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: [email protected] 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 [email protected] 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

22 The late enrllment penalty des nt apply t individuals wh qualify fr Extra Help with their drug plan csts. NOTE: Many Medicare-eligible UPREHS members are still active wrkers with the Unin Pacific Railrad. Yu will NOT be assessed the late enrllment penalty when yu decide t retire and enrll in Medicare because yu have creditable prescriptin drug cverage under the UPREHS Active Health Plan cverage. Wh pays an extra Part D amunt because f incme? Mst peple pay a standard mnthly Part D premium. Hwever, sme peple pay an extra amunt because f their yearly incme. If yur incme is abve the set amunt fr an individual (r married individuals filing separately) r abve the amunt fr married cuples, yu must pay an extra amunt directly t the gvernment fr yur Medicare Part D cverage. If yu have t pay an extra amunt, Scial Security, nt UPREHS, will send yu a letter telling yu what that extra amunt will be and hw t pay it. The extra amunt will be withheld frm yur Scial Security, Railrad Retirement Bard, r Office f Persnnel Management benefit check, n matter hw yu usually pay yur plan premium, unless yur mnthly benefit isn t enugh t cver the extra amunt wed. If yur benefit check isn t enugh t cver the extra amunt, yu will get a bill frm Medicare. The extra amunt must be paid separately t the gvernment and cannt be paid with yur UPREHS mnthly plan premium. If yu disagree abut paying an extra amunt because f yur incme, yu can ask Scial Security t review the decisin. T find ut mre abut hw t d this, cntact Scial Security at (TTY ). The extra amunt is paid directly t the gvernment (nt UPREHS) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm UPREHS Medicare plans and lse prescriptin drug cverage and yur Medicare HCPP and Medicare Secndary Plan cverage. This disenrllment actin is taken by Medicare. 16 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

23 Sectin 3 Prescriptin Drug Cverage This Sectin describes yur prescriptin drug cverage as a member f ur plan. We will explain what a frmulary is and hw t use it, ur drug management prgrams, hw much yu will pay when yu fill a prescriptin fr a cvered drug, and what an Explanatin f Benefits is. What is a frmulary? We have a frmulary that lists all drugs that we cver. Fr 2016, we have included all Medicare Part D drugs in ur frmulary. We will generally cver the drugs listed in ur frmulary as lng as the drug is medically necessary; the prescriptin is filled thrugh ur Dept Drug Pharmacies r at a retail netwrk pharmacy, it is a cvered Medicare Part D drug, and ther cverage rules are fllwed. Fr certain prescriptin drugs, we have additinal requirements fr cverage r limits. These requirements and limits are described in detail in yur Frmulary Bk and in this Sectin. Medicare and ur plan, with the help f a team f health care prviders select the drugs n the frmulary. We select the prescriptin therapies believed t be a necessary part f a quality treatment prgram and bth brand name drugs and generic drugs are included n the frmulary. A generic drug has the same active ingredient frmula as the brand name drug. Generic drugs are rated by the Fd and Drug Administratin (FDA) t be as safe and as effective as brand name drugs. We have included all Medicare Part D cvered drugs n ur frmulary. In sme cases, the law prhibits us frm cvering certain types f drugs. See Drug Exclusins, later in this Sectin, fr mre infrmatin abut the types f drugs that cannt be cvered under a Medicare Prescriptin Drug Plan. In certain situatins, prescriptins filled at an ut f netwrk pharmacy may als be cvered. See Sectin 1 fr mre infrmatin abut filling prescriptin at ut f netwrk pharmacies. If yu need yur maintenance prescriptin filled urgently, yu may have a 30-day fill at a retail netwrk pharmacy. 90-day refills must g thrugh the Dept Drug Mail Pharmacy with the exceptin f narctic drugs, drugs btained thrugh a Specialty Drug Pharmacy and drugs with Quantity Limits. Hw d yu find ut which drugs are n ur frmulary? Yu have been sent a 2016 UPREHS Prime Medicare Plan Drug Frmulary Bk with Tier 1, 2, 3, 4 and 5 drugs listed. Yur Frmulary Bk is an abridged versin that des nt list all strengths r multiple names f the drug. All cvered Medicare Part D drugs are n yur frmulary. Since a frmulary can change at any time, if there is any questin abut drug cverage, yu can visit ur Website at r yu can call Custmer Service fr clarificatin at What are drug tiers? Drugs n ur frmulary are rganized int different drug tiers, r grups f different drug types. Yur cpayment depends n which drug tier yur drug is in. The table belw shws the cpayment and/r cinsurance amunt yu pay fr each tier when yu are in yur initial cverage limit and when yu btain yur prescriptin frm the Dept Drug Pharmacies, r a retail netwrk r specialty drug pharmacy. As yu can see, yur benefits are stretched thrugh lwer cpayments and lwer drug prices when yu btain yur prescriptins frm the Dept Drug Pharmacies. These savings are returned t yu in the frm f lwer cpayments and expanded pharmacy benefits. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

24 2016 Prescriptin Cpayment Amunts 2016 Prescriptin Cpayment Amunts fr Part D Drugs In Initial Cverage Stage Dept Drug Pharmacies $$$ Yur Best Mney Saver Tier 1 Generic drugs 90-day supplies nly. Tiers 2, 3 & 4 drugs may be 30, 60, r 90-day supplies. Natinal Retail Pharmacy Netwrk Includes Specialty Pharmacies 30-Day Supplies (r less) TIER 1 Preferred Generic (30-Day) $3 ($9 fr 90-day) TIER 2 Generic Drugs (30-Day) TIER 3 Preferred Brand (30-Day) $10 $15 $15 $20 $30 TIER 4 Brand Drugs (30-Day) Greater f $75 r 33% f drug cst Greater f $90 r 33% f drug cst TIER 5 Specialty & High Cst (30-Day) Nt Available 33% f drug cst Nte: If the actual cst f a drug is less than the Tier cpayment amunt fr that drug, yu will pay the actual cst plus dispensing fee, nt the cpayment! Sme drugs wuld cst yu less under this rule s make sure that yu use yur UPREHS ID Card! Changes t available drug supplies frm Dept Drug Mail Pharmacy 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. Changes t generic drug Tiers and cpayments fr 2016 Generic drugs have been changed t nw have tw Tiers. Tier 1 includes all lw cst Part D generic drugs. Tier 1 generic drug cpayments remain the same at $9 fr a 90-day supply frm Dept Drug Mail Pharmacy. 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. Csts fr Tier 1 generic drugs remain the same at retail pharmacies at $15 fr a 30-day supply. Tier 2 includes much mre expensive generic drugs. Tier 2 generic drug cpayments are $10 fr a 30- day supply frm the Dept Drug Mail Pharmacy and $20 fr a 30-day supply frm retail netwrk pharmacies. 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. Smetimes yu can get less than a full mnth s supply Dept Drug Pharmacies d nt supply a partial fill fr a drug nrmally taken daily, r fr prescriptins regarded as a ne mnth supply but are taken fr a shrter time (sme antibitics). Yu will need t get thse frm retail netwrk pharmacies. Usually yu pay a cpay t cver a full mnth s supply f a cvered drug, r fr a full prescriptin that is less than 30 days (like an antibitic). Fr drugs that wuld nrmally be taken daily, yur dctr can prescribe less than a mnth s supply f drugs. There may be times when yu want t ask yur dctr abut prescribing less than a mnth s supply f a drug that is new fr yu (fr example, when yu are 18 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

25 trying a medicatin fr the first time that is knwn t have serius side effects). If yu dctr agrees, yu will nt have t pay fr the full mnth s supply fr certain drugs n a new prescriptin. The amunt yu pay when yu get less than a full mnth s supply fr a new drug that is nrmally taken daily will depend n whether yu are respnsible fr paying cinsurance (a percentage f the ttal cst) r a cpayment (a set amunt depending n tier placement). Daily cst-sharing allws yu t make sure a drug wrks fr yu befre yu have t pay fr an entire mnth s supply. If yu are respnsible fr cinsurance, yu pay a percentage f the ttal cst f the drug. Yu pay the same percentage regardless f whether the prescriptin is fr a full mnth s supply r fr fewer days. Hwever, because the entire drug cst will be lwer if yu get less than a full mnth s supply, the amunt yu pay will be less. If yu are respnsible fr a cpayment fr the drug, yur cpay will be based n the number f days f the drug that yu receive. We will calculate the amunt yu pay per day fr yur drug (the daily cst-sharing rate) and multiply it by the number f days f the drug yu receive. Here s an example: Let s say the cpay fr yur drug fr a full mnth s supply (a 30-day supply) is $30. This means that the amunt yu pay per day fr yur drug is $1. If yu receive a 7 days supply f the drug, yur payment will be $1 per day multiplied by 7 days, fr a ttal payment f $7. Yu shuld nt have t pay mre per day just because yu begin with less than a mnth s supply. Let s g back t the example abve. Let s say yu and yur dctr agree that the drug is wrking well and that yu shuld cntinue taking the drug after yur 7 days supply runs ut. If yu receive a secnd prescriptin fr the rest f the mnth, r 23 days mre f the drug, yu will still pay $1 per day, r $23. Yur ttal cst fr the mnth will be $7 fr yur first prescriptin and $23 fr yur secnd prescriptin, fr a ttal f $30 the same as yur cpay wuld be fr a full mnth s supply. Can the frmulary change? We and/r Medicare may add r remve drugs frm the frmulary during the year. If the drug is cvered by Medicare, it will be cvered by UPREHS. Drug manufacturers cnstantly change, discntinue and/r add new drugs. Changes in the frmulary may affect which drugs are cvered and hw much yu will pay when filling yur prescriptin. If we remve drugs frm the frmulary, add prir authrizatins, quantity limits, any ther restrictins, r mve a drug t a higher cst-sharing tier, and yu are taking the drug affected by the change, we will ntify yu f the change at least 60 days befre the date that the change becmes effective. If we dn't ntify yu f the change in advance, we will give yu up t a 60-day supply (depending n the number f refills left n yur prescriptin) f the drug when yu request a refill f the drug. Hwever, if a drug is remved frm ur frmulary because the drug has been recalled frm the market, r the manufacturer stps making the drug, we will nt give 60 days ntice befre remving the drug frm the frmulary. Instead, we will remve the drug frm ur frmulary immediately and ntify members abut the change as sn as pssible. Frmulary changes are als available by visiting ur Website at r calling Custmer Service at What if yur drug is nt n the frmulary? All Part D drugs are n the UPREHS frmulary. If Medicare Part D cvers yur drug, it is included in ur frmulary. Yu can g t ur website at r cntact Custmer Service at t be sure if a drug is cvered. If Custmer Service cnfirms that Medicare Part D des nt cver yur drug, yu have three ptins: UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

26 Yu can ask yur dctr if yu can switch t anther drug that is cvered by Medicare. If yu wuld like t give yur dctr a list f cvered drugs that are used t treat similar medical cnditins, please shw him/her yur Frmulary Bk, g t r cntact Custmer Service. Yu can ask us t make an exceptin t cver yur drug nly if it is a Medicare-cvered Part D drug, and all f thse are already n ur plan frmulary. Yu can pay ut-f-pcket fr the drug and request that ur plan reimburse yu by requesting a frmulary exceptin if the drug is cvered by Medicare Part D. Since ALL Part D drugs are n the UPREHS frmulary, this wuld rarely apply. This des nt bligate ur plan t reimburse yu if the exceptin request is nt apprved. See Sectin 5 fr mre infrmatin n hw t request an appeal. If there are extra rules that apply t the drug yu take Sme f the drugs cvered by UPREHS have extra rules t restrict their use. In mst instances, the rules applied are required by Medicare, Federal, r state. Sme drugs are limited in the number f pills cvered during a particular time perid because f safety rules applied t that drug. If yur drug is restricted, here are things yu can d: Yu may be able t get a temprary supply f the drug (nly members in certain situatins can get a temprary supply). This will give yu and yur prvider time t change t anther drug r t file a request t have the drug cvered. Yu can change t anther drug. Yu can request an exceptin and ask the plan t cver the drug r remve restrictins frm the drug. Temprary (r transitin) drug supplies The intent f prviding a temprary (transitin) supply f a Medicare Part D drug that has restrictins applied t it is t allw yur physician time t prvide UPREHS with the necessary infrmatin t make a cverage determinatin. In sme cases, we will cntact yu if yu are taking a drug that is nt n the Medicare frmulary (nt cvered by Medicare Part D). We can give yu the names f cvered drugs that may be used t treat similar cnditins s yu can ask yur dctr if any f these drugs are an ptin fr yur treatment. Under certain circumstances, UPREHS can ffer a temprary supply f a Part D drug t yu when yur drug is restricted in sme way. Remember that all Part D cvered drugs are n the UPREHS Frmulary s this prcess wuld nly apply t drugs that have restrictins. Giving yu a temprary supply gives yu time t talk with yur prvider abut the restrictin and figure ut what t d. T receive a temprary supply, yu must be in ne f the situatins described belw. If there are restrictins n yur Part D drug: Fr thse members wh were in the plan last year and aren t in a lng-term care facility: We will cver a temprary supply f yur Part D drug ne time nly during the first 90 days f the calendar year. This temprary supply will be fr a maximum f 30 days at a time, r less if yur prescriptin is written fr fewer days. The prescriptin must be filled at a netwrk pharmacy. This will give yu time t have yur physician prvide the necessary infrmatin t determine if the restrictins apply t yur drug. 20 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

27 Fr thse members wh are new t the plan and aren t in a lng-term care facility: We will cver a temprary supply f yur Part D drug ne time nly during the first 90 days f yur membership in the plan. This temprary supply will be fr a maximum f 30 days at a time, r less if yur prescriptin is written fr fewer days. The prescriptin must be filled at a netwrk pharmacy. This will give yu time t have yur physician prvide the necessary infrmatin t determine if the restrictins apply t yur drug Fr thse members wh are new t the plan and reside in a lng-term care facility: We will cver a temprary supply f yur drug during the first 90 days f yur membership in the plan. The first supply will be fr a maximum f 31 days, r less if yur prescriptin is written fr fewer days. If needed, we will cver additinal refills during yur first 90 days in the plan. Fr thse members wh have been in the plan fr mre than 90 days and reside in a lngterm care facility and need a supply right away: We will cver ne 31-day supply, r less if yur prescriptin is written fr fewer days. This is in additin t the abve lng-term care transitin supply. During the time when yu are getting a temprary supply f a drug, yu shuld talk with yur prvider t decide what t d when yur temprary supply runs ut. Yu can either switch t a different drug cvered by the plan r ask the plan t make an exceptin fr yu and cver yur current drug. What types f drugs des Medicare and/r UPREHS nt cver? By law, certain types f drugs r categries f drugs are nt cvered by Medicare Prescriptin Drug Plans. These drugs are nt Part D drugs and may be referred t as exclusins r nn-part D drugs. These drugs include: Nn-prescriptin drugs (als called ver-the-cunter, r OTC drugs) Drugs when used t prmte fertility Drugs when used fr the relief f cugh r cld symptms Drugs when used fr csmetic purpses r t prmte hair grwth Prescriptin vitamins and mineral prducts, except prenatal vitamins and fluride preparatins Drugs when used fr the treatment f sexual r erectile dysfunctin, such as Viagra, Cialis, Levitra, and Caverject Drugs when used fr treatment f anrexia, weight lss, r weight gain Outpatient drugs fr which the manufacturer seeks t require that assciated tests r mnitring service be purchased exclusively frm the manufacturer as a cnditin f sale Barbiturates, except when used t treat epilepsy, cancer, r a chrnic mental health disrder A Medicare Prescriptin Drug Plan cannt cver a drug that is cvered under Medicare Part A r Part B. Our plan usually cannt cver ff-label use. Off-label use is any use f the drug ther than thse indicated n a drug s label as apprved by the Fd and Drug Administratin. Cngress specifically lists the reference bks that are used. If the use is nt supprted by ne f these references (knwn as cmpendia), then the drug is a nn-part D drug and is nt cvered by Medicare r ur plan. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

28 If yu receive Extra Help paying fr yur drugs, yur state Medicaid prgram may cver sme prescriptin drugs nt nrmally cvered in a Medicare drug plan. Please cntact yur state Medicaid prgram t determine what drug cverage may be available t yu. There are restrictins n cverage fr sme drugs Fr certain prescriptin drugs, we have additinal requirements r limits fr cverage. These requirements and limits ensure that ur members use these drugs in the mst effective way and als help us cntrl drug plan csts. In mst cases, Medicare develped these requirements and limits fr ur plan t prvide quality cverage t ur members. Examples f utilizatin management tls are described belw: Prir Authrizatin: Yu must get prir authrizatin fr certain drugs that Medicare has determined that are nly cvered under certain circumstances. This means that yu, yur representative, r yur dctr will need t get apprval frm us befre yu fill yur prescriptin. If yu dn t get apprval, we may nt cver the drug. Medicare requires all plans t prir authrize certain Part D drugs and all UPREHS members will require thse prir authrizatins. B/D Drugs Prir Authrizatin: Yu must get prir authrizatin fr certain drugs that Medicare has determined are nly cvered under Part D in certain circumstances and by Part B in ther circumstances. Yu, yur representative, r yur dctr need t get apprval frm us befre yu fill yur prescriptin. If yu dn t get apprval, we may nt cver the drug. Medicare requires all plans t prir authrize certain Part D drugs and all UPREHS members will require thse prir authrizatins. Quantity Limits: Fr certain drugs, we limit the amunt f the drug that we will cver per prescriptin r fr a defined perid f time. These limitatins are usually placed because f Federal and/r state regulatry safety requirements. Generic Substitutin: When there is a generic versin f a name brand drug available, we will autmatically give yu the generic versin. Brand name drugs with generic versins are usually fund in a higher tier cpayment n ur frmulary. If yur dctr tells yu that yu must take the brand name drug, it is still available t yu, but at a higher cpayment. Yu can find ut if yur drug is subject t these additinal requirements r limits by lking in the Frmulary Bk under the BI (Benefit Indicatr) clumn. If yur drug des have these additinal restrictins r limits, yu can ask us t make an exceptin t ur cverage rules. Fr mre infrmatin, see Hw d I request an exceptin t the frmulary? Prgrams n drug safety We cnduct drug reviews fr all f ur members t make sure that yu are receiving safe and apprpriate care. These reviews are particularly imprtant fr members wh have mre than ne dctr wh prescribe their medicatins. We d a review each time yu fill a prescriptin. During these reviews, we lk fr ptential prblems such as: Pssible medicatin errrs. Drugs that may nt be necessary because yu are taking anther drug t treat the same medical cnditin. Drugs that may nt be safe r apprpriate because f yur age r gender. Certain cmbinatins f drugs that culd harm yu if taken at the same time. Pssible errrs in the amunt (dsage) f a drug yu are taking. 22 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

29 If we see a pssible prblem in yur use f medicatins, we will wrk with yur dctr t crrect the prblem. Medicatin Therapy Management Prgram t help members manage their medicatins We have a prgram called Medicatin Therapy Management (MTM) that can help ur members with special situatins. Fr example, sme members have several cmplex medical cnditins r they may need t take many drugs at the same time, and they culd have very high drug csts. This prgram is vluntary and free t members. A team f pharmacists and dctrs develped the prgrams fr us. The prgram can help make sure that ur members are using the drugs that wrk best t treat their medical cnditins and help us identify pssible medicatin errrs. Sme members wh take several medicatins fr different medical cnditins may qualify. A pharmacist r ther health prfessinal will give yu a cmprehensive review f all yur medicatins. Yu can talk abut hw best t take yur medicatins, yur csts, r any prblems yu re having. Yu ll get a written summary f this discussin. The summary has a medicatin actin plan that recmmends what yu can d t make the best use f yur medicatins, with space fr yu t take ntes r write dwn any fllw-up questins. Yu ll als get a persnal medicatin list that will include all the medicatins yu re taking and why yu take them. We will autmatically enrll yu in the prgram and send yu infrmatin if yu fit ur requirements. If yu decide nt t participate, we will give yu instructins n hw t ntify us and we will withdraw yur participatin in the prgram. Des yur enrllment in ur Plan affect the drugs cvered under Medicare Part A r Part B? Yur enrllment in ur plan des nt affect Medicare Part A r Part B drug cverage. If yu are admitted t a hspital fr a stay cvered by Original Medicare Part A, they will generally cver the cst f yur prescriptin drugs during yur stay. Once yu leave the hspital, ur plan will cver yur Part D drugs as lng as the drugs meet all f ur rules fr cverage. See the previus parts f this Sectin that tell abut the rules fr getting drug cverage. If yu are admitted t a skilled nursing facility fr a stay cvered by Original Medicare Part A, they will generally cver yur prescriptin drugs during all r part f yur stay. If yu are still in the skilled nursing facility and Part A is n lnger cvering yur drugs, ur plan will cver yur drugs as lng as the drugs meet all f ur rules fr cverage. See the previus parts f this Sectin that tell abut the rules fr getting drug cverage. Please Nte: When yu enter, live in, r leave a skilled nursing facility, yu are entitled t a Special Enrllment Perid. During this time perid, yu can switch plans r change yur cverage. (Sectin 6 tells when yu can leave ur plan and jin a different Medicare plan.) See yur Medicare & Yu bk fr mre infrmatin abut drugs that are cvered by Medicare Part A and Part B. Hw much d yu pay fr drugs cvered by ur Plan in the different benefit levels? If yu qualify fr Extra Help with yur drug csts, yur csts may be different than thse described belw. See the Intrductin Sectin f this bk under Medicare s Extra Help. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

30 When yu fill a prescriptin fr a cvered drug, yu may pay part f the csts fr yur drug. The amunt yu pay fr yur drug depends n what benefit level yu are in (i.e., initial cverage limit, utf-pcket stage after yu reach yur initial cverage limit, and catastrphic level), the type f drug it is, and whether yu are filling yur prescriptin at the Dept Drug Mail Pharmacy, a retail netwrk pharmacy, r an ut f netwrk pharmacy. Yur drug csts fr each cverage level are described belw. Annual Deductible On yur behalf, UPREHS pays yur 2016 Part D $360 annual deductible which is determined each year by CMS. This is the amunt that must be paid each year befre Medicare will begin paying fr part f yur drug csts. After UPREHS pays the deductible fr yu, yu will cntinue t have benefits available until yu reach the initial cverage limit f yur benefits. Even thugh UPREHS pays yur deductible, during the deductible perid yur cpayments apply t yur ut-f-pcket expenses fr Medicare Part D cvered drugs. See yur Summary f Benefits. Initial Cverage Benefit Level Yu must cntinue t btain yur prescriptin drugs thrugh the Dept Drug Mail Pharmacy during all stages f yur Medicare Part D benefit year. During the initial cverage benefit level, we will pay part f the csts fr yur cvered drugs and yu (r thers n yur behalf) will pay the ther part. Every drug n ur Frmulary list is in ne f five cstsharing tiers. In general, the higher the tier, the higher yur cst fr the drug will be. The amunt yu pay when yu fill a cvered prescriptin is called the cpayment, r fr sme drugs it will be cinsurance. Yur cpayment will vary depending n the drug and where the prescriptin is filled. Cpayment (r cpay) means that yu pay a fixed amunt each time yu fill a prescriptin. Cinsurance means that yu pay a percent f the ttal cst f the drug each time yu fill a prescriptin. Once yur ttal drug csts reach $3,310 in 2016 yu will have reached the end f yur initial cverage benefit level. Yur initial cverage limit is calculated by adding payments made by ur plan and yu. If ther individuals, rganizatins, and anther insurance plan r plicy help pay fr yur drugs under ur plan, the amunt they spend may cunt twards yur initial cverage limit. Out-f-pcket Level (Cverage Gap) befre yu qualify fr Catastrphic Cverage Yu must cntinue t btain yur 90-day prescriptin drugs thrugh the Dept Drug Mail Pharmacy during all stages f yur Medicare Part D benefit year. During the cverage gap level when yu are paying ut-f-pcket fr yur drugs, yu receive a 55% discunt n brand name drugs and a 42% discunt n the csts f generic drugs. The Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n mst brand name drugs t Part D enrllees wh have reached the cverage gap and are nt already receiving Extra Help. Drug manufactures f brand name drugs that have agreed t the discunt reduce the cst f the drug by 50% n the negtiated price (excluding the dispensing fee) and the ther 5% is paid by UPREHS t equal the 55 % discunt t yu. Yu get credit twards yur ut-f-pcket amunt fr the 50% prtin f this discunt. Yu d nt get credit fr the 5% paid by UPREHS. We will autmatically apply the discunt at the Dept Drug Mail Pharmacy and retail netwrk pharmacies when yur prescriptins are filled. This infrmatin will als be displayed when yu request 24 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

31 an Explanatin f Benefits frm UPREHS. If yu have any questins abut the availability f discunts fr the drugs yu are taking r abut the Medicare Cverage Gap Discunt Prgram in general, please cntact Custmer Service at After yur ttal drug csts under yur initial cverage limit reach $3,310, yu, r thers n yur behalf, will pay the cst f the drug plus dispensing fee (less the brand and generic discunts) fr yur drugs until yur ttal ut-f-pcket csts reach $4,850 and then yu will qualify fr catastrphic cverage. Catastrphic Cverage Level Yu must cntinue t btain yur 90-day prescriptin drugs thrugh the Dept Drug Mail Pharmacy during all stages f yur Medicare Part D benefit year. All Medicare Prescriptin Drug Plans include catastrphic cverage fr peple with high drug csts. In rder t qualify fr catastrphic cverage, yu must spend $4,850 ut-f-pcket fr the year. When the ttal amunt yu have paid in cpayments and ut-f-pcket csts fr cvered Medicare Part D drugs reaches $4,850, yu will qualify fr catastrphic cverage. Remember, the 50% brand name manufacturer discunt cunts twards yur ut f pcket expenses. During catastrphic cverage yu will pay the greatest f 5% f drug csts (cinsurance), $2.95 fr generic drugs, r $7.40 fr brand name drugs and we will pay the rest. Once yu are in the catastrphic cverage stage, yu will stay in this benefit level fr the rest f the year. Hw are yur ut-f-pcket csts calculated? The fllwing types f payments fr prescriptin drugs can cunt tward yur ut-f-pcket csts and help yu qualify fr catastrphic cverage s lng as the drug is nrmally cvered by Medicare Part D, is n ur plan frmulary, and it was btained thrugh the Dept Drug Mail Pharmacy, r at a retail netwrk pharmacy, r yu have an apprved emergency claim frm an ut f netwrk pharmacy: Yur cpayments and; Payments yu make after yur initial benefit cverage limit is reached. When yu have spent a ttal f $4,850 fr these items, yu will reach the catastrphic cverage level. The amunt yu pay fr yur mnthly premium des nt cunt tward reaching the catastrphic cverage level. Purchases that will nt cunt tward yur ut-f-pcket csts: Prescriptin drugs purchased utside the United States and its territries; Prescriptin drugs nt cvered by ur Plan and Medicare Part D. Wh can pay fr yur prescriptin drugs, and hw d these payments apply t yur ut-f-pcket csts? Except fr yur premium payments, any payments yu make fr Medicare Part D drugs cvered by us cunt tward yur ut-f-pcket csts and will help yu qualify fr catastrphic cverage. In additin, when the fllwing individuals r rganizatins pay yur prescriptin drug csts, these payments will cunt tward yur ut-f-pcket csts (and will help yu qualify fr catastrphic cverage): Family members r ther individuals; Qualified State Pharmacy Assistance Prgrams (SPAP s) r an AIDS Drug Assistance Prgram (ADAP); Medicare prgrams that prvide Extra Help with prescriptin drug cverage; and/r UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

32 Mst charities r charitable rganizatins. Please nte that if the charity is established, run r cntrlled by yur current r frmer emplyer r unin, the payments usually will nt cunt tward yur ut-f-pcket csts. Payments made by the fllwing d nt cunt tward yur ut-f-pcket csts: Grup Health Plans; Insurance Plans and gvernment funded health prgrams (Veterans, TRICARE the Indian Health Service, etc.); and Third party arrangements with a legal bligatin t pay fr prescriptin csts (Wrkers Cmpensatin, accident insurance, etc.). If yu have cverage frm a third party such as thse listed abve that pays a part f r all f yur utf-pcket csts, yu must disclse this infrmatin t us. We will be respnsible fr keeping track f yur ut-f-pcket cst amunt. If yu r anther party n yur behalf has purchased drugs utside f ur Plan, yu will be respnsible fr submitting apprpriate dcumentatin f such purchases t us. Explanatin f Benefits An Explanatin f Benefits (EOB) is a dcument that details ur current recrd f all f yur prescriptin benefits prvided t yu up t the day f yur request. The EOB is subject t change at any mment and may nt reflect yur current benefit accurately if yu have btained any prescriptins frm a retail netwrk pharmacy, an ut f netwrk pharmacy, a LTC pharmacy has nt submitted their claims, r received vaccine frm yur physician. Yu may request an EOB at any time by calling ur Custmer Service at Hw des yur prescriptin drug cverage wrk if yu g t a hspital r skilled nursing facility? If yu are admitted t a skilled nursing facility fr a Medicare-cvered stay: After Medicare Part A stps paying fr yur prescriptin drug csts, ur plan will cver yur prescriptins as lng as they are nt cvered by Medicare Part A r B, they are a cvered Part D drug, and the facility s Lng Term Care Pharmacy is in ur retail netwrk. When yu enter, live in, r leave a skilled nursing facility yu are entitled t a special enrllment perid, during which time yu will be able t leave ur Plan and jin a new Medicare Prescriptin Drug Plan. 26 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

33 SECTION 4 Making Cmplaints If yur prblem is abut decisins related t benefits, cverage, r payment, then this Sectin is nt fr yu. Instead, yu need t use the prcess fr cverage decisins and appeals. G t Sectin 5. This Sectin explains hw t use the prcess fr making cmplaints. The cmplaint prcess is used fr certain types f prblems nly. This includes prblems related t quality f care, waiting times, the custmer service yu receive, r Medicare rules. Legal Terms What this Sectin calls a cmplaint is als called a grievance. Anther term fr making a cmplaint is filing a grievance. Anther way t say using the prcess fr cmplaints is using the prcess fr filing a grievance. Prblems that are handled by the cmplaint prcess The cmplaint prcess is used fr certain types f prblems ONLY. This includes prblems related t quality f care, waiting times, and the custmer service yu receive. Here are examples f the kinds f prblems handled by the cmplaint prcess. If yu have any f these kinds f prblems, yu can make a cmplaint. Call Custmer Service at if yu have a cmplaint. Quality f yur medical care Are yu unhappy with the quality f the care yu have received? Respecting yur privacy D yu believe that smene did nt respect yur right t privacy r shared infrmatin abut yu that yu feel shuld be cnfidential? Disrespect, pr custmer service, r ther negative behavirs Has smene been rude r disrespectful t yu? Are yu unhappy with hw ur Custmer Service has dealt with yu? D yu feel yu are being encuraged t leave ur plan? Waiting times Have pharmacists kept yu waiting t lng? Have ur Custmer Service r ther staff at ur plan kept yu waiting t lng? Examples include waiting t lng n the phne r when getting a prescriptin. Cleanliness Are yu unhappy with the cleanliness r cnditin f a pharmacy? Infrmatin that yu get frm ur plan D yu believe we have nt given yu infrmatin that we are required t give? D yu think written infrmatin we have given yu is hard t understand? UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

34 Cmplaints abut ur timeliness n cverage decisins and appeals The prcess f asking fr a cverage decisin and making an appeal is explained in Sectin 5 f this bk. If yu are asking fr a decisin r making an appeal, yu use that prcess, nt the cmplaint prcess. Hwever, if yu have already asked fr a cverage decisin r made an appeal, and yu think that ur plan is nt respnding quickly enugh, yu can als make a cmplaint abut ur slwness. Here are examples: If yu have asked us t give yu a fast cverage decisin r appeal and we have said we will nt, yu can make a cmplaint. If yu believe ur plan is nt meeting the deadlines fr giving yu a cverage decisin r answer t an appeal yu have made, yu can make a cmplaint. When a cverage decisin we made is reviewed and ur plan is tld that we must cver r reimburse yu fr certain drugs, there are deadlines that apply. If yu think we are nt meeting these deadlines, yu can make a cmplaint. When ur plan des nt give yu a decisin n time, we are required t frward yur case t the Independent Review Organizatin. If we d nt d that within the required deadline, yu can make a cmplaint. Step-by-step prcess fr making a cmplaint The fllwing pages give yu instructins n hw t make cmplaints. Step 1 fr making cmplaints Cntact us prmptly either by phne, fax, , r in writing. Legal Term Usually, calling Custmer Service is the first step. If there is anything else yu need t d, Custmer Service will let yu knw. We can usually reslve any cmplaint r prblem yu may have n the telephne. If yu d nt wish t call (r yu called and were nt satisfied), yu can put yur cmplaint in writing and fax it r mail it t us. If yu put yur cmplaint in writing, we will respnd t yur cmplaint in writing. Yu can yur cmplaint t us. Whether yu call, , fax, r write, yu shuld cntact Custmer Service right away. The cmplaint must be made within 60 calendar days after yu had the prblem yu want t cmplain abut. If yu are making a cmplaint because we denied yur request fr a fast cverage decisin r a fast appeal, we will autmatically give yu a fast cmplaint. If yu have a fast cmplaint, it means we will give yu an answer within 24 hurs. What this Sectin calls a fast cmplaint is als called an expedited grievance. 28 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

35 Step 2 fr making cmplaints UPREHS lks int yur cmplaint and gives yu an answer. If pssible, we will answer yu right away. If yu call us with a cmplaint, we may be able t give yu an answer n the same phne call. If yur health cnditin requires us t answer quickly, we will d that. Smetimes we will ask if we can call yu back after we find ut mre facts abut yur cmplaint. Return calls are usually made the same day, but can be within 5 business days. Mst cmplaints are answered quickly. If we need mre infrmatin and the delay is in yur best interest r if yu ask fr mre time, we can take up t 30 days and 14 mre days (44 days ttal) t answer yur cmplaint. If we d nt agree with sme r all f yur cmplaint r dn t take respnsibility fr the prblem yu are cmplaining abut, we will let yu knw. Our respnse will include ur reasns fr this answer. We must respnd whether we agree with the cmplaint r nt. Fr quality f care prblems, yu may als cmplain t the QIO Yu may cmplain abut the quality f care received under Medicare. Yu may cmplain t us using the grievance prcess, t the Quality Imprvement Organizatin (QIO) in yur state, r bth. If yu file with the QIO, we must help them reslve the cmplaint. See the Imprtant Numbers and Resurces Sectin f this bk fr help t find the QIO in yur state. When yur cmplaint is abut quality f care, yu als have tw extra ptins: Yu can make yur cmplaint t the Quality Imprvement Organizatin. If yu prefer, yu can make yur cmplaint abut the quality f care yu received directly t this rganizatin (withut making the cmplaint t us). The Quality Imprvement Organizatin is a grup f practicing dctrs and ther health care experts paid by the Federal gvernment t check and imprve the care given t Medicare patients. T find the name, addresses, and phne number f the Quality Imprvement Organizatin fr yur state, lk in the Imprtant Phne Numbers and Resurces Sectin f this bk. If yu make a cmplaint t this rganizatin, we will wrk with them t reslve yur cmplaint. Or yu can make yur cmplaint t bth at the same time. If yu wish, yu can make yur cmplaint abut quality f care t us and als t the Quality Imprvement Organizatin. Yu can als tell Medicare abut yur cmplaint Yu can submit a cmplaint abut UPREHS directly t Medicare. T submit a cmplaint t Medicare, g t Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu have any ther feedback r cncerns, r if yu feel UPREHS is nt addressing yur issue, please call MEDICARE ( ). TTY/TDD users can call UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

36 Sectin 5 Hw t get a Cverage Decisin r an Appeal This Sectin explains anther type f prcess fr handling prblems and cncerns. Fr sme types f prblems, yu need t use the prcess fr cverage decisins (asking fr exceptins) and making appeals. Fr ther types f prblems, yu need t use the prcess fr making cmplaints explained in Sectin 4. Is yur prblem r cncern abut yur benefits r cverage? N. G t Sectin 4 which explains hw t make a cmplaint (file a grievance). Yes. G n t the instructins in this Sectin. This Sectin explains what yu can d if yu have prblems getting the Part D drugs yu request, r payment (including the amunt yu paid) fr a Part D drug yu already received. If yu have prblems getting the Part D drugs yu need, r payment fr a Part D drug yu already received, yu must request an initial decisin with the plan. Legal terms There are technical legal terms fr sme f the rules, prcedures, and types f deadlines explained in this Sectin. Many f these terms are unfamiliar t mst peple and can be hard t understand. This Sectin explains the legal rules and prcedures using simpler wrds in place f certain legal terms. Fr example, this Sectin generally says making a cmplaint rather than filing a grievance, cverage decisin rather than cverage determinatin, and Independent Review Organizatin instead f Independent Review Entity. It als uses abbreviatins as little as pssible. An initial cverage decisin abut yur Part D drugs is called a cverage determinatin. Asking fr remval f a restrictin n cverage fr a drug is smetimes called asking fr a frmulary exceptin. A fast decisin is called an expedited cverage determinatin. A fast appeal is als called an expedited redeterminatin. An appeal t the plan abut a Part D drug cverage decisin is called a plan redeterminatin. It can be helpful and smetimes quite imprtant fr yu t knw the crrect legal terms fr the situatin yu are in. Knwing which terms t use will help yu cmmunicate mre clearly and accurately when yu are dealing with yur prblem and get the right help r infrmatin fr yur situatin. T help yu knw which terms t use, we include legal terms when we give the details fr handling specific types f situatins. Hw t get help when yu are asking fr a cverage decisin (exceptin) r making an appeal Wuld yu like sme help? Here are resurces yu may wish t use if yu decide t ask fr any kind f cverage decisin r appeal a decisin: Yu can call ur representatives at Catamaran at , 24 hurs a day, 365 days a year fr a cverage decisin r an appeal. T get free help frm an independent rganizatin that is nt cnnected with ur plan, cntact the State Health Insurance Assistance Prgram (SHIP) in yur state (see Imprtant Resurces Sectin). 30 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

37 Yur dctr r ther prvider can make a request fr yu. Yur dctr r ther prvider can request a cverage decisin r a Level 1 Appeal n yur behalf. T request any appeal after Level 1, yur dctr r ther prvider must be appinted as yur representative. Yu can ask smene t act n yur behalf. If yu want t, yu can name anther persn t act fr yu as yur representative t ask fr a cverage decisin r make an appeal. There may be smene wh is already legally authrized t act as yur representative under state law. If yu want a friend, relative, yur dctr r ther prescriber r ther persn t be yur representative, yu need t cmplete the Appintment f Representative frm that is available by calling UPREHS Custmer Service at , r n the Medicare website at The frm gives that persn permissin t act n yur behalf. It must be signed by yu and by the persn wh yu wuld like t act n yur behalf. Yu must give us a cpy f the signed frm. Yu als have the right t hire a lawyer t act fr yu. Yu may cntact yur wn lawyer, r get the name f a lawyer frm yur lcal bar assciatin r ther referral service. There are als grups that will give yu free legal service if yu qualify. Hwever, yu are nt required t hire a lawyer t ask fr any kind f cverage decisin r appeal a decisin. GET HELP FROM AN INDEPENDENT GOVERNMENT ORGANIZATION NOT CONNECTED TO UPREHS We are always available t help yu. But in sme situatins yu may als want help r guidance frm smene wh is nt cnnected us. Yu can always cntact yur State Health Insurance Assistance Prgram (SHIP). This gvernment prgram has trained cunselrs in every state. The prgram is nt cnnected with us r with any insurance cmpany r health plan. The cunselrs at this prgram can help yu understand which prcess yu shuld use t handle a prblem yu are having. They can als answer yur questins, give yu mre infrmatin, and ffer guidance n what t d. The services f SHIP cunselrs are free. T find the SHIP in yur state call Medicare at ( ), 24 hurs a day, 7 days a week and ask them t help yu find the SHIP in yur state, r g t YOU CAN GET HELP AND INFORMATION FROM MEDICARE Fr mre infrmatin and help in handling a prblem, yu can als cntact Medicare. Here are tw ways t get infrmatin directly frm Medicare: Yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can visit the Medicare website at What is an exceptin (cverage decisin)? If a drug is nt cvered in the way yu wuld like it t be cvered, yu can ask us t make an exceptin. An exceptin is a type f cverage decisin. Similar t ther types f cverage decisins, if we turn dwn yur request fr an exceptin, yu can appeal ur decisin. When yu ask fr an exceptin, yur dctr r ther prescriber will need t explain the medical reasns why yu need the exceptin apprved. We will then cnsider yur request. Here are sme examples f exceptins: Yu cannt ask fr an exceptin fr cverage f any excluded drugs r ther nn-part D drugs which Medicare des nt cver. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

38 Asking us t remve a restrictin n ur cverage fr a cvered drug. There are extra rules r restrictins that apply t certain drugs n ur Frmulary list. We impse thse restrictins required by Medicare, state r Federal regulatins, and certain safety restrictins. Prir Authrizatin r PA B/D (PA). Getting plan apprval in advance befre we will agree t cver the drug fr yu. This is smetimes called prir authrizatin (PA). Sme prir authrizatins are required t determine if cverage shuld be under Part B r Part D. We impse PA restrictins required by Medicare, and certain safety restrictins. Quantity Limits (QL). Fr sme drugs including thse with state and Federal restrictins, UPREHS limits the amunt f the drug yu can have during a given perid f time. Changing cverage f a drug t a lwer cst-sharing tier. Every drug n ur Frmulary is in ne f five cst-sharing tiers. In general, the lwer the cst-sharing tier number, the less yu will pay as yur share f the cst f the drug. If yur drug is in Tier 2 r 4, yu can ask us t cver it at the cst-sharing amunt that applies t Tier 1 r 3. Hwever, befre yu ask fr an exceptin, please ask Custmer Service t tell yu which alternative drugs are n ur less expensive Tiers 1 r 3. Yu ask us t pay fr a prescriptin drug yu already bught. This is a request fr a cverage decisin abut payment. Imprtant things t knw abut asking fr exceptins (cverage decisins) Yur dctr r ther prescriber must give us a statement that explains the medical reasns fr requesting an exceptin. Fr a faster decisin, include this medical infrmatin frm yur dctr r ther prescriber when yu ask fr the exceptin. Typically, ur Frmulary includes mre than ne drug fr treating a particular cnditin. These different pssibilities are called alternative drugs. If an alternative drug wuld be just as effective as the drug yu are requesting and wuld nt cause mre side effects r ther health prblems, we wuld advise yu t take the alternative drug first. WE CAN SAY YES OR NO TO YOUR REQUEST If we apprve yur request fr an exceptin, ur apprval usually is valid until the end f the plan year. This is true as lng as yur dctr cntinues t prescribe the drug fr yu and that drug cntinues t be safe and effective fr treating yur cnditin. If we say n t yur request fr an exceptin, yu can ask fr a review f ur decisin by making an appeal. The fllwing tells yu hw t ask fr a cverage decisin, including an exceptin. Step-by-Step instructins t ask fr a cverage decisin r an exceptin The fllwing infrmatin gives yu step-by-step instructins n hw t ask fr a cverage decisin and/r an exceptin. Step 1 fr Cverage Decisins and Exceptins Yu ask us t make a cverage decisin abut the drug(s) r payment yu need. If yur health requires a quick respnse, yu must ask us t make a fast cverage decisin. Yu cannt ask fr a fast cverage decisin if yu are asking us t pay yu back fr a drug yu already bught. What t d: 32 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

39 Request the type f cverage decisin yu want. Start by calling, writing, r faxing us t make yur request. Yu, yur representative, r yur dctr (r ther prescriber) can d this. Or if yu are asking us t pay yu back fr a drug, g t Sectin 1 Hw d I submit a request fr payment? Yu r yur dctr r smene else wh is acting n yur behalf can ask fr a cverage decisin r a Level 1 r 2 appeal. This Sectin tld hw yu can give written permissin t smene else t act as yur representative. Yu can als have a lawyer act n yur behalf. If yu want t ask us t pay yu back fr a drug, start by reading Sectin 1 f this bklet. It describes the situatins in which yu may need t ask fr reimbursement. It als tells hw t send us the paperwrk that asks us t pay yu back fr ur share f the cst f a drug yu have paid fr. If yu are requesting an exceptin, prvide the dctr s statement. Yur dctr r ther prescriber must give us the medical reasns fr the drug exceptin yu are requesting. (We call this the dctr s statement.) Yur dctr r ther prescriber can fax r mail the statement t us. Or yur dctr r ther prescriber can tell us n the phne and fllw up by faxing r mailing a written statement if necessary. We must accept any written request, including a request submitted n the CMS Mdel Cverage Determinatin Request Frm available n ur website. If yur health requires it, ask us t give yu a fast decisin. When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard decisin means we will give yu an answer within 72 hurs after we receive yur dctr s statement. A fast decisin means we will answer within 24 hurs. T get a fast decisin, yu must meet tw requirements: Yu can get a fast decisin nly if yu are asking fr a drug yu have nt yet received. (Yu cannt get a fast decisin if yu are asking us t pay yu back fr a drug yu have already bught.) Yu can get a fast decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin. If yur dctr r ther prescriber tells us that yur health requires a fast decisin, we will autmatically agree t give yu a fast decisin. If yu ask fr a fast decisin n yur wn (withut yur dctr s r ther prescriber s supprt), we will decide whether yur health requires that we give yu a fast decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr r ther prescriber asks fr the fast decisin, we will autmatically give a fast decisin. The letter will als tell hw yu can file a cmplaint abut ur decisin t give yu a standard decisin instead f the fast decisin yu requested. It tells hw t file a fast cmplaint, which means yu wuld get ur answer t yur cmplaint within 24 hurs. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

40 Step 2 fr Cverage Decisins and Exceptins We cnsider yur request and we give yu ur answer. Deadlines fr a fast cverage decisin: If we are using the fast deadlines, we must give yu ur answer within 24 hurs. Generally, this means within 24 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 24 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this Sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 24 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin abut a drug yu have nt yet received: If we are using the standard deadlines, we must give yu ur answer within 72 hurs. Generally, this means within 72 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 72 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this Sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested If we apprve yur request fr cverage, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Deadlines fr a standard cverage decisin abut payment fr a drug yu have already bught We must give yu ur answer within 14 calendar days after we receive yur request. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this Sectin, we tell abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested, we are als required t make payment t yu within 14 calendar days after we receive yur request. 34 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

41 If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Step 3 fr Cverage Decisins and Exceptins If we say n t yur cverage request, yu decide if yu want t make an appeal. If we say n, yu have the right t request an appeal. Requesting an appeal means asking us t recnsider and pssibly change the decisin we made. Making an appeal If we make a cverage decisin and yu are nt satisfied with this decisin, yu can appeal the decisin. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu make an appeal we review the cverage decisin we have made t check t see if we were fllwing all f the rules prperly. Yur appeal is handled by different reviewers than thse wh made the riginal unfavrable decisin. When we have cmpleted the review we give yu ur decisin. If we say n t all r part f yur Level 1 Appeal, yu can ask fr a Level 2 Appeal. The Level 2 Appeal is cnducted by an independent rganizatin that is nt cnnected t us. If yu are nt satisfied with the decisin at the Level 2 Appeal, yu may be able t cntinue thrugh several mre levels f appeal. Making an appeal If we make a cverage decisin and yu are nt satisfied with this decisin, yu can appeal the decisin. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu make an appeal we review the cverage decisin we have made t check t see if we were fllwing all f the rules prperly. Yur appeal is handled by different reviewers than thse wh made the riginal unfavrable decisin. When we have cmpleted the review we give yu ur decisin. If we say n t all r part f yur Level 1 Appeal, yu can ask fr a Level 2 Appeal. The Level 2 Appeal is cnducted by an independent rganizatin that is nt cnnected t us. If yu are nt satisfied with the decisin at the Level 2 Appeal, yu may be able t cntinue thrugh several mre levels f appeal. Step-by-Step instructins t make an Appeal The fllwing infrmatin gives yu instructins n hw t make an appeal (hw t ask fr a review f a cverage decisin made by ur plan). Step 1 t make a Level 1 Appeal Yu cntact us and make yur Level 1 Appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal. What t d: T start yur appeal, yu, yur dctr, r yur representative, must cntact us. Details n hw t reach us by phne, fax, r mail fr any purpse related t yur appeal are n the cver f this bklet. If yu are asking fr a standard appeal, make yur appeal by submitting a written request. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

42 If yu are asking fr a fast appeal, yu may make yur appeal in writing r yu may call us at the phne number shwn n the cver f this bklet. Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Examples f gd cause fr missing the deadline may include if yu had a serius illness that prevented yu frm cntacting us r if we prvided yu with incrrect r incmplete infrmatin abut the deadline fr requesting an appeal. We must accept any written request, including a request submitted n the CMS Mdel Cverage Determinatin Request Frm, which is available n ur Web site. Yu can ask fr a cpy f the infrmatin in yur appeal and add mre infrmatin. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. If yu wish, yu and yur dctr r ther prescriber may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal. If yu are appealing a decisin we made abut a drug yu have nt yet received, yu and yur dctr r ther prescriber will need t decide if yu need a fast appeal. The requirements fr getting a fast appeal are the same as thse fr getting a fast cverage decisin in this Sectin. Step 2 t make a Level 1 Appeal We cnsider yur appeal and we give yu ur answer. When ur plan is reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur cverage request. We check t see if we were fllwing all the rules when we said n t yur request. We may cntact yu r yur dctr r ther prescriber t get mre infrmatin. Deadlines fr a fast appeal If we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires it. If we d nt give yu an answer within 72 hurs, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. (Later in this Sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess.) If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 7 calendar days after we receive yur appeal. We will give yu ur decisin sner if yu have nt received the drug yet and yur health cnditin requires us t d s. If yu believe yur health requires it, yu shuld ask fr fast appeal. 36 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

43 If we d nt give yu a decisin within 7 calendar days, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. Later in this Sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested If we apprve a request fr cverage, we must prvide the cverage we have agreed t prvide as quickly as yur health requires, but n later than 7 calendar days after we receive yur appeal. If we apprve a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive yur appeal request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Step 3 t make a Level 1 Appeal If we say n t yur appeal, yu decide if yu want t cntinue with the appeals prcess and make anther appeal. If ur plan says n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anther appeal. If yu decide t make anther appeal, it means yur appeal is ging n t Level 2 f the appeals prcess (see belw). Step-by-step instructins t make a Level 2 Appeal If ur plan says n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anther appeal. If yu decide t g n t a Level 2 Appeal, the Independent Review Organizatin reviews the decisin ur plan made when we said n t yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. Step 1 t make a Level 2 Appeal T make a Level 2 Appeal, yu r yur representative, yur dctr, r ther prescriber must cntact the Independent Review Organizatin and ask fr a review f yur case. If ur plan says n t yur Level 1 Appeal, the written ntice we send yu will include instructins n hw t make a Level 2 Appeal with the Independent Review Organizatin. These instructins will tell wh can make this Level 2 Appeal, what deadlines yu must fllw, and hw t reach the review rganizatin. When yu make an appeal t the Independent Review Organizatin, we will send the infrmatin we have abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file. Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Step 2 t make a Level 2 Appeal The Independent Review Organizatin des a review f yur appeal and gives yu an answer. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

44 The Independent Review Organizatin is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with us and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t review ur decisins abut yur Part D benefits with us. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. The rganizatin will tell yu its decisin in writing and explain the reasns fr it. Deadlines fr fast appeal at Level 2 If yur health requires it, ask the Independent Review Organizatin fr a fast appeal. If the review rganizatin agrees t give yu a fast appeal, the review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs after it receives yur appeal request. If the Independent Review Organizatin says yes t part r all f what yu requested, we must prvide the drug cverage that was apprved by the review rganizatin within 24 hurs after we receive the decisin frm the review rganizatin. Deadlines fr standard appeal at Level 2 If yu have a standard appeal at Level 2, the review rganizatin must give yu an answer t yur Level 2 Appeal within 7 calendar days after it receives yur appeal. If the Independent Review Organizatin says yes t part r all f what yu requested If the Independent Review Organizatin apprves a request fr cverage, we must prvide the drug cverage that was apprved by the review rganizatin within 72 hurs after we receive the decisin frm the review rganizatin. If the Independent Review Organizatin apprves a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive the decisin frm the review rganizatin. What if the review rganizatin says n t yur appeal? If this rganizatin says n t yur appeal, it means the rganizatin agrees with ur decisin nt t apprve yur request. (This is called uphlding the decisin. It is als called turning dwn yur appeal.) T cntinue and make anther appeal at Level 3, the dllar value f the drug cverage yu are requesting must meet a minimum amunt. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal and the decisin at Level 2 is final. The ntice yu get frm the Independent Review Organizatin will tell yu the dllar value that must be in dispute t cntinue with the appeals prcess. Step 3 t make a Level 2 Appeal If the dllar value f the cverage yu are requesting meets the requirement, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. If yu decide t make a third appeal, the details n hw t d this are in the written ntice yu gt after yur secnd appeal. 38 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

45 The Level 3 Appeal is handled by an Administrative Law Judge. The fllwing pages tell mre abut Levels 3, 4, and 5 f the appeals prcess. Taking yur appeal t Level 3 and beynd The fllwing infrmatin tells yu abut Levels f appeals 3, 4, and 5 fr Part D Drugs. This infrmatin may be apprpriate fr yu if yu have made a Level 1 Appeal and a Level 2 Appeal, and bth f yur appeals have been turned dwn. If the value f the drug yu have appealed meets a certain dllar amunt, yu may be able t g n t additinal levels f appeal. If the dllar amunt is less, yu cannt appeal any further. If the dllar value is high enugh, the written respnse yu receive t yur Level 2 Appeal will explain wh t cntact and what t d t ask fr a Level 3 Appeal. Fr mst situatins that invlve appeals, the last three levels f appeal wrk in much the same way. Here is wh handles the review f yur appeal at each f these levels. Level 3 Appeal A judge wh wrks fr the Federal gvernment will review yur appeal and give yu an answer. This judge is called an Administrative Law Judge (ALJ). If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. We must authrize r prvide the drug cverage that was apprved by the Administrative Law Judge within 72 hurs (24 hurs fr expedited appeals) r make payment n later than 30 calendar days after we receive the decisin. If the Administrative Law Judge says n t yur appeal, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu can cntinue t the next level f the review prcess. If the Administrative Law Judge says n t yur appeal, the ntice yu get will tell yu what t d next if yu chse t cntinue with yur appeal. Level 4 Appeal The Medicare Appeals Cuncil will review yur appeal and give yu an answer. The Medicare Appeals Cuncil wrks fr the Federal gvernment. If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. We must authrize r prvide the drug cverage that was apprved by the Medicare Appeals Cuncil within 72 hurs (24 hurs fr expedited appeals) r make payment n later than 30 calendar days after we receive the decisin. If the answer is n, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu might be able t cntinue t the next level f the review prcess. If the Medicare Appeals Cuncil says n t yur appeal r denies yur request t review the appeal, the ntice yu get will tell yu whether the rules allw yu t g n t a Level 5 Appeal. If the rules allw yu t g n, the written ntice will als tell yu wh t cntact and what t d next if yu chse t cntinue with yur appeal. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

46 Level 5 Appeal A judge at the Federal District Curt will review yur appeal. This is the last step f the appeals prcess. Yu will be infrmed after Level 4 hw t g t Level UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

47 Sectin 6 Ending yur Membership in the UPREHS Medicare Plans When can yu end yur membership in UPREHS? If yu d nt want t end yur membership, d nthing. UPREHS will autmatically reenrll yu fr the cming year. Yu shuld end yur membership in ur plan nly during certain times f the year, knwn as enrllment perids. All members have the pprtunity t leave during the Annual Enrllment Perid. In certain situatins, yu may als be eligible t leave at ther times f the year. Yu can end yur membership frm ur plan during the Annual Enrllment Perid frm Octber 15 thrugh December 7. In certain cases yu can leave at ther times f the year such as if yu enter a nursing hme. After yu request t leave, we will let yu knw in writing the date yur cverage ends. If yu chse t disenrll frm the UPREHS Part D plan at any time, yu will als lse all ther UPREHS Medicare plans and yu may nt be allwed t jin a UPREHS Medicare plan again. What is disenrllment? All UPREHS Medicare members are enrlled in all UPREHS Medicare Plans. These plans include the HCPP & Medicare Secndary Plan and the Medicare Part D Plan. Yu are autmatically enrlled in the Medicare Plans each year. If yu chse t disenrll frm UPREHS, yu will als lse yur HCPP & Medicare Secndary Plan membership and yu may nt be allwed t jin a UPREHS Medicare plan again. Disenrllment frm ur plan means ending yur membership with us. Disenrllment can be vluntary (yur wn chice) r, in limited circumstances, invluntary (nt yur wn chice). Yu might leave ur plan because yu have decided that yu want t leave. Yu can decide t leave fr any reasn during specified times. There are als a few situatins where yu wuld be required t leave. Fr example, yu wuld have t leave ur plan if we n lnger ffer prescriptin drug cverage in yur gegraphic area. We are nt allwed t ask yu t leave ur plan because f yur health. Whether leaving ur plan is yur chice r nt, this Sectin explains yur prescriptin drug cverage chices after yu leave and the rules that apply. Yu can end yur membership during the Annual Enrllment Perid Yu can end yur membership during the Annual Enrllment Perid (als knwn as the Annual Crdinated Electin Perid) frm Octber 15 thrugh December 7 each year. This is the time when yu shuld review yur health and drug cverage and make a decisin abut yur cverage fr the upcming year. Yu are autmatically enrlled in the UPREHS Medicare Plans each year. Being a Medicare member f UPREHS, yu are enrlled under all Medicare plans. If yu chse t disenrll frm ur Part D plan during the Annual Crdinated Enrllment Perid, yu will als lse yur HCPP & Medicare Secndary Plan membership and yu may nt be allwed t jin a UPREHS Medicare plan again. When is the Annual Enrllment Perid? It is Octber 15 t December 7. What type f plan can yu switch t during the Annual Enrllment Perid? During this time, yu can review yur health cverage and yur prescriptin drug cverage. Yu can chse t keep yur current cverage r make changes t yur cverage fr the upcming year. If yu decide t change t a new plan, yu can chse any f the fllwing types f plans: UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

48 Anther Medicare prescriptin drug plan. Original Medicare withut a separate Medicare prescriptin drug plan. A Medicare managed care health plan. A Medicare health plan is a plan ffered by a private cmpany that cntracts with Medicare t prvide all f the Medicare Part A (Hspital) and Part B (Medical) benefits. Sme Medicare managed care health plans als include Part D prescriptin drug cverage. If yu enrll in anther Medicare health plan, yu will be disenrlled frm the UPREHS Medicare plans when yur new plan s cverage begins. If yu d nt want t keep ur plan, yu can chse t enrll in anther Medicare prescriptin drug plan r drp Medicare prescriptin drug cverage. Nte: If yu disenrll frm a Medicare prescriptin drug plan and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. Creditable cverage means the cverage is at least as gd as Medicare s standard prescriptin drug cverage. When will yur membership end? Yur membership will end when yur new plan s cverage begins n January 1. In certain situatins, yu can end yur membership during a Special Enrllment Perid In certain situatins, members f UPREHS may be eligible t end their membership at ther times f the year. This is knwn as a Special Enrllment Perid. In rder t qualify fr a Special Enrllment Perid, ne f the fllwing must apply t yu: Wh is eligible fr a Special Enrllment Perid? If any f the fllwing situatins apply t yu, yu are eligible t end yur membership during a Special Enrllment Perid. These are just examples, fr the full list yu can call Medicare, r visit the Medicare website : If yu have Medicaid. If yu are eligible fr Extra Help with paying fr yur Medicare prescriptins. If we vilate ur cntract with yu. If yu are getting care in an institutin, such as a nursing hme r lng-term care hspital. When are Special Enrllment Perids? The enrllment perids vary depending n yur situatin. What can yu d? Remember, yu cannt maintain yur membership in the UPREHS HCPP and Medicare Secndary Plan withut being enrlled in the UPREHS Medicare Part D plan t. T find ut if yu are eligible fr a Special Enrllment Perid, please call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call If yu are eligible t end yur membership because f a special situatin, yu can chse t change bth yur Medicare health cverage and prescriptin drug cverage. This means yu can chse any f the fllwing types f plans: Anther Medicare prescriptin drug plan. Original Medicare withut a separate Medicare prescriptin drug plan. A Medicare managed care health plan. A Medicare health plan is a plan ffered by a private cmpany that cntracts with Medicare t prvide all f the Medicare Part A (Hspital) and Part B (Medical) benefits. Sme Medicare managed care plans als include Part D prescriptin drug cverage. 42 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

49 If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs: If yu switch t Original Medicare and d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu have pted ut f autmatic enrllment. As a UPREHS HCPP & Medicare Secndary Plan member, yu are autmatically enrlled in ur Medicare prescriptin drug plan each year. If yu chse t disenrll during the Annual Crdinated Enrllment Perid, yu may nt be allwed t jin a UPREHS Medicare plan again and yu will als lse yur UPREHS HCPP & Medicare Secndary Plan membership. When will yur membership in UPREHS end? Yur membership will usually end n the first day f the mnth after we receive yur request t change yur plan. If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. (Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) T get mre infrmatin abut when yu can end yur membership Yu can call Custmer Service at Yu can find the infrmatin in yur Medicare & Yu bk. All UPREHS members receive a cpy f Medicare & Yu each fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy frm the Medicare website at Or, yu can rder a printed cpy by calling Medicare at the number belw. Yu can cntact Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Hw d yu end yur membership in UPREHS? Yu have all UPREHS Medicare Plans. If yu disenrll in the Medicare Part D plan, yu cannt maintain yur membership in the UPREHS HCPP and Medicare Secndary Plan. If yu chse t end yur membership in the Part D plan at any time, yu lse all UPREHS Medicare Plans and yu may nt be allwed t jin them again. Usually, t end yur membership in ur plan, yu simply enrll in anther Medicare plan during ne f the enrllment perids. Hwever, there are tw situatins in which yu will need t end yur membership in a different way: If yu want t switch frm ur plan t Original Medicare withut a Medicare prescriptin drug plan, yu must ask t be disenrlled frm ur plan. If yu jin a plan withut prescriptin drug cverage, a Medicare Medical Savings Accunt Plan, r a Medicare Cst Plan, enrllment in the new plan will end yur membership with UPREHS. If yu d nt want t keep ur plan, yu can chse t enrll in anther Medicare prescriptin drug plan r t drp yur Medicare prescriptin drug cverage. If yu are in ne f these tw situatins and want t leave ur plan, there are tw ways yu can ask t be disenrlled: Yu can make a request t us in writing. Cntact Custmer Service t find ut hw t d this. Yu can cntact Medicare at Medicare ( ), 24 hurs a day, 7 days a week. TTY users shuld call UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

50 Yu must keep getting yur prescriptins thrugh ur plan until yur membership ends Remember if yu disenrll frm ur Part D plan, yu als disenrll frm the UPREHS Medicare HCPP & Medicare Secndary Plan, and yu may nt get anther pprtunity t enrll again. If yu leave, it may take time befre yur membership ends and yur new Medicare cverage ges int effect. During this time yu must cntinue t get yur prescriptin drugs thrugh ur plan. Yu shuld cntinue t use ur netwrk pharmacies t get yur prescriptins filled until yur membership in ur plan ends. Prescriptin drugs are nly cvered if they are filled accrding t the plan rules in this bklet. UPREHS must end yur membership in ur Medicare plans under certain situatins If yu d nt stay cntinuusly enrlled in Medicare Part A and Part B. If yu becme incarcerated (g t prisn). If yu lie abut r withhld infrmatin abut ther insurance yu have that prvides prescriptin drug cverage. If yu intentinally give us incrrect infrmatin when yu are enrlling in ur plan and that infrmatin affects yur eligibility fr ur plan. We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first. If yu cntinuusly behave in a way that is disruptive and makes it difficult fr us t prvide care fr yu and ther members f ur plan. We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first. If yu let smene else use yur membership card t get prescriptin drugs. We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first. If we end yur membership because f this reasn, Medicare may have yur case investigated by the Inspectr General. If yu are required t pay the extra Part D amunt because f yur incme and yu d nt pay it, Medicare will disenrll yu frm ur plan and yu will lse prescriptin drug cverage and yur ther UPREH Medicare plans. If yu d nt pay the plan premiums. See Sectin 2. If yu d nt pay the plan premiums, yu have a tw mnth grace perid during which yu can pay befre yu are disenrlled fr failure t pay the plan premium. If yu mve ut f ur plan s service area UPREHS Medicare Plans are natinal plans including Alaska, Hawaii and Puert Ric. If yu mve permanently utside f the United States, please call ur Custmer Service at If yu mve permanently ut f the United States, yu will need t leave (disenrll frm) ur plans. An earlier part f this Sectin tells abut the chices yu have if yu leave ur plans and explains hw t leave. 44 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

51 We cannt ask yu t leave ur plan because f yur health N member f any Medicare Prescriptin Drug Plan can be asked t leave a plan fr any health-related reasns r the number f prescriptins a member takes. If yu ever feel that yu are being encuraged r asked t leave ur plan because f yur health, yu shuld call MEDICARE ( ; TTY/TDD ), the natinal Medicare help line. Yu have the right t make a cmplaint if we ask yu t leave ur plan If we ask yu t leave ur plan, we will tell yu ur reasns in writing and explain hw yu can file a cmplaint against us if yu want. Refer t Sectin 4 fr mre infrmatin abut cmplaint. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

52 Sectin 7 Yur Rights, Respnsibilities and Prtectins Abut yur rights, respnsibilities and prtectins Yu have certain rights t help prtect yu. In this Sectin we explain yur Medicare rights, respnsibilities and prtectins as a member f ur plan. We will tell yu what yu can d if yu think yu are being treated unfairly r yur rights are nt being respected. We will als tell yu abut yur respnsibilities as a member. If yu want Medicare publicatins n yur rights, yu may call and request them at MEDICARE ( ). TTY/TDD users shuld call Yu can call 24 hurs a day, 7 days a week. Yur right t be treated with fairness and respect Our plan must bey laws against discriminatin that prtect yu frm unfair treatment. We d nt discriminate based n a persn s race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, health status, claims experience, medical histry, genetic infrmatin, evidence f insurability, r gegraphic lcatin within ur natinal service area. If yu want mre infrmatin r have cncerns abut discriminatin r unfair treatment, please call the Department f Health and Human Service Office fr Civil Rights at r TTY/TDD , r, call yur lcal Office fr Civil Rights. If yu have a disability and need help with access t care, please call ur Custmer Service at If yu have a cmplaint such as a prblem with wheelchair access, we can help. We must ensure that yu get timely access t yur cvered drugs As a member f UPREHS, yu have the right t get yur prescriptins filled r refilled withut lng delays. As explained in this Benefit Guide, yu shuld get 90-day supplies f yur maintenance prescriptins filled frm the Dept Drug Mail Pharmacy. If yu think yu are nt getting yur Part D drugs within a reasnable amunt f time, yu can call ur Custmer Service fr persnal help. Sectin 1 explains hw t use the Dept Drug Mail Pharmacy, r a retail netwrk pharmacy t get yur temprary prescriptins filled. We must prtect the privacy f yur persnal health infrmatin Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Yur persnal health infrmatin includes the persnal infrmatin yu give us when yu enrll, yur medical recrd infrmatin and ther medical and health infrmatin. The laws that prtect yur privacy give yu rights related t getting infrmatin and cntrlling hw yur health infrmatin is used. Upn request, we prvide a written ntice called a Ntice f Privacy Practice that tells abut these rights and explains hw we prtect the privacy f yur persnal infrmatin. HOW DO WE PROTECT THE PRIVACY OF YOUR HEALTH INFORMATION? We make sure that unauthrized peple dn t see r change yur recrds. In mst situatins, if we give yur health infrmatin t anyne wh isn t prviding yur care r paying fr yur care, we are required t get written permissin frm yu first. Written 46 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

53 permissin can be given by yu r by smene that yu have given legal pwer t make decisins fr yu. There are certain exceptins that d nt require us t get yur written permissin first. These exceptins are allwed r required by law. Fr example, we are required t release health infrmatin t gvernment agencies that are checking n quality f care. Because yu are a member f UPREHS thrugh Medicare, we are required t give them yur health infrmatin and infrmatin abut yur Part D prescriptin drugs. If Medicare releases yur infrmatin fr research r ther uses, this is dne accrding t Federal statutes and regulatins. YOU CAN SEE THE INFORMATION IN YOUR RECORDS AND KNOW HOW IT HAS BEEN SHARED WITH OTHERS. Yu have the right t lk at yur medical recrds and t get a cpy f yur recrds. UPREHS is usually nt in pssessin f yur medical recrds thse are at yur health care prvider s site. The prvider is allwed t charge yu a fee fr making cpies f yur recrds. Yu have the right t ask yur prvider t make additins r crrectins t yur medical recrds. Yu have the right t knw hw yur health infrmatin has been shared with thers fr any purpses that are nt rutine. If yu have questins r cncerns abut the privacy f yur persnal health infrmatin, please call Custmer Service at Yur right t get infrmatin abut ur plan, pharmacies and yur cvered drugs As a member f UPREHS, yu have the right t get several kinds f infrmatin frm us. If yu want any f the fllwing kinds f infrmatin, please visit ur website at r call Custmer Service at : Infrmatin abut ur plan. This includes infrmatin abut ur financial cnditin. It als includes infrmatin abut the number f appeals made by members f ur plan. Infrmatin abut ur netwrk pharmacies. Fr mre detailed infrmatin abut use f the UPREHS Dept Drug pharmacies and the retail netwrk pharmacies, see Sectin 1 f this bklet. Infrmatin abut yur cverage and rules yu must fllw in using yur cverage. T get the details n yur Part D cverage, read this bklet. If yu have questins abut the rules r restrictins, please call Custmer Service at Infrmatin abut why smething is nt cvered and what yu can d abut it. If a Part D drug is nt cvered fr yu, r if yur cverage is restricted in sme way, yu can ask us fr a written explanatin. Yu have the right t this explanatin even if yu received the drug frm an ut-f-netwrk pharmacy. If yu are nt happy, r if yu disagree with a decisin we make abut what Part D drug is cvered fr yu, yu have the right t ask us t change the decisin by making an appeal. See Sectin 5 fr details n hw t make an appeal. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

54 If yu want us t pay ur share f the cst fr a Part D prescriptin drug and yu did nt use a participating pharmacy, see Sectin 1 n hw t submit a paper claim. We must supprt yur right t make decisins abut yur care Yu have the right t give instructin abut what is t be dne if yu are nt able t make medical decisins fr yurself. Smetimes peple becme unable t make health care decisin fr themselves due t accidents r serius illness. Yu have the right t say what yu want t happen if yu are in this situatin. This means that if yu want t, yu can: Fill ut a written frm t give smene the legal authrity t make medical decisins fr yu if yu ever becme unable t make decisins fr yurself. Give yur dctrs written instructins abut hw yu want them t handle yur medical care if yu becme unable t make decisins fr yurself. The legal dcuments that yu can use t give yur directins in advance in these situatins are called advance directives. There are different types f advance directives and different names fr them. Dcuments called living will and pwer f attrney fr health care are examples f advance directives. If yu want t use an advance directive t give yur instructins, here is what t d: Get the frm. If yu want t have an advance directive, yu can get a frm frm yur lawyer, frm a scial wrker, r frm sme ffice supply stres. Yu can smetimes get advance directive frms frm rganizatins that give peple infrmatin abut Medicare. Fill it ut and sign it. Regardless f where yu get this frm, keep in mind that it is a legal dcument. Yu shuld cnsider having a lawyer help yu prepare it. Give cpies t apprpriate peple. Yu shuld give a cpy f the frm t yur dctr and t the persn yu name n the frm as the ne t make decisins fr yu if yu can t. Yu may want t give cpies t clse friends r family members as well. Be sure t keep a cpy at hme. If yu knw ahead f time that yu are ging t be hspitalized, and yu have signed an advance directive, take a cpy with yu t the hspital. If yu are admitted t the hspital, they will ask yu whether yu have signed an advance directive frm and whether yu have it with yu. If yu have nt signed an advance directive frm, the hspital has frms available and will ask if yu want t sign ne. Remember, it is yur chice whether yu want t fill ut an advance directive (including whether yu want t sign ne if yu are in the hspital). Accrding t law, n ne can deny yu care r discriminate against yu based n whether r nt yu have signed an advance directive. What if yur instructins are nt fllwed? If yu have signed an advance directive, and yu believe that a dctr r hspital hasn t fllwed the instructins in it, yu may file a cmplaint with yur state Department f Health. Yur right t make cmplaints and t ask us t recnsider decisins we have made If yu have any prblems r cncerns abut yur cvered service r care, Sectin 4 f this bklet tells what yu can d. It gives the details abut hw t deal with all types f prblems and cmplaints. 48 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

55 As explained in Sectin 4 and 5, what yu need t d t fllw up n a prblem r cncern depends n the situatin. Yu might need t ask ur plan t make a cverage decisin fr yu, make an appeal t us t change a cverage decisin, r make a cmplaint. Whatever yu d ask fr a cverage decisin, make an appeal, r make a cmplaint we are required t treat yu fairly. Yu have the right t get a summary f infrmatin abut the appeals and cmplaints that ther members have filed against ur plan in the past. T get this infrmatin, please call Custmer Service at What can yu d if yu think yu are being treated unfairly r yur rights are nt being respected? If yu think yu have been treated unfairly r yur rights have nt been respected due t yur race, disability, religin, sex, health, ethnicity, creed (beliefs), age, r natinal rigin, yu shuld call the Department f Health and Human Service Office fr Civil Rights at r TTY , r call yur lcal Office fr Civil Rights. Is it abut smething else? If yu think yu have been treated unfairly r yur rights have nt been respected, and it s nt abut discriminatin, yu can get help dealing with the prblem yu are having: Yu can call Custmer Service at Yu can call yur State Health Insurance Assistance Prgram. Or, yu can call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Hw t get mre infrmatin abut yur rights There are several places where yu can get mre infrmatin abut yur rights: Yu can call Custmer Service at Yu can call the State Health Insurance Assistance Prgram (SHIP) mentined in the Imprtant Phne Numbers and Resurces Sectin f this bk. Yu can cntact Medicare. Yu can visit the Medicare website t read r dwnlad the publicatin Yur Medicare Rights & Prtectins. The publicatin is available at Or, yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu have sme respnsibilities as a member f the UPREHS Medicare Plans Alng with the rights yu have as a member f ur plan, yu als have sme respnsibilities. Yur respnsibilities include the fllwing: Becme familiar with yur cvered drugs and the rules yu must fllw t get these cvered drugs. Use this Benefit Guide (EOC) and all the Medicare material we send t yu t learn what is cvered fr yu and the rules yu need t fllw t get yur cvered drugs. Sectins 1, 2 and 3 give the details abut yur cverage fr Part D prescriptin drugs. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

56 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 cverage 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. Tell yur dctr and pharmacist that yu are enrlled in ur plan. Shw yur plan membership ID card whenever yu get yur Part D prescriptin drugs. Help yur dctrs and ther prviders help yu by giving them infrmatin, asking questins, and fllwing thrugh n yur care. T help yur dctrs and ther health prviders give yu the best care, learn as much as yu are able t abut yur health prblems and give them the infrmatin they need abut yu and yur health. Fllw the treatment plans and instructins that yu and yur dctrs agree upn. Make sure yur dctrs knw all f the drugs yu are taking, including ver-the-cunter drugs, vitamins and supplements. If yu have any questins, be sure t ask. Yur dctrs and ther health care prviders are suppsed t explain things in a way yu can understand. If yu ask a questin and yu dn t understand the answer yu are given, ask again. Pay what yu we. As a plan member, yu are respnsible fr these payments: Pay yur UPREHS premiums and pay yur Medicare Part B premium. Fr sme f yur drugs cvered by us, yu must pay yur share f the cst when yu get the drug. This will be a cpayment. Sectins 1 and 3 tell what yu must pay fr yur Part D prescriptin drugs. If yu get any drugs that are nt cvered by ur plan r by ther insurance yu may have, yu must pay the full cst. If yu are required t pay a late enrllment penalty, yu must pay the penalty t remain a member f UPREHS. If yu are required t pay the extra amunt fr Part D because f yur yearly incme, yu must pay the extra amunt directly t the gvernment t remain a member r ur plan. Tell us if yu mve. If yu are ging t mve, it s imprtant t tell us right away. Call Custmer Service (phne numbers are n the cver f this bklet). Call Custmer Service at fr help if yu have questins r cncerns, prblems, r suggestins. We als welcme any suggestins yu may have fr imprving ur plan. Phne numbers and calling hurs are als n the frnt and back cver f this bk. 50 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

57 Sectin 8 Legal Ntices Ntice abut gverning law Many laws apply t this Benefit Guide and sme additinal prvisins may apply because they are required by law. This may affect yur rights and respnsibilities even if the laws are nt included r explained in this dcument. The principal law that applies t this dcument is Title XVIII f the Scial Security Act and the regulatins created under the Scial Security Act by the Centers fr Medicare & Medicaid Service, r CMS. In additin, ther Federal laws may apply and, under certain circumstances, the laws f the state yu live in. Ntice abut nndiscriminatin We dn t discriminate based n a persn s race, disability, religin, sex, health, ethnicity, creed, age, r natinal rigin. All rganizatins that prvide Medicare Advantage Plans, and plans like UPREHS plans, must bey Federal laws against discriminatin, including Title VI f the Civil Rights Act f 1964, the Rehabilitatin Act f 1973, the Age Discriminatin Act f 1975, the Americans with Disabilities Act, all ther laws that apply t rganizatins that get Federal funding, and any ther laws and rules that apply fr any ther reasn. Ntice abut Medicare Secndary Payer subrgatin rights We have the right and respnsibility t cllect fr cvered Medicare prescriptin drugs fr which Medicare is nt the primary payer. Accrding t CMS regulatins at 42 CFR Sectins and , UPREHS, as a Medicare prescriptin drug plan spnsr, will exercise the same rights f recvery that the Secretary exercises under CMS regulatins in subparts B thrugh D f part 411 f 42 CFR and the rules established in this Sectin supersede any state laws. Infrmatin required by the Emplyee Retirement Incme Security Act f 1974 (ERISA) As a Member in the Unin Pacific Railrad Emplyes Medicare Plans, yu are entitled t certain rights and prtectins under the Emplyee Retirement Incme Security Act f 1974 (ERISA). ERISA prvides that all Plan participants shall be entitled t: Examine, withut charge, at the UPREHS ffice all dcuments gverning the Plan, including a cpy f the latest annual reprt filed by ur Plan with the U.S. Department f Labr and available at the Public Disclsure Rm f the Emplyee Benefits Security Administratin. Obtain cpies f dcuments gverning the peratin f the Plan including cllective bargaining agreements and cpies f the latest annual reprt and updated summary plan descriptin upn written request t ur Plan Administratr. The Administratr may make a reasnable charge fr the cpies. Receive a summary f ur Plan s annual financial reprt. The Plan Administratr is required by law t furnish each participant with a cpy f this summary annual reprt. In additin t creating rights fr Plan participants, ERISA impses duty upn the peple wh are respnsible fr the peratin f the emplyee benefit plan. The peple wh perate UPREHS are called Fiduciaries f the Plan. They have a duty t d s prudently and in the interest f yu and ther Plan participants and beneficiaries. Under ERISA, there are steps yu can take t enfrce yur rights. Fr instance, if yu request cpies f Plan dcuments r the latest annual reprt and d nt receive them within thirty days, yu may file suit UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

58 in a Federal curt. In such case, the curt may require the Plan Administratr t prvide the materials and pay yu up t $110 a day until yu receive the materials, unless the materials were nt sent because f reasns beynd the cntrl f the Administratr. T ensure yur request was nt lst in the mail, yu shuld call the Plan Administratr first. If it shuld happen that Plan Fiduciaries misuse the Plan s mney, r if yu are discriminated against fr asserting yur rights, yu may seek assistance frm the US Department f Labr, r yu may file suit in a Federal curt. The curt will decide wh shuld pay curt csts and legal fees. If yu are successful, the curt may rder the persn yu have sued t pay these csts and fees. If yu lse, the curt may rder yu t pay these csts and fees: fr example, if it finds yur claim is frivlus.if yu have any questins abut yur Plan, yu shuld cntact the Plan Administratr. If yu have any questins abut this statement r abut yur rights under ERISA, yu shuld cntact the nearest ffice f the Emplyee Benefits Security Administratin, US Department f Labr, listed in yur telephne directry r the Divisin f Technical Assistance and Inquiries, Emplyee Benefits Security Administratin, US. Department f Labr, 200 Cnstitutin Avenue N.W., Washingtn D.C , telephne (tll free). Yu may als btain certain publicatins abut yur rights and respnsibilities under ERISA by calling the publicatins line f the Emplyee Benefits Security Administratin at (this is a tll line). Name f Plan Plan Spnsr Plan Identificatin Numbers Plan Administratr Type f Plan Trustee Current Bard f Trustees f Plan Operating Trustees Agent fr Service f Legal Prcess Type f Administratin f Health Care Benefits Prvided by the Plan & Plan Year Unin Pacific Railrad Emplyes Health Systems (the Plan ) Unin Pacific Railrad Cmpany Emplyee Identificatin Number (EIN): ; CMS HCPP Plan Number (PN): H4652; CMS PDP Plan Number (PN) E7316; HPID Number Unin Pacific Railrad Emplyes Health Systems P.O. Bx Salt Lake City, UT Telephne: (801) Fax: (801) Health Care Benefit Plan; Medicare HCPP; Medicare Prescriptin Drug Plan Zins Bank 1 Suth Main Street Salt Lake City, UT B. Lenard, Chairman T. Graumann S. Mele S.R. Hirschbein R. Orsc J. McArthur A. Nwlin J. Daytn J. Larreau D. R. Albers C. Wilburn B. Lenard, Chairman R. B. Egan, President & CEO K.J. Ptts, Vice President Service f Legal Prcess may be made upn the Plan Administratr r any Trustee listed abve. Trustees and Self-Administered. The Plan is administered directly by the Plan Administratr. The Plan s healthcare benefits are funded directly by the Plan and are nt insured by an utside entity. Each Plan Year ends each year n December UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

59 Sectin 9 Definitins f Imprtant Wrds Used in This Benefit Guide (Evidence f Cverage) Fr the terms listed belw, this Sectin either gives a definitin r directs yu t a place in this Benefit Guide that explains the term. Annual Enrllment Perid A set time each fall when members can change their health r drug plans. The Annual Enrllment Perid (AEP) is frm Octber 15 until December 7. Yu can nly jin a new Medicare health r drug plan during the AEP unless yu qualify fr a special enrllment perid. Appeal An appeal is smething yu d if yu disagree with ur decisin t deny a request fr cverage f prescriptin drugs r payment fr drugs yu already received Remember that UPREHS includes all Part D drugs n ur frmulary. Sectin 5 explains what appeals are, including the prcess invlved in making an appeal. Benefit Guide (Evidence f Cverage) and Disclsure Infrmatin This dcument, alng with yur enrllment frm and any ther attachments, which explains yur cverage, defines ur bligatins, and explains yur rights and respnsibilities as a member f ur plan. Brand Name Drug This is a prescriptin drug that is manufactured and sld by the pharmaceutical cmpany that riginally researched and develped the drug. Brand name drugs have the same activeingredient frmula as the generic versin f the drug. Hwever, generic drugs are manufactured and sld by ther drug manufacturers and are smetimes nt available until after the patent n the brand name drug has expired. Catastrphic Cverage Level This is the benefit stage in the Part D Drug prgram where yu pay a lw c-payment r cinsurance fr yur drugs. This ccurs after yu r ther qualified parties n yur behalf have spent the annual required ut-f-pcket amunt in cvered drugs during the cvered year. Centers fr Medicare & Medicaid Service (CMS) This is the Federal agency that runs the Medicare prgram. The Intrductin tells yu hw yu can cntact CMS. Cinsurance An amunt yu may be required t pay as yur share f the cst fr Medicare Part D prescriptin drugs. Cinsurance is a percentage f the cst as in sme Tier 4 and Tier 5 frmulary drugs. Cpayment An amunt yu may be required t pay as yur share f the cst fr a Medicare Part D prescriptin drug. A cpayment is a set amunt as in Tier 1, Tier 2 and Tier 3 drugs. Cst Sharing Cst sharing refers t amunts that a member has t pay when drugs are received. This is in additin t the mnthly premium. It includes any cmbinatin f the fllwing three types f payments: (1) any deductible amunt a plan may impse befre drugs are cvered. UPREHS pays yur annual deductible amunt s this des nt apply t yu; (2) any fixed cpayment amunts that a plan may require be paid when specific drugs are received (Tiers 1, 2 & 3); r (3) any cinsurance amunt that must be paid as a percentage f the ttal amunt paid fr a drug (Tiers 4 & 5). Cverage Determinatin A decisin abut whether a drug prescribed fr yu is cvered by the plan and the amunt, if any, yu are required t pay fr the prescriptin. In general, if yu bring yur prescriptin t a pharmacy and the pharmacy tells yu the prescriptin isn't cvered under yur plan, that isn't a cverage determinatin. Yu need t call r write t yur plan t ask fr a frmal decisin abut the cverage. Cverage determinatins are als called cverage decisins made fr exceptin requests. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

60 Cvered Drugs The term we use t mean all f the prescriptin drugs cvered by us and Medicare Part D. UPREHS includes all Part D drugs in yur frmulary. Creditable Prescriptin Drug Cverage This is prescriptin drug cverage that is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. Peple wh have this kind f cverage when they becme eligible fr Medicare can generally keep that cverage withut paying a penalty when they enrll in Medicare Part D later. Custmer Service This is a department within UPREHS respnsible fr answering yur questins abut yur membership, benefits, grievances, and appeals. See the Intrductin fr infrmatin abut hw t cntact UPREHS Custmer Service r call Daily Cst-Sharing Rate A daily cst-sharing rate may apply when yur dctr prescribes less than a full mnth s supply f certain drugs fr yu and yu are required t pay a cpayment. A daily cstsharing rate is the cpayment divided by the number f days in a mnth s supply. Example: If yu cpayment fr a ne-mnth supply f a drug is $30, and a ne-mnth s supply in yur plan is 30 days, then yur daily cst-sharing rate is $1 per day. This means yu pay $1 fr each day s supply when yu fill yur prescriptin. Deductible The annual amunt f mney that Medicare requires yu t pay fr yur drugs first, befre the plan will begin paying fr yur cvered drugs. UPREHS pays yur annual deductible fr yu. Disenrll r Disenrllment The prcess f ending yur membership in ur plan. Disenrllment can be vluntary (yur wn chice) r invluntary (nt yur wn chice). Dispensing Fee A fee charged each time a cvered drug is dispensed t pay fr the cst f filling a prescriptin. The dispensing fee cvers csts such as the pharmacist s time t prepare and package the prescriptin, and the pstage csts if a mail rder drug. Emergency A medical emergency is when yu, r any ther prudent laypersn with an average knwledge f health and medicine, believe that yu have medical symptms that require immediate medical attentin t prevent lss f life, lss f a limb, r lss f functin f a limb. The medical symptms may be an illness, injury, severe pain, r a medical cnditin that is quickly getting wrse. Evidence f Cverage (EOC) and Disclsure Infrmatin This dcument, alng with yur enrllment frm and any ther attachments, riders, r ther ptinal cverage selected, which explains yur cverage, what we must d, yur rights, and what yu have t d as a member f ur plan. Exceptin A type f cverage determinatin that, if apprved, allws yu t get a drug at a less cstly Tier (a tiering exceptin), have an exceptin t prir authrizatin rules, r yu may als request an exceptin if ur plan limits the quantity r dsage f the drug yu are requesting (a frmulary exceptin). Extra Help A Medicare prgram t help peple with limited incme and resurces pay Medicare prescriptin drug prgram csts, such as premiums, deductibles, and cinsurance. Frmulary A list f cvered Medicare Part D drugs prvided by ur plan. UPREHS Prime Medicare Plan includes all Medicare Part D cvered drugs n ur frmulary. Generic Drug Generic drugs are prescriptin drugs that are apprved by the Fd and Drug Administratin (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a generic drug wrks the same as a brand name drug and usually csts less. 54 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

61 Grievance - A type f cmplaint yu make abut us, Medicare, ne f ur netwrk pharmacies, including a cmplaint cncerning the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes. Incme Related Mnthly Adjustment Amunt (IRMAA) If yur incme is abve a certain limit, yu will pay an incme-related mnthly adjustment amunt in additin t yur plan premium. Single and married cuples with the higher incme must pay a higher Medicare Part B medical and Medicare Part D prescriptin drug cverage premium amunt. The additinal amunt is called the incme-related mnthly adjustment amunt. Less than 5% f peple with Medicare are affected. Initial Cverage Limit The maximum limit f cverage under the Part D Initial Cverage Stage. Initial Cverage Stage This is the benefit stage befre yur ttal drug expenses have reached $3,310 including amunts yu ve paid and what ur plan has paid n yur behalf. Initial Enrllment Perid When yu are first eligible fr Medicare, the perid f time when yu can sign up fr Medicare Part A and B. Fr example, if yu re eligible fr Part B when yu turn 65, yur Initial Enrllment Perid is the 7-mnth perid that begins 3 mnths befre the mnth yu turn 65, includes the mnth yu turn 65, and ends 3 mnths after the mnth yu turn 65. Late Enrllment Penalty An amunt added t yur mnthly premium fr Medicare drug cverage if yu g withut creditable cverage (cverage that expects t pay, n average, at least as much as standard Medicare prescriptin drug cverage) fr a cntinuus perid f 63 days r mre. Yu pay this higher amunt as lng as yu have a Medicare drug plan. There are sme exceptins. Fr example, if yu receive Extra Help frm Medicare t pay yur prescriptin drug plan csts, the late enrllment penalty rules d nt apply t yu. If yu receive Extra Help, yu d nt pay a penalty, even if yu g withut creditable prescriptin drug cverage. List f Cvered Drugs (Frmulary r Drug List) A frmulary is a list f prescriptin drugs cvered by UPREHS. The UPREHS Frmulary includes all brand name and generic Medicare Part D drugs. Lw Incme Subsidy See Extra Help Medicaid (r Medical Assistance) - A jint Federal and state prgram that helps with medical csts fr sme peple with lw incmes and limited resurces. Medicaid prgrams vary frm state t state, but mst health care csts are cvered if yu qualify fr bth Medicare and Medicaid. Medically Accepted Indicatin This is the use f a drug that is either apprved by the Fd and Drug Administratin r supprted by certain reference bks. Medicare This is the Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with disabilities, and peple with End-Stage Renal Disease (generally thse with permanent kidney failure wh need dialysis r a kidney transplant). Peple with Medicare can get their Medicare health cverage thrugh Original Medicare, a Medicare Cst Plan, r a Medicare Advantage Plan. Medicare Advantage (MA) Plan Smetimes called Medicare Part C. UPREHS is nt an MA plan. A plan ffered by a private cmpany that cntracts with Medicare t prvide yu with all yur Medicare Part A (Hspital) and Part B (Medical) benefits. A MA plan can be an HMO, PPO, a Private Fee-fr-Service (PFFS) Plan, r a Medicare Medical Savings Accunt (MSA) plan. If yu are enrlled in a MA plan, Medicare services are cvered thrugh the plan, and are nt paid fr under Original Medicare. In mst cases, MA plans als ffer Medicare Part D. These plans are called Medicare Advantage Plans with UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

62 Prescriptin Drug Cverage. Everyne wh has Medicare Part A and Part B is eligible t jin any Medicare Health Plan that is ffered in their area, except peple with End-Stage Renal Disease (unless certain exceptins apply). Medicare Cverage Gap Discunt Prgram - A prgram that prvides discunts n mst cvered Part D brand name drugs t Part D enrllees wh have reached the Cverage Gap Stage and wh are nt already receiving Extra Help. Discunts are based n agreements between the Federal gvernment and certain drug manufacturers. Fr this reasn, mst, but nt all, Medicare Part D brand name drugs are discunted. Medicare Cvered Services Services cvered by Medicare Part A and Part B. Medicare Health Plan A Medicare health plan is ffered by a private cmpany that cntracts with Medicare t prvide Part A and Part B benefits t peple with Medicare wh enrll in the plan. This term includes all Medicare Advantage Plans, Medicare Cst Plans, Demnstratin/Pilt Prgrams, and Prgrams f All-inclusive Care fr the Elderly (PACE). Medicare Prescriptin Drug Cverage (Medicare Part D) Insurance t help pay fr utpatient prescriptin drugs, vaccines, bilgicals, and sme supplies nt cvered by Medicare Part A r B. Medigap Plicy Medicare supplement insurance sld by private insurance cmpanies t fill gaps in the Original Medicare Plan cverage. Medigap plicies nly wrk with the Original Medicare Plans. (A Medicare Advantage plan is nt a Medigap plicy.) The UPREHS Medicare Secndary Plan is NOT a Medigap Plicy because we are nt-fr-prfit and nly certain RR retirees can jin ur plan. Member (member f ur plan) A persn with Medicare wh is eligible fr UPREHS and enrlled in Medicare Parts A and B, wh has enrlled in ur plan, and whse enrllment has been cnfirmed by the Centers fr Medicare & Medicaid Service (CMS). Retail Netwrk Pharmacy A retail pharmacy that ffers cvered drugs t members f ur plan. Original Medicare This is Traditinal Medicare r Fee-fr-service Medicare. All UPREHS Medicare members access their benefits under Original Medicare A and B. Original Medicare is ffered by the gvernment and nt a private health plan like MA plans and prescriptin drug plans. Under Original Medicare, services are cvered by paying dctrs, hspitals, and ther health care prviders payment amunts established by Cngress. Yu can see any dctr, hspital, r ther health care prvider that accepts Medicare. Yu must pay the deductible and yur share f these amunts. Medicare pays its share f the apprved amunt and UPREHS pays yur share (sme exceptins and ut-f-netwrk reductins apply). Original Medicare has tw parts: Part A (Hspital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. Out f Netwrk Pharmacy A pharmacy that desn t have a cntract with ur plan t crdinate r prvide cvered Part D drugs t UPREHS members. As explained in this Benefit Guide, mst f the prescriptins yu get frm ut f netwrk pharmacies are nt cvered by ur plan unless certain cnditins apply. Out-f-Pcket Csts See the definitin fr cst sharing abve. A member s cst-sharing requirement t pay fr a prtin f drugs received is als referred t as the member s ut-f-pcket csts. Part C see Medicare Advantage (MA) Plan. Part D The vluntary Medicare Prescriptin Drug Benefit Prgram. Fr ease f reference, we refer t the prescriptin drug benefit prgram as Medicare Part D. 56 UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE 2016

63 Part D Drugs Drugs that can be cvered under Medicare Part D. UPREHS includes all Part D drugs in ur frmulary. See yur frmulary fr a specific list. Certain categries f drugs were specifically excluded by Cngress frm being cvered as Part D drugs. Premium The mnthly r quarterly payment t UPREHS fr yur Part D plan and yur Medicare Secndary Plan cverage. Yu must als make payment t Medicare fr yur Part B cverage. Prir Authrizatin (r Preauthrizatin, PA) This is apprval in advance t get certain drugs that may r may nt be cvered by us. Medicare requires us t preauthrize certain drugs that may be cvered under Part B r Part D, r nly cvered if yu have certain cnditins. These drugs are cvered nly if yur dctr r ther plan prvider gives us yur infrmatin. Cvered drugs that need prir authrizatin are marked with a PA, r BD in the frmulary bk. Quality Imprvement Organizatin (QIO) Grups f practicing dctrs and ther health care experts that are paid by the Federal gvernment t check and imprve the care given t Medicare patients. They must review yur cmplaints abut the quality f care given by Medicare prviders. Quantity Limits Designed t limit the use f selected drugs fr quality, safety, r utilizatin reasns. Limits may be n the amunt f the drug that we cver per prescriptin r fr a defined perid f time. Service Area A gegraphic area apprved by Medicare within which an eligible individual may enrll in a particular plan. The UPREHS Medicare Plans are natinal. Special Enrllment Perid A set time when yu can change health r drug plans r return t Original Medicare. Situatins fr a Special Enrllment Perid include: if yu are getting Extra Help with yur prescriptin drug csts, if yu mve int a nursing hme, r if we vilate ur cntract with yu. Specialty Drug Pharmacy A pharmacy that prvides high cst medicatins that treat cnditins such as Rheumatid Arthritis, Multiple Sclersis, Hepatitis-C, Cancer, Transplant, etc. (excluding insulin). Step Therapy A utilizatin tl that requires yu t first try anther drug t treat yur medical cnditin befre the plan cvers the drug that yur physician may have initially prescribed. UPREHS applies NO step therapy requirements fr yur drugs. Supplemental Security Incme (SSI) This is the mnthly benefit paid by the Scial Security Administratin t peple with limited incme and resurces wh are disabled, blind, r age 65 and lder. SSI benefits are nt the same as Scial Security benefits. Unin Pacific Railrad Emplyes Health Systems (UPREHS) - A vluntary emplyee benefit administratin prgram that administers health care benefits t certain emplyees f UPRR and their subsidiaries and affiliated cmpanies, UPRR retirees, UPRR pensiners and their qualified spuse, and dependents f UPRR emplyees. UPREHS PRIME MEDICARE PART D PLAN BENEFIT GUIDE

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67 UPREHS PRIME MEDICARE PART D PLAN (EMPLOYER PDP) BENEFIT GUIDE Yur Medicare Prescriptin Drug cverage as a Member f the UPREHS Prime Medicare Part D Plan 2016 This Benefit Guide gives the details abut yur Medicare Prescriptin Drug cverage frm January 1, 2016 thrugh December 31, It 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: