2017 BENEFITS WORKBOOK · PDF fileGeneric Drugs ... Carrier enrollment forms can be obtained...

2017 BENEFITS WORKBOOKFOR RETIRED CARNEGIE MELLON FACULT Y AND STAFF

For more information about 2017 benefi ts, go online to http://www.cmu.edu/hr/benefi ts.

B E N E F I T S W O R K B O O K

Fo r m o r e i n fo r m a t i o n , g o o n l i n e t o h t t p : / / w w w. c m u . e d u / h r / b e n e f i t s / b e n e f i t _ p r o g r a m s / r e t i r e e - m e d i c a l . h t m l .2

Table of ContentsCarnegie Mellon Retiree Benefi ts ..............................................................page 3

Open Enrollment ....................................................................................... page 3

Medical Options for Carnegie Mellon Retirees ........................................page 4

HealthAmerica Advantra Coverage Summary ..................................page 5

Highmark Security Blue Coverage Summary ....................................page 8

UPMC for Life Coverage Summary ....................................................page 11

Prescription Drug Coverage ......................................................................page 14

Generic Drugs .......................................................................................page 15

Formulary ..............................................................................................page 15

Mail Order Prescriptions: Convenience and Affordability ............. page 15

Life and Family Status Changes ...............................................................page 16

Denial of Coverage Appeals ......................................................................page 16

Contact Information ................................................................................... page 17

Creditable Coverage Notice (Medicare HMOs) .......................................page 18

Non-Creditable Coverage Notice (Major Medical/Supp. Rx) ................page 20

Read This Workbook

You should read this workbook thoroughly and select the medical benefi t that best meets your needs. Please note the new contribution amounts. If you require more information, contact the HR Benefi ts Offi ce at 412-268-2047.

Carnegie Mellon reserves the right to modify, amend, or terminate any or all of the provisions of these benefi ts at any time for any reason upon appropriate action by the university. Notwithstanding any of the prior statements, in all cases, university policies will govern.

Fo r m o r e i n fo r m a t i o n , g o o n l i n e t o h t t p : / / w w w. c m u . e d u / h r / b e n e f i t s / b e n e f i t _ p r o g r a m s / r e t i r e e - m e d i c a l . h t m l . 3

F O R R E T I R E D C A R N E G I E M E L L O N F A C U L T Y A N D S T A F F

Carnegie Mellon Retiree Benefi tsWe are pleased to offer retired Carnegie Mellon University faculty and staff medical and prescription drug benefi ts. Post-65 retirees may participate in one of our Medicare HMO or Retiree Major Medical health plans. Pre-65 retirees are offered coverage under COBRA until they reach age 65 (see box to the right).

Who is Eligible for Retiree Medical Benefi ts?

To participate in the Retiree Medical Benefi ts plan, you must:

• Be eligible for full-time health benefi ts at the time of retirement

• Be at least 60 years of age

• Have at least fi ve years of service with the university

You may also cover your dependents. Eligible dependents include:

• Your spouse/registered domestic partner• Your unmarried children up to their 26th birthday• Your unmarried children of any age who were covered under the particular

benefi t and were disabled as defi ned in the information provided by the third party administrator or insurance company

Note: If you are reemployed after your retirement from CMU, your eligibility for Retiree Medical Benefi ts may be impacted.

For further details about your eligibility for benefi ts, contact the HR Benefi ts Offi ce at 412-268-2047 or visit http://www.cmu.edu/hr/benefi ts/benefi t_programs/retiree-medical.html.

Open EnrollmentEach year, Open Enrollment (OE) provides you the opportunity to review your benefi ts coverage and make new elections for the upcoming calendar year. Elections made during OE will become effective the following January 1. Unless you experience a life or family status change, OE is the only time during the year when you may change your benefi ts. All information contained in this booklet is also available online at http://www.cmu.edu/hr/benefi ts/benefi t_programs/retiree-medical.html.

If you want to change your elections during OE, you must complete the university’s enrollment/change form and return it to the HR Benefi ts Offi ce. If you do not want to make changes, you do not need to take further action.

• If you are newly enrolling in/changing HMO plans, you must also complete the carrier’s enrollment form and return it to the HR Benefi ts Offi ce.

• If you are newly enrolling in or changing to the Major Medical and Supplemental Prescription plan, you must also complete the Highmark Major Medical enrollment form and return it to the HR Benefi ts Offi ce.

Carrier enrollment forms can be obtained by contacting the HR Benefi ts Offi ce at 412-268-2047.

Retirees Outside of Pennsylvania

Out-of-town retirees are eligible for the Major Medical and Supplemental Prescription benefi ts through Carnegie Mellon.

The HMO plans do NOT provide coverage outside of Pennsylvania. If you are not living in the area and want to participate in a Carnegie Mellon retiree health plan, you can NOT select a Medicare HMO plan.

Pre-65 Coverage under COBRA

Retirees (and their eligible spouses/registered domestic partners) who are age 60–64 are offered retiree medical coverage through COBRA. Retiree medical coverage through COBRA can continue until age 65.

Coverage for eligible dependent children is also offered through COBRA. Dependent children under the age of 26 can continue coverage up to their 26th birthday, or for a period of 36 months, whichever is greater. Disabled dependents can continue coverage so long as they remain disabled.

For information on COBRA coverage, including premiums, please reference the 2017 Benefi ts Guide for Domestic Faculty and Staff, which can be found online at http://www.cmu.edu/hr/benefits/index.html.



Medical Options for Carnegie Mellon RetireesOption 1: Medicare HMOs

Carnegie Mellon offers Pittsburgh-area retirees the opportunity to elect a Medicare HMO. Prescription drug coverage is included in the HMO plans.

Our Medicare HMO plans provide extensive coverage and do not require you to purchase supplemental coverage on your own. (You must still enroll in Medicare A and B, however.) The out-of-pocket costs are very low, and there are NO prescription annual limits or coverage gap. However, the plan will only cover expenses when you use in-network providers. In addition, the HMO coordinates all care and claims payment with one card. You cannot enroll in our Major Medical/Supplemental Rx Coverage (see option 2 to the right) if you enroll in one of our HMO plans.

The three Carnegie Mellon Medicare HMOs are:

• HealthAmerica Advantra

• Highmark Blue Cross/Blue Shield Security Blue

• UPMC for Life

Option 2: Major Medical/Supplemental Rx Coverage

Carnegie Mellon offers a Retiree Major Medical and Supplemental Prescription Drug plan to supplement the coverage for retirees who have enrolled in coverage outside the university. In order to be eligible, you must enroll, on your own and at your own expense, in:

• Medicare Part A and Part B

• A Medicare-approved Medigap* or private (not Carnegie Mellon) Medicare Advantage plan

• A Medicare Part D plan (if drug coverage is not included in your Medigap/Advantage plan)

Our Major Medical coverage, through Highmark, protects against the cost of catastrophic illness. There is no annual deductible and a $100,000 lifetime maximum. Durable medical equipment coverage is also included. Major Medical covers 80% of eligible expenses.

Caremark provides supplemental prescription coverage for participants in the Major Medical plan (see page 14). The member is responsible for 100% of cost prior to meeting the $250 deductible. Once the $250 deductible is met, Caremark will cover 80% of the remaining cost associated with generic and preferred medications.

*A Medigap plan bridges the gap between where Medicare Part A & B stops paying and Retiree Major Medical begins paying. Carnegie Mellon does not offer a Medigap plan. Retirees elect this coverage outside of the university plan on their own.

Monthly Retiree Contributions

Less than 15 Years of ServiceFor Each Individual Covered

15 or More Years of ServiceFor Each Individual Covered

HealthAmerica Advantra $357.27 $337.27Highmark Blue Cross/Blue Shield Security Blue $359 $339

UPMC for Life $480 $460

Retiree Major Medical and Supplemental Prescription* $40.07* $0*

* Participants in the Major Medical/Supplemental Prescription Drug coverage must also purchase, on their own, a Medigap or Medicare Advantage policy and Medicare Part D coverage, if not included in the Medigap/Advantage plan. The costs for these plans vary; contact insurance carriers for rates. Our Medicare HMO participants do not need to purchase either of these policies.



Advantra HMO – Carnegie Mellon University2017 Benefits Summary

CAN I CHOOSE MY DOCTORS? HealthAmerica Advantra has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list. Our number is listed at the end of this document.

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK?If you choose to go to a doctor outside our network, you must pay for these services yourself. Neither HealthAmerica Advantra nor the Original Medicare Plan will pay for these services.

GENERAL INFORMATIONYour Annual Deductible $0Out-of-Pocket Maximum $6,700BENEFITSPhysician Office Visits $10 copaymentSpecialist Office Visits $10 copaymentInpatient Hospital Care Covered 100%Inpatient Mental Health Covered 100%Skilled Nursing Care (100 days) Covered 100%Home Health Care Covered 100%Outpatient Mental Health & Substance Abuse

$10 copayment

Outpatient Surgery Services Covered 100%Ambulance Covered 100%Emergency Care & Urgent Care $50 copayment

Waived if admitted as an inpatient.Outpatient Rehabilitation Services $10 copayment

Durable Medical Equipment Covered 100%Prosthetic Devices Covered 100%Diabetes Self-Monitoring Trainingand Supplies Covered 100%

Diagnostic Tests, x-rays, and lab services Covered 100%



PREVENTIVE SERVICESBone Mass Measurement Covered 100%

Colorectal Screening Exams Covered 100%

Immunizations Covered 100%

Prostate Cancer Screening Exam Covered 100%

Pap Smears and Pelvic Exams Covered 100%

Mammograms Covered 100%

ADDITIONAL BENEFITSRoutine Annual Hearing Exam $0 copayment

Hearing Aids $500 allowance for the 1st hearing aid$500 allowance for the 2nd hearing aid

Routine Annual Eye Exam $0 copayment

Eyeglasses/Contacts (Every 2 years)

$150 allowance

Part B drugs Covered 100%

Routine Physical Exams $10 office visit copayment

Health/Wellness Education Covered 100% including health club membership and fitness classes.



PRESCRIPTION DRUGSDeductible NoneInitial Coverage Limit Up to $3,700

Coverage Gap Continuous coverage at tier copays as listed below. (No donut hole)

RETAIL/30-DAY SUPPLYTier 1 - Preferred Generic $10 copaymentTier 2 - Preferred Brand $10 copayment

Tier 3 - Non-Preferred Brand $10 copayment

Tier 4 - Specialty Drugs 25% coinsuranceMAIL-ORDER/90-DAY SUPPLYTier 1 - Preferred Generic $20 copayment

Tier 2 - Preferred Brand $20 copayment

Tier 3 - Non-Preferred Brand $20 copayment

Tier 4 - Specialty Drugs NOT AVAILABLE

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $4,950, you pay 5% coinsurance for all generic and brand drugs if the 5% coinsurance is greater than:

$3.30 copayment for generic (including branddrugs treated as generic)

$8.25 copayment for all other drugs

Advantra is a Medicare-approved Medicare Advantage Plan offered through HealthAmerica; who contracts with the Center for Medicare and Medicaid Services (CMS), a federal agency that administers Medicare.

If you have any questions regarding these benefits or how to enroll, please call 1-800-470-4272, M – F, 8AM – 5PM (TDD USERS CALL 1-800-207-1262).



2017 Benefit Summary

Carnegie Mellon University584267 Security Blue HMO

HEA

LTH

BA

SIC

PLA

N

CO

STS

Deductible $0

Coinsurance 0%

Out-of-Pocket Maximum $3,400

PREV

ENTI

VE C

AR

E (O

FFIC

E VI

SIT

CO

ST S

HA

RIN

GM

AY

APP

LY)

Annual Physical Exam $0 cost sharing

Screenings & Exams (Preventative PAP/Pelvic, Mammograms, Colorectal, Prostate & Bone Mass Measurement)

Covered in Full

PHYS

ICIA

N

SER

VIC

ES

Doctor Office Visit $10 cost sharing

Specialist Office Visit $20 cost sharing

X-ray or Radiology 0% coinsurance

Diagnostic Testing 0% coinsurance

FAC

ILIT

Y SE

RVI

CES

Outpatient Surgery 0% coinsurance

Emergency Room Services (Worldwide Coverage) $50 cost sharing

Urgently Needed Care (this is NOT emergency care) $40 cost sharing

Inpatient Hospital Stay 0% coinsurance

Skilled Nursing Facility Care (100 days per Medicare benefit period)

$0 cost sharing per day




AD

DIT

ION

AL

BEN

EFIT

S

Annual Routine Vision Exam (Includes refraction) $0 cost sharing

Eyeglasses or Contact Lenses(Covered every year)

Standard eyeglass lenses and frames or contact lenses are covered in full. A $100 benefit

maximum applies to non-standard frames and a $100 benefit maximum for specialty contact

lenses.Annual Routine Hearing Exam $20

Hearing Aids(covered every year)

Hearing aid: $499-$799 copay for each hearing aid, depending on the type

Chiropractic Office Visits $20 cost sharing

Home Health $0 for Medicare-covered home health services

Physical, Speech and Occupational Therapy(per visit/per day/per provider)

$20 cost sharing

Part B Drugs 10%, up to $300 out-of-pocket quarterly maximum

Ambulance (Emergent Services per one way trip) $25 cost sharing

Durable Medical Equipment (Prosthetics/Orthotics, Diabetic Testing Supplies, Oxygen/Oxygen Supplies)

15% coinsurance

MEN

TAL

HEA

LTH

SE

RVI

CES

Inpatient Psychiatric Hospital Care (Limited to 190 days per lifetime)

0% coinsurance

Outpatient Mental Health/Psychiatric Services or Chemical Dependency Substance Abuse Treatment (per individual or group session)

0% coinsurance

DEL

UXE

SER

VIC

ES

Routine Chiropractic & Podiatry Not Covered




Dental Services (Routine Exam and dental service

cost sharing is not applied to the deductible or out of

pocket maximums)

Not Covered

DR

UG

S

PAR

T D

DR

UG

S(U

P T

O 3

1 D

AY

RET

AIL

SU

PPLY

)

Initial Coverage Period (up to $3,700 in total drug costs)

Tier 1 (Preferred Generic) - $15Tier 2 (Generic) - $15

Tier 3 (Pref. Brand & Generic) - $30Tier 4 (Non-Pref. Brand & Generic) - $60

Tier 5 (Specialty) – $60

Coverage Gap Period (from $3,700.01 in total drug costs to $4,950 in yearly out-of-pocket drug costs)

Tier 1 (Preferred Generic) - $15Tier 2 (Generic) - $15

Tier 3 (Pref. Brand & Generic) - $30Tier 4 (Non-Pref. Brand & Generic) - $60

Tier 5 (Specialty) – $60

Catastrophic Coverage Period (after $4,950.01 in total out-of-pocket drug costs)

The greater of 5% or $3.30 for generic or multi-source drugs or $8.25 for all other drugs.

Mail Order (up to 90-day supply, Specialty Drug up to 31-day supply)

2.5 times the retail cost sharing

Diagnostic or outpatient surgery cost sharing may apply for non-screening preventive services.

Physician office visit cost sharing may apply if a separately billable physician service is rendered.

Certain categories of Medicare Part B drugs have been excluded from member cost sharing. They includecertain vaccines and toxoids, certain miscellaneous drugs and solutions, certain miscellaneous pathologyand laboratory drugs, and certain contrast materials. Prior authorization is necessary for coverage of certain medications. Medicare Part B drugs are not available via retail pharmacy network.

This information is not a complete description of benefits. Contact the plan for more information. Limitations,copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time.You will receive notice when necessary. You must continue to pay your Medicare Part B premium. HighmarkChoice Company is an HMO plan with a Medicare contract. Enrollment in Highmark Choice

Company depends on contract renewal. Highmark Blue Cross Blue Shield and Highmark Choice Company are independent licensees of the Blue Cross and Blue Shield Association.

Highmark Blue Cross Blue Shield complies with applicable Federal civil rights laws and does not discriminateon the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: Si usted habla español, servicios de asistencia lingüística, de forma gratuita, estándisponibles para usted. Llame al número en la parte posterior de su tarjeta de identificación (TTY: 711).

TTY 711

Questions on Security Blue HMO benefits? Call 1-800-227-8195 seven days a week, from 8 a.m. to 8 p.m.(TTY users call 711).

Reference Code (Please have this number ready when you call): 17SB4267



Benefits HMO Custom

Annual Out-of-Pocket Limit1 $3,400

Inpatient Hospital2$100 copay per stay

$300 annual maximum

Inpatient Mental Health Care2 $100 copay per stay$300 annual maximum

Skilled Nursing Facility2

(100 day benefit limit)$0 copay per day for days 1-100

Blood (3 pints) $0 copay

Home Health Care2 $0 copay

Hospice Medicare-covered

Primary Care Doctor Visits $10 copay

Specialist Visits $20 copay

Chiropractic Services $20 copay Routine Chiropractic Services(6 visits every year) $20 copay

Podiatry Services $20 copayRoutine Podiatry Services(4 visits every year) $20 copay

Outpatient Mental Health $20 copay

Outpatient Psychiatric Services $20 copay

Outpatient Substance Abuse $20 copay

Partial Hospitalization2 $0 copay

Outpatient Surgery and Ambulatory Surgical Center2$25 copay

$75 annual limit

Observation Stay $25 copay

Ambulance Services $50 copayper one-way trip

Emergency Care(waived if admitted within 3 days)

$75 copay

Urgently Needed Care (Clinics) (out-of-area; urgent care clinics)

$20 copay

Outpatient Rehab Services (PT, OT, ST)

$20 copay

Cardiac/Pulmonary Rehab $0 copay

Durable Medical Equipment/Oxygen2 $0 copay

Prosthetic Devices and Medical Supplies $0 copay

Diabetes Training and Diabetic Supplies

$0 copay - training$0 copay - supplies

Diabetic Shoes or Inserts $0 copay

Kidney Disease Training andRenal Dialysis (ESRD)

$0 copay - training $0 copay - dialysis

Part B Drugs2 10% coinsuranceall Part B drugs; chemotherapy / self-administered

Lab Services $0 copay

Diagnostic Procedures/Tests $0 copay

X-Ray Services $0 copay

UPMC for Life2017 HMO Custom Plan - Carnegie Mellon University

OUTPATIENT MEDICAL AND SUPPLIES

OUTPATIENT CARE

INPATIENT CARE



Benefits HMO Custom


Diagnostic Radiological Services (Advanced Imaging)2 $0 copay

Therapeutic Radiological Services (Radiation) $0 copay

Immunizations3

(influenza, pneumonia, Hepatitis B)$0 copay

Annual Wellness Exam/Routine Physical Exam3

(one exam per year)$0 copay

Screening Exams3

Includes: Bone Mass Measurement, Colorectal Screening, Mammograms, Pap & Pelvic, Prostate Exams, all Medicare-covered Preventive Services

$0 copay

Medicare-covered Dental Services $20 copay

Routine Dental Oral Exam & Cleaning(once every 6 months) $20 copay

Routine Dental Bitewing X-rays not covered

Restorative Services not covered

Medicare-covered Hearing Services $20 copay

Routine Hearing Exam(once every year) $20 copay

Routine Hearing Aid Fitting(once every three years) $20 copay

Routine Hearing Aids(once every three years) $1,000 allowance

Medicare-covered Vision Services $20 copay

Medicare-covered Glaucoma Screening and Diabetic Retinal Eye Exam $0 copay

Medicare-covered EyewearCataract Glasses/Lens

$0 copay

Routine Vision Exam & Eyewear(once every two years)Allowance must be used for both routine eye exam and eyewear.

$250 allowance

Health & Wellness Fitness Center Benefit

Silver & Fit

Remote Technologies $10 copay - eVisits$20 copay - eDerm

Worldwide Emergency Coverage Assist America Travel Benefit

Dental Services

Hearing Services

Vision Services

Other Services

PREVENTIVE SERVICES

ADDITIONAL BENEFITS



Benefits HMO Custom


Tier 1: Preferred Generic Drugs $5 copay - 30 day supply (retail)$15 copay - 90 day supply (retail & mail-order)

Tier 2: Preferred Brand Drugs $25 copay - 30 day supply (retail)$75 copay - 90 day supply (retail & mail-order)

Tier 3: Non-Preferred Drugs $50 copay - 30 day supply (retail)$150 copay - 90 day supply (retail & mail-order)

Tier 4: Specialty Drugs $50 copay - 30 day supply only

Tier 5: Select Care Drugs $0 copay - 30 day supply (retail)$0 copay - 90 day supply (retail & mail-order)

Initial Coverage Limit $3,700

30-day SupplyOnce the Initial Coverage Limit ($3,700) is met, the following cost-sharing

applies until the member reaches ($4,950) (TrOOP):$5 copay for Preferred Generic Drugs$25 copay for Preferred Brand Drugs$50 copay for Non-Preferred Drugs

$50 copay for Specialty Drugs$0 copay for Select Care Drugs

90-day SupplyOnce the Initial Coverage Limit ($3,700) is met, the following cost-sharing

applies until the member reaches $4,950 (TrOOP):$15 copay for Preferred Generic Drugs$75 copay for Preferred Brand Drugs$150 copay for Non-Preferred Drugs

$0 copay for Select Care Drugs

Out-of-Pocket Limit (TrOOP) $4,950

Catastrophic Coverage CopaysGreater of:

$3.30 generic/brand treated as generic$8.25 or 5% all others

This grid is not intended to provide a full description of benefits. Please refer to the Evidence of Coverage for complete benefit information.

NOTE: UPMC Health Plan has determined that the prescription drug coverage offered by this employer group plan for 2017 is creditable coverage.

2 These services require prior authorization.3 A separate copay may apply if additional medical services are performed during the same visit as a preventive service.

1 Member's cost-sharing for Medicare-covered benefits accumulates toward the OOP limit (excludes Part D drugs, routine dental, routine hearing, routine vision and fitness benefit). Once the annual out-of-pocket maximum is met, additional covered services are paid at 100% by the plan.

Coverage Gap Cost-SharingDuring the Coverage Gap Stage, the member will continue to pay the same copays as in the Initial Coverage stage.

PART D PRESCRIPTION DRUGS



Prescription Drug CoverageCaremark: For Major Medical/Supplemental Drug PlanCaremark is the supplemental prescription administrator for our Major Medical coverage. It must be paired with a primary Medicare Part D plan. Medicare Part D plans vary, but have a minimum level of coverage that may include a deductible, member coinsurance responsibility, and a coverage gap. Once the $250 deductible is met, the Caremark Supplemental Prescription Drug coverage pays 80% coinsurance of the remaining cost associated with generic and preferred medications. If a medication is non-preferred, it will not be covered by the Caremark secondary coverage.

When you need a prescription (re)fi lled at a participating pharmacy:

• You must present and identify your Primary Part D coverage card and your Caremark card as secondary when you visit your pharmacist.

• If you do not present your Caremark and Primary Part D cards, or you use an out-of-network pharmacy, you will be required to pay for the drug in full and then fi le for reimbursement. Reimbursement of your prescription could take up to several weeks to be processed. In order to receive reimbursement, you will need to obtain a Caremark claim form and provide your receipts along with your explanation of benefi ts. The claim form is available online at the Caremark website, www.caremark.com, or by calling 877-347-7444. The form is also available on the CMU website, www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.

Medicare HMO Prescription Coverage

Participants in Carnegie Mellon’s retiree HMOs have prescription coverage through their medical plan. To fi ll a prescription, you must go to a participating pharmacy. Present your HMO member card along with your prescription. You’ll pay the designated copay, based on the drug’s generic or formulary status. If you do not present your medical card at the time of your fi rst purchase, you will have to pay for the medication in full and later fi le a request for reimbursement.

Prescription Drug Participant Copays/Coinsurance

HealthAmerica Advantra

Highmark Security Blue

UPMC for Life Caremark Supplemental Rx

Retail Generic (automatic substitution) Preferred Brand Non-preferred Brand Specialty

(30-day supply)$10.00$10.00$10.00

25% coinsurance

(31-day supply)$15.00$30.00$60.00$60.00

(30-day supply)$5.00

$25.00$50.00$50.00

Member is responsible for 100% of cost prior to meeting the $250 deductible. Once the $250 deductible is met, Caremark will cover 80% of the remaining cost associated with generic and preferred medications. I f a medica t ion is non-preferred, it will not be covered by the Caremark secondary coverage. P a r t D m u s t b e purchased on your own.

Mail Order (Up to 90-day supply) Generic (automatic substitution) Preferred Brand Non-preferred Brand Specialty

$20.00$20.00$20.00

not available

$37.50$75.00

$150.00not available

$15.00$75.00

$150.00not available

Participating Pharmacies

Many chain and independent pharmacies participate in the prescription carrier networks. A partial list of participating pharmacies includes:

▪ Costco ▪ CVS ▪ Giant Eagle ▪ K-Mart ▪ Medicine Shoppe ▪ RiteAid ▪ Target ▪ Walgreens ▪ Wal-Mart

Major Medical Participants: Enroll in Medicare Part D

In order to receive Carnegie Mellon’s supplemental prescription coverage (which provides benefi ts for the Medicare Part D coverage gaps), you must enroll in a Medicare Part D plan or a Medigap/Advantage plan with drug coverage through a participating carrier of your choice.

Participants in one of our Medicare HMOs need not enroll in Medicare Part D, as these plans include creditable coverage.



Generic DrugsThe Medicare HMO plans require that generic drugs be substituted automatically for brand-name medications when available, unless a medical necessity waiver has been submitted by your physician and approved in advance. Generic drugs have been tested by the FDA to ensure that they contain equivalent active ingredients. Utilizing a brand-name drug when a generic substitution can be made will result in additional costs to you.

Formulary Our retiree HMO plans and most Medicare Advantage and Part D plans utilize a formulary. A formulary is a list of preferred medications that have been selected for treating various conditions. The medications on the formulary are based on effectiveness, cost, and demand.

You should consider trying a formulary medication before a non-formulary option in order to maximize your cost savings. It is wise to bring the formulary list with you to the doctor’s offi ce to ensure that a formulary medication has been selected before having the prescription fi lled.

See your Medicare D carrier or HMO carrier website for a complete list of the drugs on its formulary. The formulary can be modifi ed at any time by the carrier, so refer to the website for the most up-to-date information.

Mail Order Prescriptions: Convenience and AffordabilityCMU Retiree HMOs all provide mail order services for medications prescribed more than two months. When you order long-term use or maintenance medications through mail order:

• Your nearest pharmacy is as close as your phone, computer or mailbox.

• You only need to order refi lls every few months, instead of going to the pharmacy every few weeks.

• You generally save money with lower copays or coinsurance based on bulk prices.

The forms and instructions for using the mail order services can be found on the carriers’ websites.

Writing Prescriptions for Mail Order

For the quickest service and best prices, submit mail order prescriptions correctly:

• Your doctor should write the prescription for a 90-days supply (not 30-days) with the appropriate number of refi lls.

• Be sure the prescription is signed and written legibly.

• New prescriptions take up to two weeks to fi ll. (Refi lls generally take less time.) If you need the drug immediately, ask for samples or a script for a short-term supply that can be fi lled at your pharmacy.

Caremark Reimbursement with Mail Order

• Send the prescription to your Part D carrier’s mail order service.

• Pay the amount billed and keep your receipts.

• Complete the Caremark Prescription Claim form in its entirety. (Complete all questions, even if the receipt contains some of the information requested.)

• Send a copy of the receipt and the completed claim form to Caremark.

• Caremark will reimburse you for 80% of your costs (after the $250 deductible is met). See page 14 for more details.



Denial of Coverage AppealsMost questions or concerns about your coverage, fi ling claims, or eligible expenses should be directed to the carrier of the plan you selected. Contact information for each of our carriers is found on the next page. You should have your group and ID numbers available when you contact the carrier so they can see the specifi c provisions of the Carnegie Mellon plan. If a claim that you submitted to one of our benefi t plans is denied by the carrier, you should follow these procedures:

For Medical Appeals:

Appeals concerning a medical treatment plan or medical assessment can only be appealed through the carrier. Please follow the procedures outlined in your plan booklet to appeal a medical decision. To obtain a plan booklet, contact the HR Benefi ts Offi ce at 412-268-2047 or visit the CMU website at www.cmu.edu/hr/benefi ts/benefi t_programs/retiree-medical.html.

For Other (Administrative) Appeals:If you believe the denial was made in error, contact the carrier directly to begin the appeals process. (See Contact Information on the next page.) If you are unable to resolve the situation with the carrier, please contact the HR Benefi ts Offi ce at 412-268-2047 for assistance in working with the carrier. The HR Benefi ts Offi ce can also provide information about fi ling a formal appeal with the carrier to challenge the denial.

Life and Family Status Changes The elections that you make will remain in effect for the entire calendar year, unless you experience a life or family status change. The events listed in the chart below are changes that permit you to modify your coverage outside of the Open Enrollment period. All life or family status changes must be requested within 30 days of the event. You must also provide supporting documentation, such as a marriage certifi cate or proof of new coverage, within 30 days of the life or family status change.

Qualifying Life or Family Status Changes Under the Retiree Benefi ts Program

Marital/Domestic Partnership Status Changes • Marriage/registration of domestic partnership • Death of spouse/domestic partner • Divorce/termination of domestic partnership

Number of Covered Dependent Children Changes

Spouse/Domestic Partner Gains or Loses Coverage from Another Source

Signifi cant Change in Cost of Plan

Signifi cant Change in Coverage of Plan • New or improved plan is offered • Signifi cant reduction in overall coverage of current plan

Signifi cant Change in Location (if have an HMO)



Contact InformationDo you need more information about a specifi c benefi t option? Contact the carrier directly to request details about levels of coverage, provider networks, directories, and claims issues. Website addresses, telephone numbers, and group numbers are provided below. For issues related to eligibility, enrollment or unresolved issues, contact Human Resources.

Medicare 800-633-4227

www.medicare.gov

Social Security Administration800-772-1213

http://www.ssa.gov

Carnegie Mellon HR Benefi ts Offi ce412-268-2047http://www.cmu.edu/hr

Medical OptionsHighmark Blue Cross/Blue Shield Retiree Major Medical

Group Number: 50387-02800-472-1506http://www.highmarkbcbs.com

Signature 65 (for Mellon Institute retirees only)Group Number: 62387-00800-367-6565http://www.highmarkbcbs.com

Highmark Blue Cross/Blue Shield Security Blue HMO/Prescription Coverage

Group Number: 58426-60 (less than 15 years service)Group Number: 58426-70 (more than 15 years service) 800-935-2583http://www.highmarkbcbs.com

UPMC for Life Medicare HMO/Prescription CoverageGroup Number: MC0144877-381-3765http://www.upmchealthplan.com

HealthAmerica Advantra Medicare HMO/Prescription Coverage

Group Number: 2101881001800-470-4272http://www.pa.chcadvantra.com

Prescription Drug PlanCaremark (Retiree Major Medical Plan)

Group Number (15 or more years of service): Carrier 5806 RET/001Group Number (less than 15 years of service): Carrier 5806 RET/002877-347-7444http://www.caremark.com



Creditable Coverage Notice (Medicare HMOs)OMB 0938-0990

Important Notice from Carnegie Mellon University AboutYour Prescription Drug Coverage and Medicare

The Carnegie Mellon University Benefit PlanMedicare Advantage HMO

(HealthAmerica Advantra, Highmark Blue Cross Blue Shield Security Blue, UPMC For Life)

Please read this notice carefully and keep it where you can find it. This notice has information about yourcurrent prescription drug coverage with Carnegie Mellon University and about your options underMedicare’s prescription drug coverage. This information can help you decide whether or not you want tojoin a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to makedecisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. Youcan get this coverage if you join a Medicare Prescription Drug Plan or join a MedicareAdvantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drugplans provide at least a standard level of coverage set by Medicare. Some plans may also offermore coverage for a higher monthly premium.

2. Carnegie Mellon University has determined that the prescription drug coverage offered by theCarnegie Mellon University Benefit Plan-Medicare Advantage HMO (HealthAmerica Advantra,Highmark Blue Cross Blue Shield Security Blue, UPMC For Life) is, on average for all planparticipants, expected to pay out as much as standard Medicare prescription drug coverage paysand is therefore considered Creditable Coverage. Because your existing coverage is CreditableCoverage, you can keep this coverage and not pay a higher premium (a penalty) if you laterdecide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drugplan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Carnegie Mellon University coverage will not beaffected.

If you do decide to join a Medicare drug plan and drop your current Carnegie Mellon University coverage, you and your dependents will be able to get this coverage back.



Creditable Coverage Notice (Medicare HMOs)When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Carnegie Mellon University anddon’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premiummay go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premiummay consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, youmay have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact information is provided on the last page of this document. NOTE: You’ll get this notice eachyear. You will also get it before the next period you can join a Medicare drug plan, and if this coveragethrough Carnegie Mellon University changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:• Visit www.medicare.gov.• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help.• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: 10/15/2016 Name of Entity/Sender: Carnegie Mellon UniversityContact–Position/Office: Benefits OfficeAddress: 5000 Forbes Avenue, Pittsburgh, PA 15213-3815 Phone Number: 412-268-2047



Non-Creditable Coverage Notice (Major Medical & Supp. Rx)

OMB 0938-0990

Important Notice From Carnegie Mellon University AboutYour Prescription Drug Coverage and Medicare

The Carnegie Mellon University Benefit PlanRetiree Major Medical and Supplemental Prescription Plan

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Carnegie Mellon University and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you wantto join a Medicare drug plan. Information about where you can get help to make decisions about yourprescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. Youcan get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare AdvantagePlan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plansprovide at least a standard level of coverage set by Medicare. Some plans may also offer morecoverage for a higher monthly premium.

2. Carnegie Mellon University has determined that the prescription drug coverage offered by theRetiree Major Medical and Supplemental Prescription Plan is, on average for all planparticipants, NOT expected to pay out as much as standard Medicare prescription drug coveragepays. Therefore, your coverage is considered Non-Creditable Coverage. This is importantbecause, most likely, you will get more help with your drug costs if you join a Medicare drugplan, than if you only have prescription drug coverage from the Retiree Major Medical andSupplemental Prescription Plan. This also is important because it may mean that you may paya higher premium (a penalty) if you do not join a Medicare drug plan when you first becomeeligible.

3. You can keep your current coverage from the Retiree Major Medical and SupplementalPrescription Plan. However, because your coverage is non- creditable, you have decisions tomake about Medicare prescription drug coverage that may affect how much you pay for thatcoverage, depending on if and when you join a drug plan. When you make your decision, youshould compare your current coverage, including what drugs are covered, with the coverageand cost of the plans offering Medicare prescription drug coverage in your area. Read thisnotice carefully - it explains your options.

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you decide to drop your current coverage with Carnegie Mellon University, since it is employer/union sponsored group coverage, you will be eligible for a two (2) month Special EnrollmentPeriod (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under the Retiree Major Medical and Supplemental Prescription Plan.



Non-Creditable Coverage Notice (Major Medical & Supp. Rx)

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

Since the coverage under Carnegie Mellon University Retiree Major Medical and Supplemental PrescriptionPlan is not creditable, depending on how long you go without creditable prescription drug coverage, youmay pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer withoutprescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait untilthe following October to join.

What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Carnegie Mellon University coverage will not beaffected. You can keep this coverage if you elect Part D and this plan will coordinate with Part D coverage.

If you do decide to join a Medicare drug plan and drop your current Carnegie Mellon Universitycoverage, be aware that you and your dependents will be able to get this coverage back.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact information is provided on the last page of this document. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through Carnegie Mellon University changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare.You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov.• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help.• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: 10/15/2016Name of Entity/Sender: Carnegie Mellon UniversityContact–Position/Office: Benefits OfficeAddress: 5000 Forbes Avenue, Pittsburgh, PA 15213-3815 Phone Number: 412-268-2047

Carnegie Mellon University does not discriminate in admission, employment, or administration of its programs or activities on the basis of race, color, national origin, sex, handicap or disability, age, sexual orientation, gender identity, religion, creed, ancestry, belief, veteran status, or genetic information. Furthermore, Carnegie Mellon University does not discriminate and is required not to discriminate in violation of federal, state, or local laws or executive orders.

Inquiries concerning the application of and compliance with this statement should be directed to the university ombudsman, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, telephone 412-268-1018.

Obtain general information about Carnegie Mellon University by calling 412-268-2000.

2017 BENEFITS WORKBOOK · PDF fileGeneric Drugs ... Carrier enrollment forms can be obtained...

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