cpayments when yu dn t knw hw much t pay. We tell yu hw much we applied t yur debit r credit card fr yur cpayment n yur receipt. Mail the prescriptin(s), yur persnal infrmatin, and yur applicable Tier cpayment (r debit r credit card infrmatin and yur authrizatin t charge yur card) fr the prescriptin(s) t: Dept Drug Mail Pharmacy, PO Bx , Salt Lake City, UT Using ur Website fr refills UPREHS ffers yu the cnvenience f rdering yur prescriptin refills using ur Website at Yu must use yur debit r credit card (MasterCard, Discver, r Visa nly) fr Website rdering. T register n the UPREHS website, fllw the instructins belw. Yu can call UPREHS Custmer Service at r Help@uphealth.cm if yu need help. When yu fill r refill prescriptins at the Dept Drug Mail Pharmacy, yu can receive ntificatins abut yur prescriptin rders. T receive cnfirmatin that Dept Drug has received yur rder and cnfirmatin abut when yur rder was shipped yu must register as a member with yur address at (See hw under Getting yur passwrd t use the UPREHS Website n the next page.) Use the Dept Drug Mail Pharmacy Yur prescriptins are easy t refill nce they are already n file with the Dept Drug Mail Pharmacy. Yu may re-rder anther 90-day supply in 69 days, r mre after yur last 90-day refill s that yu wn t run ut f yur medicatin. A cnvenient rerder frm is included in each prescriptin sent t yu. Simply indicate the supply and yur methd f payment. If yu are nt using yur debit r credit card, include a check r mney rder fr yur cpayment and mail the frm t the address indicated n the frm. Getting yur passwrd t use the UPREHS Website First, g t ur hme page at and chse Fr Members and select Member Lgin. If yu are nt yet registered t use ur Website, select registratin prcess frm the text t get the registratin frm. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

16 Fill in all f the blanks presented. Please use the infrmatin shwn n yur current ID card. When the cmputer matches this infrmatin t yur membership file, yur registratin will be cmpleted. Yu will receive a Cngratulatins ntice. Yur new passwrd will be ed t the address that yu used t register. Yur website user name will be yur Unique Member ID Number as shwn n yur UPREHS Health Insurance and Rx Card. Yur assigned passwrd will be made up f at least six digits including bth letters and numbers. Once yu receive yur cmputer-assigned passwrd, yu will be able t lg n and change the passwrd t ne that yu can easily remember. Ordering yur refills n the UPREHS Website Yu can lg int the UPREHS Website at using yur persnal passwrd. Select the Fr Members buttn at the tp f the hme page and then chse Member Lg in. After yu are lgged in yu can select, Order Prescriptin Refills in the center f the page. Frm Order Prescriptin Refills, yu can chse the prescriptin yu want t refill; click Add t Order; check yur cst fr the prescriptin and add the prescriptin t yur rder. When yu have entered all the prescriptins yu want t rder, click n Begin Checkut Prcess. Yu will be asked t enter yur daytime telephne number and then t verify the last 4 digits f yur debit r credit card and the expiratin date. Yu may enter different debit r credit card infrmatin, r if a debit r credit card is nt n file, yu may enter yur card number and expiratin date (MasterCard, Discver, r Visa nly). Yu will be asked t verify the prescriptins yu have rdered, and the amunt t be charged t yur debit r credit card and the address t which the prescriptins will be shipped. Remember, Dept Drug Mail Pharmacy prvides nly 90-day supplies f Tier 1 generic drugs. At any time up t this pint yu can g back t edit yur entries r cancel the entire rder. Please cancel the rder and call Custmer Service at if the shipping address is incrrect, r if yu d nt agree with the ttal cst t yu. Yu can then click n Submit Order fr Prcessing, and the message will verify that yur rder has been placed and will display an rder cnfirmatin number. Order refills at Dept Drug Mail Pharmacy by telephne Just call UPREHS Custmer Service tll-free number, and fllw the interactive vice respnse instructins. Yu must use yur debit r credit card (MasterCard, Discver, r VISA) fr cpayments t rder refills by telephne. T use the telephne refill service: Have yur UPREHS ID card; yur debit r credit card (MasterCard, Discver, r Visa) and the prescriptin number(s) t be refilled ready befre yu place yur call. Call the UPREHS Custmer Service telephne number tll free at Fllw the instructins f the autmated service line t rder yur refill(s) and pay the cpayment(s) using yur debit r credit card. The autmated system will tell yu the amunt t be applied t yur card. Yu may place yur autmated telephne rder any day (including weekends and hlidays) between the hurs f 4 am and 11 pm, Muntain Time. 10 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

17 Filling prescriptins utside the netwrk Befre yu fill yur prescriptin utside the retail pharmacy netwrk, call UPREHS Custmer Service at t see if there is a retail netwrk pharmacy in yur area where yu can fill yur prescriptin. Failure t d s may cause yur payment request t be denied. Generally, UPREHS als limits the quantity f drugs cvered ut f netwrk when apprved. We will cver yur prescriptin at an ut f netwrk pharmacy if at least ne f the fllwing applies: If yu are trying t fill a prescriptin drug that is nt regularly stcked at the Dept Drug Mail Pharmacy, r an accessible retail netwrk pharmacy (including mst specialty, high cst and unique drugs). If yu are unable t btain a cvered drug in a timely manner because there is n retail netwrk pharmacy within a reasnable driving distance that prvides 24-hur service. If yu are getting a cvered vaccine that is medically necessary but nt cvered by Medicare Part B and/r sme cvered drugs that are administered in yur dctr s ffice. Sme hspital take-hme drugs are cvered by Part D. If yu d g t an ut f netwrk pharmacy fr the reasns listed abve, yu will have t pay the full cst (rather than paying just yur cpayment) when yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share f the cst by submitting a paper claim cmpleted by the pharmacy and yur receipt fr the medicatin with a letter explaining yur situatin t Catamaran, the UPREHS representative fr these issues. If yu g t an ut f netwrk pharmacy, yu are respnsible fr paying the applicable cpayment and the difference between what we wuld have paid fr the medicatin and what the ut f netwrk pharmacy charged fr yur medicatin. Yu shuld submit a claim t us if yu fill a prescriptin at an ut f netwrk pharmacy as any amunt yu pay will help yu qualify fr catastrphic cverage (see Sectin 3). T learn hw t submit a request fr payment, please refer t the prcess described next. Hw d I submit a request fr payment? When yu get yur prescriptins frm a Dept Drug Pharmacy, r a retail netwrk pharmacy, yur claim is autmatically submitted t UPREHS. If yu g t an ut f netwrk pharmacy because f the reasns listed abve, the pharmacy will usually nt be able t submit the claim directly t us and yu will have t pay the full cst f yur prescriptin. Yu may have the pharmacy submit yur claim fr yu. UPREHS prvides a claim frm n ur website at Please submit yur cmpleted frm, yur receipt and yur letter explaining yur situatin t the fllwing address: Catamaran P.O. Bx Schaumburg, IL Upn receipt, an initial cverage decisin will be made n yur request. If it is determined that the prescriptin is cvered, and the paper claims frm is cmpleted by the pharmacy, Catamaran will mail the payment fr ur cst f the drug minus the applicable cpay amunt directly t yu. All payment requests will be paid at the UPREHS Dept Drug cntract rate and the applicable Tier c-payment will be applied based n yur Part D benefit level. Payment culd be denied if yur receipt des nt cntain all f the infrmatin that Medicare requires us t have fr a cverage decisin. (Please refer t Sectin 5 fr mre infrmatin abut initial cverage decisins.) T receive ur cverage decisin and pssible payment fr vaccine and administratin csts frm yur physician that is nt cvered by Medicare Part B, please have yur physician print, cmplete and mail the Prescriptin Drug Claim Frm fund n ur website at Yu may cntact ur Custmer Service at They will supply yu and/r yur physician with a paper claim UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

18 frm that gives the infrmatin that Medicare requires that we have in rder t pay fr yur vaccine and administratin csts. Hme Infusin Pharmacies It is ur plicy t cntract with any willing Hme Infusin Pharmacy that meets state, Federal and UPREHS requirements t becme a netwrk HI Pharmacy. UPREHS requires that yu, yur representative r the Hme Infusin Pharmacy immediately cntact UPREHS Custmer Service if yu find yu need HI therapy. We will direct yu t the nearest netwrk HI Pharmacy. UPREHS usually cannt supply Hme Infusin therapy drugs s yu must use ne f ur HI netwrk pharmacies. We will cver HI drugs that are nt btained thrugh either f these surces n a temprary basis if the need is urgent. The UPREHS Part D Medicare Plan will cver hme infusin therapy if: Yur prescriptin drug is a Part D drug and n ur frmulary; Yur prescriptin is written by an authrized prescriber; and Yu get yur hme infusin Service frm a UPREHS Hme Infusin netwrk pharmacy. Lng-term Care Pharmacies UPREHS has many Lng Term Care netwrk pharmacies thrugh ur netwrk that prvide special Lng Term Care prescriptin dsing and packaging. UPREHS has a natinal LTC pharmacy netwrk, but it is impssible fr us t cntract with every LTC pharmacy in the natin. It is ur plicy t cntract with any willing LTC pharmacy that meets state, Federal and UPREHS requirements t becme a netwrk LTC Pharmacy. UPREHS will cver Lng Term Care drugs that are nt btained thrugh a netwrk pharmacy n a temprary basis if the need is urgent. Fr mre infrmatin, please cntact Custmer Service. Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies Only Native Americans and Alaska Natives have access t Indian Health Service/Tribal/Urban Indian Health Prgram (I/T/U) Pharmacies thrugh ur netwrk pharmacy and in limited areas. It is ur plicy t cntract with any willing I/T/U pharmacy that meets state, Federal and UPREHS requirements t becme a netwrk pharmacy. Please cntact Custmer Service fr mre infrmatin. What yu pay fr vaccinatins cvered by Part D We cver a number f Part D vaccines. There are tw parts t ur cverage f vaccinatins: The first part f cverage is the cst f the vaccine medicatin itself. The vaccine is a prescriptin medicatin. The secnd part f cverage is fr the cst f giving yu the vaccinatin sht. (This is smetimes called the administratin f the vaccine.) What yu pay fr a Part D vaccinatin depends n three things: 1. The type f vaccine (what yu are being vaccinated fr). Sme vaccines are cnsidered Part D drugs. Yu can find these vaccines listed in ur Frmulary Bk. Other vaccines are cnsidered medical benefits. They are cvered under Original Medicare. 12 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

19 2. Where yu get the vaccine medicatin. 3. Wh gives yu the vaccinatin sht. What yu pay at the time yu get the Part D vaccinatin can vary depending n the circumstances. Fr example: Smetimes when yu get yur vaccinatin sht, yu will have t pay the entire cst fr bth the vaccine medicatin and fr getting the vaccinatin sht. Yu can ask ur plan t pay yu back fr ur share f the cst. Other times, when yu get the vaccine medicatin r the vaccinatin sht, yu will pay nly yur share f the cst. T shw hw this wrks, here are three cmmn ways yu might get a Part D vaccinatin sht: Situatin 1: Yu buy the Part D vaccine at the pharmacy and yu get yur vaccinatin sht at the netwrk pharmacy. (Whether yu have this chice depends n where yu live. Sme states d nt allw pharmacies t administer a vaccinatin.) Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine and administratin f the vaccine. Situatin 2: Yu get the Part D vaccinatin at yur dctr s ffice. When yu get the vaccinatin, yu will pay fr the entire cst f the vaccine and its administratin. Yu can then ask ur plan t pay ur share f the cst by using the prcedures fr submitting a request fr payment that is described in this Sectin f this bklet. Situatin 3: Yu buy the Part D vaccine at yur pharmacy, and then take it t yur dctr s ffice where they give yu the vaccinatin sht. Yu will have t pay the pharmacy the amunt f yur cpayment fr the vaccine serum itself. When yur dctr gives yu the vaccinatin sht, yu will pay the entire cst fr this service. Yu can then ask ur plan t pay ur share f the cst by using the prcedures described in this Sectin. Yu will be reimbursed the amunt UPREHS nrmally pays fr the dctr t administer the vaccine. The rules fr cverage f vaccinatins are cmplicated. We are here t help. We recmmend that yu call us first at Custmer Service whenever yu are planning t get a vaccinatin. We can tell yu abut hw yur vaccinatin is cvered by ur plan and explain yur share f the cst. Yur physician can cpy the Prescriptin Drug Claim Frm frm ur website and submit a claim fr vaccine and administratin directly t Catamaran at P.O. Bx Schaumburg, IL Yu can cntact ur Custmer Service at and they will supply yu and/r yur physician with this claim frm that gives us the infrmatin that Medicare requires. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

20 Sectin 2 Plan Premium NOTE: If yu are receiving Extra Help paying fr yur drug cverage, the premium amunt that yu pay as a member f ur plan is listed in yur Evidence f Cverage Rider. Or, if yu are a member f a State Pharmacy Assistance Prgram (SPAP), yu may get help paying yur premiums. Please cntact yur SPAP t determine what benefits are available t yu. Hw much is yur mnthly plan premium and hw d yu pay it? Yur 2016 UPREHS Medicare Plans premium is $230 per mnth. Members pay a cmbined premium fr all Medicare Plans each mnth. Because the premiums are cmbined, UPREHS members are nt eligible fr premium withhld frm the RRB. UPREHS charges a $20 service fee fr any premium payments rejected fr any reasn. There are tw ways t pay yur mnthly plan premium. Optin ne pay quarterly: Pay yur plan premium quarterly (3 mnths at a time) by check, mney rder, r autmatic deductin frm yur checking r savings accunt. If yu pay by check r mney rder, we must receive yur payment by the first f the mnth f every January, April, July, and Octber beginning with January 1, If yu chse autmatic deductins, we will debit yur bank accunt n the secnd Mnday f every December, March, June, and September. If yu have any questins abut signing up fr the autmatic premium payment ptin, t receive an authrizatin frm, yur plan premiums r the different ways t pay them, please call ur Custmer Service at Optin tw pay mnthly: Yu can pay yur plan premium mnthly thrugh autmatic premium deductin frm yur checking r savings accunt. We cannt accept mnthly payments sent directly t UPREHS. We ffer payment f yur cmbined UPREHS Medicare Plans premiums mnthly nly if yu have the amunt autmatically deducted frm yur bank accunt. If yu d nt have a checking accunt yu can use yur savings accunt. Mnthly payments must be made thrugh autmatic bank accunt withdrawals. We cannt accept mnthly payments sent directly t us. If yu have any questins abut signing up fr the autmatic premium payment ptin, t receive an authrizatin frm, yur plan premiums r the different ways t pay them, please call ur Custmer Service at What happens if yu dn t pay yur plan premiums, r dn t pay them n time? If yur plan premiums are past due, we will tell yu in writing within 15 days. Medicare requires us t disenrll yu frm ur plan after the secnd mnth f failure t pay yur past-due plan premiums. If yu are disenrlled frm UPREHS fr any reasn including nnpayment f yur premium, yu may nt have anther pprtunity t enrll again. Als, if yu are disenrlled fr this reasn, yu will nt be able t enrll in anther Medicare Prescriptin Drug Plan until the next Annual Crdinated Enrllment Perid, unless yu qualify fr a Special Enrllment Perid. If yu d nt qualify fr a Special Enrllment Perid r have anther surce f creditable prescriptin drug cverage, yu may have t pay a late enrllment penalty the next time yu enrll in a Medicare Prescriptin Drug Plan r a Medicare Advantage Plan with prescriptin drug cverage. Please see Sectin 6 fr mre abut enrllment perids. 14 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

21 Yu have t cntinue t pay yur Part A and/r Part B premiums T be a member f ur plan, yu must be entitled t Medicare Part A and enrlled in Medicare Part B. Yu must pay yur Part B premiums. If yu currently pay a premium fr Medicare Part A (mst peple dn t) and/r Medicare Part B, yu must cntinue paying yur premium in rder t keep yur Medicare Part A and/r Medicare Part B and t remain a member f ur UPREHS Medicare Plans. Can yur plan premiums change during the year? Generally, UPREHS cannt change yur plan premium during the calendar year. We will tell yu in advance if there will be any changes fr the next calendar year in yur plan premiums r in the amunts yu will have t pay when yu get yur prescriptins cvered. If there are any changes fr the next calendar year, they will take effect n January 1, Refer t yur 2016 Annual Ntice f Changes. In limited circumstances, yur plan premium may change during the calendar year. If yu aren t currently receiving Extra Help but yu qualify fr it during the year, yur mnthly premium culd be lwer. 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. If yu qualify, enrlling in ne f these prgrams might lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, the infrmatin abut yur premiums in this Benefit Guide may nt apply t yu. In sme situatins yur plan premium culd be mre 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. Their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. If yu are required t pay the late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. If yu have a late enrllment penalty and d nt pay it, yu culd be disenrlled frm the plan. What is the late enrllment penalty? Yu will have t pay a late enrllment penalty in additin t yur mnthly plan premium if bth f the fllwing tw factrs are present: Yu were eligible t enrll in a Medicare Prescriptin Drug Plan; and After the end f yur initial enrllment perid, there was a cntinuus perid f 63 days r lnger in which yu were nt enrlled in a Medicare Prescriptin Drug Plan r ther creditable prescriptin drug cverage. Creditable prescriptin drug cverage is cverage that is at least as gd as the standard Medicare Prescriptin Drug cverage that expects t pay, n average, at least as much as the Medicare Prescriptin Drug benefit expects t pay. Yu pay this late enrllment penalty fr as lng as yu have Medicare Prescriptin Drug cverage. The amunt f the late enrllment penalty may increase every year. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE