Medex 2 & Medicare Part D

Southeastern Massachusetts Health Group

• Medical benefits do not change.

• Medicare is still the primary payer for all of medical claims.

• You do not have to change doctors or providers.

• Use the same local pharmacies you enjoy today.

What’s the Same?

2

• The monthly premium is lower

• The prescription drug plan will change from Express Scripts to a CVS/Caremark Medicare Part D plan. The RX plan is called Blue MedicareRX.

• The list of covered drugs is unique to this plan and differs slightly from Medex covered list of drugs.

• Mail order co-pays will be 2X retail. You get a 90 day supply for 2 copays – not 3!

• For Mail order medications – When your Doctor files your prescriptions for mail order CVS will call for medication approvals in order for medications to

ship, they will also call before all refills are shipped.

• Shingles vaccine is covered at participating pharmacies.

What’s the Difference?

3

Member Cost Share

Part D Benefit Phase

Member Pays

Yearly Deductible $0

Initial Coverage 30-Day Supply RetailTier 1 Generic Drugs: $5Tier 2 Preferred Brand Drugs: $10Tier 3 Non-Preferred Brand Drugs: $25

90-Day Supply Mail OrderTier 1 Generic Drugs: $10Tier 2 Preferred Brand Drugs: $20Tier 3 Non-Preferred Brand Drugs: $50

Coverage Gap The Town provides supplemental coverage that keep your copayments the same as what you pay in Initial Coverage.

CatastrophicCoverage(Member cost share after member pays $4,700)

Generic drugs (including brand drugstreated as generic): $2.65All other drugs: $6.60

Specialty drugs are limited to a 30-day supply.

Blue MedicareRx Benefit Design

4

The Blue MedicareRx list of Covered Drugs (Formulary) is reviewed and approved annually by the Centers for Medicare & Medicaid Services (CMS). The Formulary must abide by all CMS regulations for Part D plans.

Formulary Facts •Consists of 3 drug tiers – Generic, Preferred Brand & Non-Preferred Brand

•Covers over 2,800 drugs, including Specialty drugs.

•Some covered drugs may have additional requirements or limits like Prior Authorization, Quantity Limits or Step Therapy.

•Formulary changes are reported annually.

Formulary Drug Coverage

5

Medicare Part D Excluded Drugs• Non-prescription drugs, (OTC – over the counter drugs)

• Examples would be non-prescribed drugs including those for cough and cold symptoms

• Prescription vitamins and mineral products• Drugs when used for cosmetic purposes or to promote hair growth• Lifestyle drugs when used for the treatment of fertility, sexual or erectile

dysfunction, such as Viagra, Cialis, Levitra and Caverject.• Drugs when used for treatment of anorexia, weight loss or weight gain• Embrel - a medication used to treat moderate to severe psoriasis and

rheumatoid arthritis. *A coverage determination process can be requested for individual consideration of coverage.

FormularyDrug Coverage

6

Vaccines• Blue MedicareRx provides coverage for a number of Part D

vaccines, including the shingles vaccine (Zostavax) when administered at the pharmacy.

Diabetic Testing Supplies and Insulin• Diabetic testing supplies (including test strips

and lancets) are not covered under Part D; they are covered under Part B.

• Insulin and medical supplies used to deliver insulin (including needles, syringes, alcohol swabs, gauze, insulin pens and pen supplies) are covered under Part D when they are listed

on the Blue MedicareRx formulary.

FormularyDrug Coverage

7

Specialty Drugs• There are a number of specialty drugs covered by Blue MedicareRx.

Generic specialty drugs are on Tier 1. Brand specialty drugs are on Tier 2.

• Specialty drugs are limited to a 30 day supply and process through the retail pharmacy copayment structure only.

Specialty Pharmacy Access• Members are not restricted to using CVS Caremark Specialty Pharmacy. • Specialty drugs can be filled at any network pharmacy (including standard retail

pharmacies) that are able to dispense the drug.• Due to special handling requirements and other factors, standard retail

pharmacies and CVS Caremark Mail Order Pharmacy may not be able to dispense certain drugs in which case members would be referred to a specialty pharmacy.

FormularyDrug Coverage

8

Blue MedicareRX CMS Required Mailings

You will receive a 21 day letter from the account advising you will be auto enrolled into the Blue MedicareRX product if you are enrolled in Medex today.

You will need to supply your residential address to be enrolled into this federally regulated product, P.O Boxes will not be accepted for the initial enrollment. Please advise if you’d like your mail sent to a different address in addition.

Do not enroll separately into any other outside Part D product or this will automatically disenroll you from the Town’s coverage.

Power of Attorney (POA) or Appointment of Representation (AOR) – Be sure to file paperwork with Medex and Blue MedicareRx plan when you enroll.

First Packet from CVS - *****ID Card*****, Confirmation of Coverage Letter and Evidence of Coverage Packet. Low Income subsidy/surcharge rider if applicable.

Second Packet from CVS - Formulary Book, Pharmacy Directory, Mail Order Form and Instructions to complete, Claim Form and Appointment of Personal Representative Form

Additional information from CVS - Coordination of Benefit Survey/Explanation of Benefits Language/HIPAA-Privacy is Key

Annually sent notices: Annual Notice of Change (ANOC), Evidence of Coverage (EOC) and Coordination of Benefits (COB)

Blue MedicareRXCustomer CareDedicated Call Center team of approximately 50 Customer Care Representatives (CCRs), 3 Senior Representatives, 3 call center Supervisors and 1 Quality/Training Analyst.

Blue MedicareRx (BMRx) Service Model – “Concierge Service”:Assure that our members are aware of how their plan works, and are aware of the tools and resources available to make important decisions in the future.Ask productive questions and provide pro-active solutions. Completely and accurately resolve inquiries during the first point of contact. Provide detailed explanation and guidance to members.

Customer Care phone number: 1-888-543-4917, 24 hours a day, 7 days a week. TTY/TDD users 1-866-236-1069.

Insert for groups opting for Pre-Service Calls: Pre-Service line available for retirees beginning [60 days prior to enrollment (for existing benefit options)/30 days prior to enrollment (for new benefit options)]. CCRs will be available to answer plan design and medication coverage questions in advance of your enrollment effective date. Phone number: 1-866-832-9775.

Blue Cross Blue Shield of Massachusetts works in partnership with CVS Health to develop, review and implement annual Customer Care training.

The BMRx Call Center is monitored for call volume, trends and level of service offered to members. Monitoring is performed via conference calls, onsite meetings and review of materials and reports.

New Medex 2 Medical ID CardID Card #1

New Blue MedicareRX ID cardID Card #2

CVS Discount CardExtra Savings

For use only at CVS Retail Pharmacy Stores -This card is similar to a regular retail store rewards card where members can receive coupons and take advantage of specials for store branded items and receive up to a 20% discount. *Restrictions apply.

Blue MedicareRXDefinition of TermsFormulary - A list of covered drugs.

Step Therapy (ST) - Use of a formulary generic prescription first for treatment over the more expensive formulary covered alternative.

Quantity Limits (QL)- The amount of a drug allowed to be dispensed based on the drugs application and usage.

Generic Substitution- Massachusetts is a required generic substitution state, when a generic is available it will be dispensed

Prior Authorization (PA) - an approval needed before a drug can be dispensed. Coverage Determination- A member or physician may request exception to a non covered drug by submission of a form

B vs D – Medications that can covered under Medicare Part B or Part D (Coverage allowance will be based after review of PA)

Specialty Drugs – Unique medications not readily available at the retail pharmacy and that need to be supplied under certain circumstances.

No Mail Order (NMO) - This includes speciality medications, controlled substances, and other drugs requiring special handling. •These medications must be filled through the retail pharmacy and retail pharmacy copays will apply

Questions?

15