12/13/2017 Agreement1 GUI1gr Q
°F 0 0 � Kevin Madok CPA
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o ........ � Clerk of the Circuit Court &Comptroller Monroe County, Florida
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DATE: February 23, 2018
TO: Maria Fernandez - Gonzalez
Employee Benefits
FROM: Pamela G. Hancock, D.C.
SUBJECT: December 13' BOCC Meeting
Enclosed is a duplicate original of Item C10, three (3) year Pharmacy Benefit
Management Services Agreement with Envision Pharmaceutical Services, LLC, and the three (3)
year Medicare Employer Group Administrative Services Only Agreement with supplemental
wrap- around benefits (EGWP/WRAP ASO) with Envision Insurance Company, for your
handling.
Should you have any questions, please feel free to contact me at ext. 3130. Thank you.
cc: County Attorney
Finance
File
KEY WEST MARATHON PLANTATION KEY
500 Whitehead Street 3117 Overseas Highway 88820 Overseas Highway
Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070
305 - 294 -4641 305 - 289 -6027 305 - 852 -7145
PK/ROTH BUILDING
50 High Point Road
Plantation Key, Florida 33070
305 - 852 -7145
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A Medicare Approved Prescription Drug Plan Meclicarel c
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2018 MEDICARE EMPLOYER GROUP AGREEMENT
(EGWP/WRAP ASO)
Envision Insurance Company
2181 East Aurora Road
Twinsburg, OH 44087
Toll Free Telephone: (866) 250 =2005
\EGWP +WRAP SELF - INSURED ASO (2017) Cover Page
2018 PLAN YEAR COVER SHEET
Employer Group Name: Monroe County Board of County Commissioners
Notice Address for Employer Group:
1100 Simonton St. # 2 -268
Key West, FL 33040
Employer Group Telephone Number: (305) 292 - 4452
Notice Address for Envision Insurance Company: 2181 East Aurora Rd
Twinsburg, OH 44087
Effective Date of Service: 12:01a.m. January 1, 2018
Term of Service: From 12:01 a.m. January 1, 2018 through 11:59 p.m.
December 31, 2018, unless otherwise agreed upon by
the parties
Administrative Fee: $10.00 per Member, per month (PMPM)
Covered Benefits: Please refer to the Evidence of Coverage and Summary
of Benefits.
This Employer Group Agreement (the "Employer Group Agreement ") is a legal contract between the Employer
Group named above and Envision Insurance Company ( "EIC"). This Cover Sheet provides only a brief outline of
some of the terms. The provisions below set forth, in detail, the rights and obligations of the Employer Group and
EIC.
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MEDICARE EMPLOYER GROUP AGREEMENT
Administrative Services Only ( "ASO ")
This Employer Group Agreement is entered into by and between Envision Insurance Company (EIC), a Medicare Part
D Prescription Drug Plan, and the Employer Group specified in the attached Cover Sheet. This Employer Group
Agreement shall be effective on the Effective Date of Service specified in the Cover Sheet and shall continue in force
for the Term of Service, unless terminated as provided herein.
THIS IS NOT A CONTRACT OF INSURANCE. THE EMPLOYER GROUP IS SELF - INSURED AND RESPONSIBLE
FOR ALL CLAIMS AND EXPENSES PROVIDED HEREUNDER. AMOUNTS PAID TO EIC BY EMPLOYER GROUP
HEREUNDER ARE NOT INSURANCE PREMIUMS.
BACKGROUND
The Employer Group desires to enroll its Medicare Eligible retirees into a Medicare Part D Employer Group Waiver
Plan ( "EGWP ") with supplemental wraparound ( "Wrap ") benefits (EGWP /wrap) to be sponsored by Employer Group
and administered by EIC in accordance with the applicable federal and state rules and regulations governing such
plans. Employer Group desires to self- insure and be solely responsible for the costs, fees, and expenses associated
with the provision and administration of Covered Benefits, as more fully described herein. Notwithstanding the financial
responsibility of Employer Group, each retiree enrolled in the plan will be a Member of EIC and be subject to all
applicable rules and regulations governing Medicare Part D Plan Beneficiaries. All eligibility, enrollment and other Part
D benefit rules applicable to Employer Group Waiver Plans will apply to Employer Group and its enrolled Medicare
Eligible retirees.
In consideration of the mutual promises hereunder and the receipt of payments required hereunder when due, EIC will
provide for the administration of prescription drug benefits in accordance with the terms, conditions, limitations, and
exclusions set forth in this Employer Group Agreement.
SECTION 1 - DEFINITIONS
Capitalized terms not defined in this Employer Group Agreement shall have the meaning set forth in the attached
schedules and exhibits.
1.1 The terms "Employer Group ", "Effective Date of Service ", "Term of Service" and Administrative Fee will have
the meaning set forth in the attached Cover Sheet.
1.2 "Benefit Specification Form" or "Benefit Specification Change Form" means the forms, submitted by Employer
Group, that specify (i) the terms and conditions for coverage of Covered Benefits; (ii) any limitations, conditions, or
exclusions; (iii) the EGWP /wrap Formulary tier structure and Cost Share requirements; and (iii) any other terms and
conditions associated with the specific services to be rendered by EIC under this Agreement (i.e. Clinical Prior
Authorizations, Drug Therapy Management, etc.). If there is any inconsistency between the terms of this Agreement
and the Benefit Specification Form or any Benefit Specification Change Form submitted in connection with the
administrative services to be provided under this Agreement, then the provisions of the most recent signed Benefit
Specification Form or Benefit Change Form shall control.
1.3 "Brand Drug" means a Prescription Drug designated as a branded drug product by Medi -Span as indicated
by the multisource (i.e. MONY) code attached to the 11 digit NDC for such drug.
1.4 "Contract Year" means the Term of Service set forth on the Cover Sheet, and each subsequent Term of
Service should this Employer Group Agreement be renewed in accordance with Section 6.1.
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1.5 "Claim" means an invoice or electronic submission by a dispensing pharmacy or Member for a Covered
Benefit.
1.6 "Covered Benefits" means those prescription drugs and related services covered by, and paid for by Employer
Group, as specified by Employer Group on the most recent Benefit Specification Form or Benefit Change Form, as
permitted under applicable law, the Evidence of Coverage, and Summary of Benefits incorporated herein.
1.7 "Cover Sheet" means the page entitled "2018 Plan Year Cover Sheet ", attached hereto and incorporated
herein by this reference.
1.8 "CMS" means the Centers for Medicare and Medicaid Services, which administers the Medicare Part D
program and with which EIC maintains a contract as a Medicare Part D Prescription Drug Plan.
1.9 "CMS Receipts" means all premiums, subsidies, catastrophic reinsurance, and other amounts paid to EIC by
CMS connected with Employer Group under the Medicare Part D program.
1.10 "EGWP" means the Employer Group's Medicare Part D Employer Group Waiver Plan (Series 800 Plan)
administered by EIC hereunder.
1.11 "EIC Formulary" means the list of drugs, filed by EIC and approved by CMS, which are covered under the
EGWP. Employer Group acknowledges that the EIC Formulary may be modified from time -to -time by EIC's Pharmacy
and Therapeutics (P &T) Committee when it becomes necessary to remove drugs from the EIC Formulary which have
been taken off the market or have been determined to not meet safety and /or efficacy standards, or to add new drugs
that are required to be covered by Medicare Part D..
1.12 "Eligible Individual" means an individual who (i) is eligible for coverage of prescription drug benefits under the
Employer Group's Retiree Benefit Plan (ii) is Medicare Eligible; and (iii) has retired from Employer Group and is NOT
an active employee or a dependent of an active employee. An Eligible Individual may be a Medicare Eligible dependent
of an individual who is not Medicare Eligible; a Medicare Eligible dependent survivor of a deceased individual; or such
other Medicare Eligible individual who is not covered under the Employer Group's health benefit plan for active
employees and dependents; provided that such individual is eligible for prescription drug benefits under the Employer
Group Retiree Benefit Plan.
1.13 "Employer Group Agreement" means this document and attachments hereto, including the Cover Sheet, the
Summary of Benefits, the Evidence of Coverage (EOC), and any amendments to such attachments, in addition to any
riders, amendments, endorsements, inserts, or other documents describing the terms for coverage under the
EGWP /wrap, together with the information provided by Employer Group on its application or other written
documentation upon which EIC relied to enter into this Employer Group Agreement. EIC agrees that to the extent any
such documents are written for all EIC enrollees (including enrollees who are not Plan Beneficiaries of Employer
Group), and certain terms in said documents do not describe Employer Group's EGWP /wrap, or certain material terms
in Employer Group's EGWP /wrap are not described in the documents, EIC will generate an exhibit or attachment
describing any differences. Any document transmitted by EIC to Members that is created for Employer Group (as
opposed to for Employer Group and other EIC clients) will be given to Employer Group by EIC for review and approval
prior to EIC's transmittal to Employer Group's Members.
1.14 "Evidence of Coverage" or "EOC" means the CMS approved document setting out the rules of coverage for
Members under the EGWP, along with any riders, amendments, or endorsements thereto.
1.15 "Financial Contribution" means any monthly or other payment required under the Employer Group's Retiree
Benefit Plan to be made by a Member for coverage under the EGWP, including without limitation, a contribution
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required under the Retiree Benefit Plan for Medicare Part D coverage (the "Group Coverage Fee "), a deductible
payment, Copayment, Coinsurance and Late Enrollment Penalty ( "LEP ").
1.16 "Generic Drug" means a Prescription Drug that is not a Brand Drug.
1.17 "Limited Distribution Drugs" means Prescription Drugs that are distributed by manufacturers through a limited
number of pharmacies and wholesalers which have been selected by the manufacturer based on approved participation
criteria.
1.18 "Medicare Part D" means the Medicare Part D Prescription Drug Program regulated by CMS and its
associated regulations under 42 C.F.R. 423.100, et. seq.
1.19 "Medicare Eligible" means the individual is eligible for coverage for Medicare Part D benefits at all times during
the Term of Service. If, at any time during the Term of Service, an individual is no longer eligible for coverage for
Medicare Part D benefits (e.g. fails to make required payments to the Social Security Administration), such individual
shall be dis- enrolled by EIC.
1.20 "Member" means an Eligible Individual who has been enrolled in the EGWP by Employer Group and accepted
for membership by CMS, as further described in Section 3.1.1.
1.21 "Network Providers" means those pharmacies (including retail, mail order, specialty, long term care, and home
infusion pharmacies) that have entered into a contract with EIC to dispense Covered Benefits to Members. EIC
maintains a national network of contracted pharmacies, and Members may obtain Covered Benefits from any Network
Provider regardless of the Member's residence. Employer Group acknowledges that the list of Network Providers may
change from time -to -time. However, EIC agrees that any such change will not violate CMS access requirements. EIC
will maintain a current directory of Network Providers on its website.
1.22 "Prescription Drug" means a substance intended for use in the diagnosis, cure, mitigation, treatment, or
prevention of disease which is dispensed by a duly licensed pharmacy and required by federal law to be dispensed
only upon the authorization of a Prescriber. For purposes of this Agreement, over - the - counter medications, medical
supplies, and medical devices are not Prescription Drugs, whether or not ordered by a prescriber.
1.23 "Retiree Benefit Plan" means the Employer Group's employment -based benefit plan for coverage of retiree
prescription drug benefits.
1.24 "Summary of Benefits" means a description of the prescription drug benefits, as set forth in Exhibit "A ", to be
administered by EIC under this Employer Group Agreement.
1.25 "Wrap" means a prescription drug benefit plan design that provides commercial, non - Medicare EGWP
coverage that is supplemental to the standard Medicare Part D benefits.
SECTION 2 - SERVICES
2.1 Covered Benefits
2.1.1 EIC will administer Covered Benefits to Members subject to the terms and conditions of this Employer
Group Agreement and consistent with applicable law. Members covered under the EGWP /wrap are subject to all of
the conditions and provisions required by CMS and contained herein and incorporated documents. Claims are
accepted, processed, and adjudicated for Members under the EGWP before they are accepted, processed, and
adjudicated for Members under the Wrap. Employer Group acknowledges and agrees that its Wrap must comply with
CMS guidelines and cannot diminish the standard Medicare Part D benefit. A Wrap is considered by CMS to be other
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health insurance coverage, and as such, discounts provided under the Medicare Coverage Gap Discount Program are
applied before any additional coverage beyond the standard Medicare Part D benefits have been taken into account.
2.1.2 If a Member has other insurance coverage, identified by CMS or through information proved by the
Member or the Employer Group, EIC will coordinate benefits with these other carriers.
2.2 Evidence of Coverage, and Summary of Benefits: Additional rules governing the provision of Covered Benefits
under the EGWP /wrap are stated in the Evidence of Coverage (EOC) and the Summary of Benefits, as interpreted by
EIC to comply with applicable law. Employer Group acknowledges that adherence to these rules by Members is
required to receive Covered Benefits hereunder.
2.3 EIC Formulary: The EIC Formulary shall be used to determine Covered Benefits for the EGWP. Employer
Group shall identify on the Benefit Specification Form those items and services that will be processed under the Wrap.
Unless otherwise specified, drugs covered under the Wrap may not be eligible for coverage under the Medicare Part
D program. Notices of any changes removing drugs from the EIC Formulary will be mailed by EIC to Members.
SECTION 3 - ELIGIBILITY AND ENROLLMENT
3.1 Eligibility
3.1.1 Necessity for Adhering To Eligibility Standards. Employer Group acknowledges that CMS
establishes explicit eligibility standards, which EIC has specifically identified in the Notice of Important Information, and
which, if violated, result in the potential imposition of penalties on EIC. Employer Group acknowledges its responsibility
to ensure that all such standards are satisfied. Accordingly, Employer Group acknowledges that only Medicare Eligible
retirees or Medicare Eligible dependents who are eligible for Employer Group's Retiree Benefit Plan are eligible to
enroll in the EGWP /wrap. Employer Group also acknowledges that the following individuals are NOT eligible to be a
Member in the EGWP /wrap:
(1) Spouses or dependents who are not eligible for Medicare Part D coverage, even if they are the
spouses or dependent of an Eligible Individual; or
(ii) Current employees of Employer Group (i.e., active employees) or their eligible spouses and
dependents, even if eligible for Medicare Part D.
To be eligible for enrollment in the EGWP /wrap, the individual must also be eligible for Medicare Part A and/or Medicare
Part B and must have a place of permanent residence inside the fifty United States or Washington, D.C. or any
territories where EIC is authorized to do business. Individuals who are incarcerated and identified as such by CMS, or
by Employer Group, are not eligible for the EGWP /wrap and may be retroactively dis- enrolled if EIC receives
confirmation that the date incarceration began was prior to the Effective Date of Service.
Each Medicare Eligible retiree is an individual Member, regardless of whether that individual is a spouse or dependent
of another Medicare Eligible retiree.
3.1.2 Attestation of Eligibility. In executing this Employer Group Agreement, Employer Group submits the
attestation of eligibility identified in Section 5.1 attesting that the individuals submitted by Employer Group for enrollment
in the EGWP /wrap meet the above - stated CMS eligibility requirements and did not opt out after receiving Employer's
notice of opt -out rights.
3.1.3 Removal of Medicare Eligible Individuals From Other Medicare Coverage. Employer Group
acknowledges that any Medicare Eligible retiree who appears on the eligibility file supplied to EIC will be automatically
dis- enrolled by CMS from his or her current Medicare plan, if any, upon EIC's submission of his or her name to CMS
for coverage under the EGWP /wrap.
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3.1.4 No Waiting Period. Employer Group may not impose a waiting period before individuals are eligible
for coverage under the EGWP /wrap.
3.2 Enrollment
3.2.1 Timing of Enrollment. Eligible Individuals may be enrolled by Employer Group only during the
Employer Group's annual open enrollment period ( "Open Enrollment Period ") or specialty enrollment period upon
becoming eligible for prescription drug benefits under the Employer Group's Retiree Benefit Plan. Eligible Individuals
who opt -out during the Open Enrollment Period may be enrolled only during a subsequent Open Enrollment Period or
as permitted under CMS regulations. Coverage under the EGWP /wrap will not become effective until approved by CMS
and confirmed by EIC. Employer Group agrees to hold the Open Enrollment Period concurrent with any other open
enrollment period applicable to retiree health benefits covering prescription drugs that is being offered to Employer
Group's Medicare Eligible retirees or as otherwise required by CMS. The Employer Group shall permit EIC
representatives to meet with Eligible Individuals during the Open Enrollment Period unless EIC and Employer Group
agree upon an alternate enrollment procedure. As described in the EOC, other special enrollment periods may apply.
Employer Group acknowledges that each Eligible Individual may be required to complete and provide Employer Group
and/or EIC with certain eligibility information, including, without limitation, the individual's Medicare ID Number.
3.2.2 Compliance with Enrollment and Disenrollment Procedures. Employer Group and EIC agree to
comply with the enrollment and disenrollment procedures described in this Employer Group Agreement and required
by CMS.
3.3 Eligibility and Enrollment Procedures
3.3.1 After EIC receives Employer Group's EGWP /wrap file of Eligible Individuals, EIC will submit the
information to CMS, and CMS will confirm or reject each Eligible Individual's enrollment into the EGWP /wrap. An
Eligible Individual must be enrolled based on his or her state of residence. The Eligible Individual's address used for
enrollment must be his or her permanent residence. A mailing address may be provided in a separate field on the
EGWP /wrap Eligibility file. If a Member moves to a new permanent state of residence, his or her new residence address
must be communicated to EIC. CMS may reject an Eligible Individual's enrollment into the EGWP /wrap for various
reasons. EIC will inform Employer Group if EIC receives a CMS rejection and work with Employer Group to determine
why the Eligible Individual was rejected and to obtain the information needed to enroll the Eligible Individual into the
EGWP /wrap, if possible.
3.3.2 The number of Eligible Individuals and composition of the Employer Group, the identity and status
of the Employer Group, the eligibility requirements used to determine membership in the Employer Group, and the
participation and contribution standards applicable to the Employer Group which exist at the Effective Date of Service
are material to the execution and continuation of this Employer Group Agreement by EIC. The Employer Group shall
not, during the Term of Coverage under this Employer Group Agreement, modify the Open Enrollment Period, or any
other eligibility requirements as described in the EOC and on the Summary of Benefits, for the purposes of enrolling
Eligible Individuals in the EGWP /wrap, unless EIC agrees to the modification in writing.
3.4 Maintenance of Eligibility and Eligibility Updates
3.4.1 Once enrolled by Employer Group and accepted by CMS, Members will continue to be enrolled until
any of the following occur:
(i) CMS notifies EIC that the Member is no longer eligible for Medicare Part D;
(ii) The Member's death;
(iii) The Member fails to timely pay Financial Contributions;
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(iv) The Employer Group notifies EIC of the disenrollment of the Member from the EGWP /wrap because
the Member no longer qualifies for coverage; or
(v) The Eligible Individual notifies the Employer Group or EIC that the Eligible Individual is dis- enrolling.
The Employer Group shall provide EIC with a monthly eligibility update showing eligibility changes (new Members or
terminated Members), but does not need to provide a full eligibility file each month. EIC will also notify Employer Group
of eligibility changes each month, to the extent EIC learns of such changes during that month.
3.4.2 Disenrollment. For purposes of this Employer Group Agreement, the effective date of termination, in
all cases except the Member's death, will be the end of the last calendar month in which the Member was listed as
eligible for coverage under the EGWP /wrap. In the case of a Member's death, the effective date of termination will be
the date of death as indicated by CMS.
For disenrollment by Employer Group to be effective, Employer Group must notify EIC of the date of a Member's
termination of coverage under the EGWP /wrap. Employer Group must notify EIC of any terminated Members no later
than the twenty -fifth of the month in order for the effective date of termination to be effective the end of such month.
GIVEN THAT EIC RECEIVES "ERRORS" FROM CMS FOR RETROACTIVE ENROLLMENT OR DISENROLLMENT,
MEMBERS MAY NOT BE RETROACTIVELY ENROLLED OR DISENROLLED BY EMPLOYER GROUP. The only
instances where retroactive enrollment or disenrollment will take place is when CMS notifies EIC to process retroactive
enrollment or retroactive disenrollment.
SECTION 4 — FINANCIAL TERMS
4.1 In General: The financial arrangement between EIC and Employer Group is as follows:
(i) EIC will invoice Employer Group the negotiated contractual amount payable to the dispensing pharmacy (plus
any applicable taxes, assessments, or fees) for a Covered Benefit without any mark -up or spread;
(ii) Employer Group is ultimately liable for 100% of all costs of Covered Benefits;
(iii) Employer Group is also ultimately liable for 100% of the PMPM Administrative Fee identified in the Cover
Sheet and any Additional Fees as agreed upon in writing by the parties and identified in Exhibit C;
(iv) EIC will perform the administrative services necessary to collect all amounts connected with the EGWP /wrap,
including CMS Receipts, premium revenue from State Pharmaceutical Assistance Programs ( "SPAPs ") and
amounts due from other payors, as further described below;
(v) EIC will also perform the administrative services necessary to collect all Direct and Indirect Remuneration
( "DIR ") from pharmaceutical manufacturers and other third parties, as required by CMS;
(vi) The Employer Group will need to establish a reserve equal to three (3) weeks of pharmacy claims payments
due from Employer Group under item (i) above, and the reserve amount will be: (x) invoiced fifteen (15) days
prior to the Benefit Effective Date, and (y) repaid upon final settlement with CMS which occurs approximately
eleven (11) months after the end of the Contract Year;
(vii) Monthly, EIC will invoice the Employer Group for (a) all amounts owed under items (i) and (ii) above, minus
(b) all amounts collected under item (iv) and (v) above;
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(viii) EIC will make all payments due pharmacies for Covered Benefits in accordance with Medicare Part D prompt
payment rules for the EGWP and in accordance with applicable state prompt pay laws and regulations for the
Wrap.
EIC and the Employer Group agree that (i) Employer Group is responsible for assuring that it provides the prescription
coverage that it is obligated to provide to its Members; and (ii) EIC, as the administrator of the Employer's Group's
coverage program, is responsible for complying with applicable federal and state statutes, rules and regulations and
therefore shall have the final authority to determine coverage of Part D benefits in accordance with Medicare Part D
requirements. All Claims, settlements, loss payments, drug costs or other amounts of any sort payable under Medicare
Part D requirements, irrespective of whether such settlements and payments are included in CMS reinsurance or
subsidized by CMS, shall be deemed accepted by Employer Group and Employer Group shall be bound by the
settlements made by EIC.
Employer Group acknowledges that catastrophic reinsurance amounts may take from nine to twelve months after the
end of the Contract Year to be paid by CMS.
4.2 EIC's Statement Obligations and Employer Group's Payment Obligations
4.2.1 EIC's Statement Obligations. EIC shall provide Employer Group with an invoice statement once each
month. The invoice statement will show: (i) amounts owed for Covered Benefits; (ii) amounts collected from all third
parties, itemizing each such amount; (iii) the difference between item (i) less item (ii); and (iv) any balance remaining
to be paid by Employer Group to EIC. Any collected amounts remaining will be refunded to the Employer Group by
EIC. A separate invoice statement will be provided for the amounts owed for the Administrative and Additional Fees.
4.2.2 Employer Group's Claims Payment Obligations: EIC will provide Employer Group with an invoice of
payable Claims once a week and Employer Group agrees to pay EIC's invoices no later than 12:00 p.m. Eastern time
on the third (3rd) business day from receipt of said invoices ( "Claims Payment Due Date "). Invoices shall be deemed
to have been received by Employer Group upon the earliest delivery of the invoice by mail, e-mail, fax, or courier. If
payment is received after the Claims Payment Due Date, Employer Group agrees to pay EIC, in addition to any
outstanding amounts payable hereunder, a fee of $1,500 to compensate EIC for the calculation of interest penalties or
fines required to be paid under CMS regulations for late payments to pharmacies. Employer Group acknowledges that
it will be solely responsible for any and all interest penalties and fines assessed by CMS for late payments to
pharmacies that result from Employer Group's failure to provide adequate and timely funds. In addition, if EIC has to
make an unscheduled Claims payment to avoid further interest penalties and fines, Employer Group agrees to pay
EIC, in addition to the full amount of the Claims invoice, a processing fee of $1,500.00.
4.2.3 Employer Group's Administrative Fee Payment Obligations: Beginning with the first month under this
Employer Group Agreement, EIC shall provide Employer Group with an invoice of Administrative Fees prior to the first
day of each month. Administrative Fees are due within seven (7) calendar days of receipt of EIC's invoice. The monthly
Administrative Fee is calculated by multiplying the number of Members who are eligible to receive services hereunder
at any time during the prior month (as reflected in the Claims Adjudication System) by the Administrative Fee amount
set forth on the Cover Sheet (except for the initial invoice which is based on Employer Group's initial Eligibility File).
Invoices shall be deemed to have been received by Employer Group upon the earliest delivery of the invoice by mail,
e -mail, fax, or courier.
4.2.4 Fees for Additional Services and Miscellaneous Expenses: Employer Group agrees to reimburse
EIC for Additional Services and Miscellaneous Expenses (e.g. postage) specified in an attached exhibit hereunder,
within seven (7) calendar days of receipt of an invoice.
4.3 Financial Responsibility: Employer Group understands and agrees that EIC cannot obligate Network
Providers to continue to dispense Covered Benefits without receiving payment for past Claims and EIC shall not be
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obligated to pay Network Providers if Employer Group fails to timely pay EIC as required under this Employer Group
Agreement. Employer Group understands that, if Employer Group has not paid within seven (7) calendar days of
' written notice by EIC of a past due Claims invoice, EIC may notify Network Providers that Employer Group has not
timely paid amounts due for Claims. Further, EIC may suspend the provision of services until any unpaid balance is
received and, as a condition of continuing to perform services under this Employer Group Agreement, require Employer
Group to deposit additional funds with EIC to ensure the timely payment of future invoices. Employer Group further
agrees that EIC shall not be liable for any consequences resulting from the untimely payment of Network Providers,
including, without limitation, failure to meet any applicable prompt payment laws, due to the failure of Employer Group
to timely pay EIC as required under this Employer Group Agreement. Employer Group acknowledges that it is, and
remains responsible for, the payment of all invoices for Covered Benefits dispensed to Members, along with any
associated amounts not timely paid by Members, together with any dispensing fees and taxes.
4.4 Financial Contributions and Refund of Low Income Subsidies (LIS): Employer Group shall comply with the
following conditions with respect to any subsidization of Financial Contributions by the Members:
4.4.1 Limitations on Employer Group Subsidies. Employer Group may subsidize different amounts for
different classes of Members, provided such classes are reasonable and based on objective business criteria, such as
years of service, business location, job category, and nature of compensation (e.g., salaried vs. hourly). However,
Financial Contribution levels cannot vary for Members within a given class, nor can classes of Members be based on
eligibility for Low Income Subsidies ( "LIS ") provided by CMS for certain individuals.
4.4.2 Identification of Low Income Subsidy ( "LIS ") Eligible Individuals. EIC will identify LIS Part D Eligible
Individuals and notify the Employer Group of these Members. Said individuals may be eligible for Low Income Premium
subsidy payments ( "LIPs ") and Low Income Cost subsidy payments ( "LICs ").
4.4.3 LIPs. During implementation, Employer Group shall provide its Retiree Benefit Plan to EIC and the
parties will review same to determine, among other factors, if any Members are making Premium Contributions. If any
Members are doing so, Employer Group will determine whether it wants EIC to issue LIP checks directly to LIP - eligible
Members, or issue a check (or credit) to Employer Group for said amounts in the aggregate, in which case Employer
Group will have the responsibility to issue checks and thereafter attest to the fact that it has appropriately done so.
CMS requires that any LIPs amounts first be used to reduce any portion of Group Coverage Fees paid to Employer
Group by the Member (or on the Member's behalf), with any remaining portion of the LIPs amount then applied toward
the portion of any monthly insurance premium the Employer Group would have paid for an equivalent fully- insured
EGWP /wrap product ( "Illustrative Premium "). Any portion of the LIP subsidy greater than the sum of the Group
Coverage Fee and the Illustrative Premium must be returned to CMS. EIC will identify for the Employer Group the
Illustrative Premium amount. If the Employer Group indicates during implementation that the Employer Group wants to
issue checks to LIPs - eligible Members, EIC shall supply data with each invoice statement identifying the name of each
LIPs - eligible Member, and the amount of LIPs that must be refunded to said Member. Employer Group must refund
the identified LIPs amounts to Members within forty -five (45) days of EIC's receipt of such amounts from CMS,
document how the LIPs amounts were refunded, and provide an attestation to EIC that the LIPs amounts have been
properly refunded. Employer Group acknowledges that it may be liable to CMS for any inappropriate retention of LIPs,
and Employer Group will forward to EIC any funds that it is not entitled to retain.
4.4.4 LICs. EIC will be responsible for providing LICs to Members at the point of sale. In the event that
incorrect amounts of LICs are paid to Members, and additional amounts need to be paid or withheld thereafter, EIC
will be responsible for ensuring said corrections are made and creating a record of such transactions as required by
CMS.
4.5 Other Member Financial Assistance: Employer Group understands that some Members are entitled to receive
other financial assistance through State Pharmaceutical Assistance Programs (SPAPs) or other programs. Such
financial assistance may take the form of premium assistance or assistance to lower the cost of copayments,
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coinsurance or the cost of drugs. The parties agree that EIC will handle all such premium assistance as described in
Section 4.4.3 for LIPs, and EIC will handle all copayment/coinsurance /cost assistance as described in Section 4.4.4
for LICs. Employer Group acknowledges that it may be liable for any inappropriate retention of premium assistance,
and Employer Group will forward to EIC any funds that it is not entitled to retain.
4.6 Additional Financial Contributions from Members:
4.6.1 Late Enrollment Penalty ( "LEP "): Employer Group acknowledges that CMS requires Plan
Beneficiaries to maintain creditable coverage. If a Plan Beneficiary does not maintain creditable coverage for more
than 63 days, CMS assesses a 1% LEP to that beneficiary once creditable coverage is reinstated. This penalty is not
included in amounts received by EIC from CMS or other payors. EIC will invoice Employer Group for any LEP that is
owed by a Member, identifying at the time of the invoice the name of the Member, and the amount owed. The Employer
Group will be obligated to pay the LEP amount invoiced to EIC. However, the Employer Group may collect the LEP
from the Member. EIC will notify Employer Group of Members owing LEPs, as EIC is notified by CMS of these
Members, and such notice will be provided on or before the date when EIC invoices the Employer Group for the LEPs.
If Employer Group or any Member has documentation that the Member did have continuous creditable coverage,
Employer Group may attest to same and EIC will submit a request for rescission of the LEP and a refund from CMS.
EIC will pass through to Employer Group any LEP amounts reimbursed by CMS. In the event that CMS determines
and notifies EIC that a LEP was wrongly or inaccurately assessed, EIC will notify Employer Group and pass through
to the Employer Group any LEP amounts reimbursed by CMS.
4.6.2 Federal Income Related Monthly Adjustment Amount ( "IRMAA "): Employer Group acknowledges
that under IRMAA, if a Member's modified adjusted gross income threshold is exceeded, the Member is required to
pay Medicare a higher monthly fee for Medicare benefits. This payment is made by the Member directly to Medicare
and is not included in amounts received by EIC from CMS or other payors.
4.6.3 Member's Non - Payment of Financial Contributions: Employer Group acknowledges that failure of a
Member to pay any Financial Contributions required under Employer Groups' Retirement Benefit Plan shall not release
Employer Group's financial obligations hereunder. If a Member is to be terminated from the EGWP /wrap for non-
payment of Financial Contributions, Employer Group must give the Member at least twenty one (21) days advance
written notice. This notice must be received by the Member at least twenty one (21) days from the effective date of
disenrollment. This should be taken into consideration when establishing the timing for payment of Financial
Contributions under Employer Group benefit rules.
SECTION 5 — EMPLOYER GROUP's AND EIC's ADDITIONAL RESPONSIBILITIES
5.1 Provision of Information: Employer Group shall furnish to EIC, on a monthly basis (or as otherwise required),
on EIC's form (or such other form as EIC may reasonably approve) by electronic methods (or such other means as
EIC may reasonably approve), such information as EIC may reasonably require to administer this Employer Group
Agreement. This includes, but is not limited to, each Member's Health Insurance Claim Number (HICN), Medicare
Beneficiary Identifier (MBI) or its equivalent, needed to enroll members of the Employer Group and process Member
terminations or status changes. EIC will not be liable to Members for the fulfillment of any obligation prior to information
being received in a form satisfactory to EIC.
No later than thirty (30) days prior to the Effective Date, Employer Group shall provide EIC with an executed Benefit
Specification Form and such data as necessary for EIC to set up the benefit and to commence the provision of services
for the EGWP /wrap.
Employer Group certifies, based on its best knowledge, information and belief, that all enrollment and eligibility
information that has been or will be supplied to EIC is accurate, complete and truthful. Employer Group acknowledges
Page 10 of 29
•
that EIC can and will rely on such enrollment and eligibility information in determining whether an individual is eligible
for Covered Benefits under the EGWP /wrap.
5.2 Maintenance of Information and Records: Employer Group and EIC shall maintain Information and Records '
(as such terms are defined in Section 5.3 below) for the longer of: (i) a period of ten (10) years from the end of the final
contract period under which EIC offers Covered Benefits hereunder, or (ii) the date the U.S. Department of Health and
Human Services, the Comptroller General or their designees complete an audit. This Section 5.2 shall survive the
termination of this Employer Group Agreement, regardless of the cause of the termination.
5.3 Access to Information and Records: Employer Group and EIC shall provide to federal, state and local
governmental authorities having jurisdiction, directly or through their designated agents (collectively "Auditors "), upon
request, access to all books, records and other papers, documents, materials and other information (including, but not
limited to, contracts and financial records) whether in paper or electronic format, relating to this Employer Group
Agreement (together "Information and Records "). Employer Group agrees to provide EIC and Auditors with access to
Information and Records, at Employer Group's offices during regular business hours and upon reasonable advance
request, for as long as such records are maintained as required in Section 5.2 above. Employer Group agrees to supply
copies of Information and Records within fourteen (14) calendar days of Employer Group's receipt of the request, where
practicable, and in no event later than the date required by any applicable law or regulatory authority. EIC also agrees
to provide Auditors with all requested and reasonable access to Information and Records. This Section 5.3 shall survive
the termination of this Employer Group Agreement, regardless of the cause of termination.
5.4 Policies and Procedures; Compliance Verification: Employer Group shall substantially comply with all
reasonable policies and procedures established by EIC in administering and interpreting this Employer Group
Agreement. Employer Group shall, upon request, provide a certification of its substantial compliance with EIC's
participation and contribution requirements and the requirements for a group as defined under 42 C.F.R. 423.100, et.
seq.
5.5 Forms: Unless otherwise agreed, and with the exception of the initial letter transmitted by Employer Group to
Members to provide Members with an opt -out right from Employer Group's Medicare Part D program, EIC shall
distribute all materials to Members regarding enrollment, plan features, including Covered Benefits and exclusions and
limitations of coverage. Employer Group shall, within no fewer than thirty (30) calendar days of receipt from an Eligible
Individual, forward all completed enrollment information and other required information to EIC. Coverage in the
EGWP /wrap for any new Eligible Individuals shall not be effective until such information has been provided to EIC and
the individual has been accepted for membership by CMS.
5.6 Member Correspondence: Once an Eligible Individual is enrolled in the EGWP /wrap, the Eligible Individual
will receive documents and correspondence from EIC as required by CMS. This may be new to Members previously
covered by the Employer Group's prior benefit plan. Members will receive an Evidence of Coverage (EOC) that explains
the rules for coverage under the EGWP /wrap, an annual notice of any changes (ANOC) to the benefits, and other
correspondence related to Covered Benefits under the EGWP /wrap (i.e. Medication Therapy Management).
5.7 Employer Group Acknowledgments: Employer Group acknowledges and agrees that it may not make changes
to the Employer Group's Retiree Benefit Plan during the Term of Service without EIC's prior written approval.
SECTION 6 — RENEWAL AND TERMINATION
6.1 Renewal of Employer Group Agreement: This Employer Group Agreement is renewable upon the mutual
written agreement of EIC and Employer Group and execution of a new Cover Sheet for the subsequent Term of Service.
EIC shall, at least sixty (60) days prior to the end of the Term of Coverage, provide Employer Group with a proposal
for a subsequent Term of Coverage; unless EIC will no longer offer an EGWP /wrap plan in any service areas covered
under this Employer Group Agreement because: (i) CMS terminates or otherwise non - renews EIC's EGWP /wrap
Page 11 of 29
contract with CMS, or (ii) EIC provides CMS with notice of its intention to non -renew its EGWP /wrap contract or reduce
the service areas referenced in its Medicare Part D contract with CMS.
6.2 Termination by Employer Group: This Employer Group Agreement may NOT be terminated by Employer
Group during any Contract Year for any reason other than a material breach of this Employer Group Agreement by
EIC. Should Employer Group wish to terminate for material breach, it shall notify EIC, in writing, at least thirty (30) days
prior to the effective date of termination. Such notice shall state the material breach with sufficient specificity to permit
EIC to cure the breach. If EIC reasonably cures the breach within the thirty (30) day notice period, this Employer Group
Agreement shall not be terminated.
6.3 Termination by EIC: This Employer Group Agreement may be terminated by EIC as follows:
(i) Immediately upon notice to Employer Group if Employer Group has performed any material act or practice
that constitutes fraud or made any intentional misrepresentation of a material fact relevant to the coverage
provided under the EGWP /wrap (The parties agree that inadvertent eligibility errors by Employer. Group shall
not be characterized by EIC as such acts);
(ii) Upon 7 days written notice to Employer Group if Employer Group fails to timely make any payment due EIC,
and Employer Group has not cured its failure within seven days;
(iii) Upon 30 days written notice to Employer Group, if Employer Group ceases to meet Medicare Part D
requirements for an employer group;
(iv) Upon 180 days written notice to Employer Group (or such shorter notice as may be permitted by applicable
law, but in no event less than 30 days) if EIC ceases to offer a product or coverage in a market in which
Members covered under the EGWP /wrap reside;
(v) Upon 30 days written notice to Employer Group for any other reason consistent with the Health Insurance
Portability and Accountability Act of 1996 ( "HIPAA ") or by applicable federal rules and regulations, as
amended.
6.4 Effect of Termination: Except as otherwise stated below, no termination of this Employer Group Agreement
will relieve either EIC or Employer Group from any obligation incurred before the date of termination. When terminated,
this Employer Group Agreement and all services administered by EIC under the EGWP /wrap will end at 11:59 p.m. on
the effective date of termination.
6.5 Notices to Members: It is the responsibility of Employer Group to notify the Members of the termination of this
Employer Group Agreement in accordance with applicable laws, CMS requirements, and EIC's policies and
procedures. EIC reserves the right to notify Members of termination of this Employer Group Agreement for any reason,
including non - payment of amounts due to EIC by Employer Group; however, EIC's Notice must be presented and
approved by Employer Group prior to mailing to Members. In addition, Employer Group shall provide written notice to
Members of their rights upon termination of coverage in accordance with the EOC and applicable CMS requirements.
SECTION 7 — CONFIDENTIALITY AND PRIVACY OF INFORMATION
7.1 Confidentiality: Except as otherwise stated herein or required by law, neither party hereto shall disclose any
information of, or concerning the other party which has either been provided by one party to the other or obtained by a
party in connection with this Employer Group Agreement (including this Employer Group Agreement and the terms of
this Employer Group Agreement) or related to the services rendered under this Agreement, all of which information is
deemed confidential information. All data, information, and knowledge supplied by a party hereto shall be used by the
other party exclusively for the purposes of performing this Agreement. Upon termination of this Agreement, each party
Page 12 of 29
shall return to the other party or destroy (if such destruction is certified) all confidential information provided including,
without limitation, all copies and electronic magnetic versions thereof. Notwithstanding any of the foregoing to the
contrary, "confidential information" shall not include any information which was known by a party prior to receiving it
from the other party, or that becomes rightfully known to a party from a third party under no obligation to maintain its
confidentiality, or that becomes publicly known through no violation of this Agreement.
7.2 Compliance with Privacy Laws: Employer Group will abide by all applicable laws and regulations regarding
the confidentiality of individually identifiable health and other personal information, including the privacy requirements
of HIPAA.
7.3 Disclosure of Protected Health Information: EIC will not provide protected health information ( "PHI "), as
defined in HIPAA, to Employer Group, and Employer Group will not request PHI from EIC, unless Employer Group
complies with all applicable HIPAA requirements. Employer Group, for itself and its employees, agrees that PHI shall
not be used for any impermissible purpose, including, without limitation, the use of PHI for disciplinary or discriminatory
purposes, and any user names and passwords assigned to designated individuals shall be not shared with non -
designated individuals. Employer Group and EIC shall execute a HIPAA Business Associate Agreement.
7.4 Brokers and Consultants: To the extent any broker or consultant engaged by Employer Group receives PHI
in the underwriting process or for any other reason, Employer Group understands and agrees that such broker or
consultant is acting on behalf of Employer Group and not EIC. EIC is entitled to rely on Employer Group's
representations that any such broker or consultant is authorized to act on Employer Group's behalf and entitled to have
access to the PHI under the relevant circumstances.
SECTION 8 — MISCELLANEOUS
8.1 Independent Contractors: EIC and Employer Group are independent contractors. Notwithstanding anything
herein to the contrary, neither party hereto, nor any of its respective employees, shall be construed to be the employee,
agent, or representative of the other for any reason, or liable for any acts of omission or commission on the part of the
other.
8.2 Relationship Between EIC and Network Providers: Employer Group acknowledges that the relationship
between EIC and Network Providers is a contractual relationship among independent contractors. Network Providers
are neither agents nor employees of EIC, nor is EIC an agent or employee of any Network Provider. Network Providers
dispense covered drugs to Members, and EIC administers and determines plan benefits. EIC negotiates contracts with
pharmacies, pharmaceutical manufacturers, and vendors on its own behalf and not specifically or exclusively for
Employer Group. Network Providers are solely responsible for any services rendered to EIC Members. EIC makes no
express or implied warranties or representations concerning the qualifications, continued participation, or quality of
services of any Network Provider. A Network Provider's participation may be terminated at any time without advance
notice to the Employer Group or Members, subject to applicable law.
Employer Group further acknowledges that EIC is neither an operator of pharmacies nor exercises control over the
professional judgment used by any pharmacist when dispensing drugs or medical supplies to Members. Nothing in this
Employer Group Agreement shall be construed to usurp the dispensing pharmacist's professional judgment with
respect to the dispensing or refusal to dispense any drugs or medical supplies to Members. EIC does not indemnify
Members or Employer Group, and Employer Group hereby releases EIC, from any liability arising from the dispensing
of drugs or medical supplies by any pharmacy to Members.
8.3 Limited Indemnification and Limitation of Liability: EIC shall indemnify and hold harmless Employer Group for
that portion of any liability, settlement and related expense (including the reasonable cost of legal defense) which was
caused solely, directly and independently by EIC fraud, willful misconduct, criminal misconduct, negligence, or material
breach of this Employer Group Agreement. Employer Group shall indemnify and hold harmless EIC for that portion of
Page 13 of 29
any liability, settlement and related expense (including the reasonable cost of legal defense) which was caused solely,
directly and independently by Employer Group's fraud, willful misconduct, criminal misconduct, negligence (including,
without limitation, untimely, inaccurate, incomplete, or conflicting eligibility information), or material breach of this
Employer Group Agreement.
The party seeking indemnification must notify the indemnifying party promptly in writing of any actual or threatened
action, suit or proceeding to which it claims such indemnity applies. Failure promptly to so notify the indemnifying party
shall be deemed a waiver of the right to seek indemnification.
The parties agree that in no event shall the indemnity obligations under this Section 8.3 apply to that portion of any
liability, settlement and related expense caused by (a) EIC acts or omissions undertaken at the direction of Employer
Group or Employer Group's agent; or (b) Employer Group's act or omission undertaken at EIC's expressed written
direction.
Notwithstanding the indemnification obligations set forth above (i) each party's liability to the other hereunder will in no
event exceed the actual proximate losses or damages caused by breach of this Employer Group Agreement; and (ii)
in no event will either party or any of their respective affiliates, directors, employees or agents, be liable for any indirect,
special, incidental, consequential, exemplary or punitive damages, or any damages for lost profits relating to a
relationship with a third party, however caused or arising, whether or not they have been informed of the possibility of
their occurrence.
Except in cases of fraud or the inappropriate disclosure of PHI, the rights of the parties hereto for indemnification
relating to this Employer Group Agreement or the transactions contemplated herein shall be strictly limited to the those
contained in this Section 8.3 and such indemnification rights shall be the exclusive remedies of the parties with respect
to any matter arising under or in connection with this Employer Group Agreement.
The indemnification obligations of the parties shall terminate upon the expiration of this Employer Group Agreement
except as to any matter concerning a claim which has been asserted by notice to the other party at the time of such
expiration or within 365 days thereafter.
8.4 Delegation and Subcontracting: Employer Group acknowledges and agrees that EIC may enter into
arrangements with its affiliates and other subcontractors to perform certain functions hereunder such as the provision
of the provider network, utilization management, customer service, quality assurance and provider credentialing, as
EIC deems appropriate. EIC shall remain responsible for the performance of any such delegated functions.
8.5 Prior Agreements; Severabilitv: As of the Effective Date of Service, this Employer Group Agreement replaces
and supersedes all other prior agreements between EIC and Employer Group, as well as any other prior written or oral
understandings, negotiations, discussions or arrangements between the parties, related to matters covered by this
Employer Group Agreement or the documents incorporated herein. If any provision of this Employer Group Agreement
is deemed to be invalid or illegal, that provision shall be fully severable and the remaining provisions of this Employer
Group Agreement shall continue in full force and effect.
8.6 Amendments: This Employer Group Agreement may be amended as follows: This Employer Group
Agreement shall be deemed to be automatically amended to conform to all rules and regulations promulgated at any
time by any state or federal regulatory agency or authority having supervisory authority over EIC; or by written
agreement executed by both EIC and Employer Group. Except for said automatic amendments, all amendments to
this Employer Group Agreement must be approved and executed by EIC and Employer Group. No employee, entity,
or individual has the authority to (i) modify this Employer Group Agreement; (ii) waive any of its provisions, conditions,
or restrictions; (iii) extend the time for making a payment; or (iv) bind EIC by making any other commitment or
representation or by giving or receiving any information.
Page 14 of 29
8.7 Clerical Errors: Clerical errors or delays by EIC in keeping or reporting data relative to coverage will not reduce
or invalidate a Member's coverage. Upon discovery of an error or delay, an adjustment of Administrative Fee shall be
made to reflect the cost of the error or delay. EIC may also modify or replace an Employer Group Agreement, EOC or
other document issued in error.
8.8 Claim Determinations and Administration of Covered Benefits: EIC has complete authority to review all claims
for Covered Benefits as defined in the EOC under this Employer Group Agreement. In exercising such responsibility,
EIC shall have discretionary authority to determine whether and to what extent Members are entitled to coverage and
to construe any disputed or doubtful terms under this Employer Group Agreement, the EOC or any other document
incorporated herein. The administration of Covered Benefits and of any appeals filed by Members related to the
processing of claims for Covered Benefits shall be conducted in accordance with the EOC and CMS regulations.
8.9 Third Party Billing: EIC may engage a third party entity to provide billing services on behalf of EIC under this
Employer Group Agreement. The third party entity is not and should not be considered a third -party beneficiary.
8.10 Misstatements: If any fact as to Employer Group or a Member is found to have been misstated, an equitable
adjustment of Administrative Fee may be made. If the misstatement affects the existence or amount of coverage, the
true facts will be used in determining whether coverage is or remains in force and its amount.
8.11 Incontestability: Except as to a fraudulent misstatement, or issues concerning Administrative Fees due, no
statement made by Employer Group or any Member shall be the basis for voiding coverage or denying coverage or be
used in defense of a claim unless it is in writing.
8.12 Assignability: No rights or benefits under this Employer Group Agreement are assignable by either EIC or
Employer Group to any third party unless approved, in writing, by all parties.
8.13 Waiver: EIC's failure to implement, or insist upon compliance with, any provision of this Employer Group
Agreement or the terms of the EOC incorporated hereunder, at any given time or times, shall not constitute a waiver
of EIC's right to implement or insist upon compliance with that provision at any other time or times. This includes, but
is not limited to, the payment of Premiums or Covered Benefits. This applies whether or not the circumstances are the
same.
8.14 Third Parties: This Employer Group Agreement shall not confer any rights or obligations on third parties except
as specifically provided herein.
8.15 Non - Discrimination: Employer Group agrees to make no attempt, whether through differential contributions or
otherwise, to encourage or discourage enrollment of Eligible Individuals in EIC based on health status or health risk.
8.16 Applicable Law: This Employer Group Agreement shall be governed and construed in accordance with
applicable federal law and the applicable law, if any, of the State of Ohio, without regard to its conflict principles.
Employer Group acknowledges that EGWPs are governed by federal law and the regulations promulgated by CMS for
Medicare Part D Prescription Drug Plans and Wraps are governed by state law and regulation.
8.17 Use of the EICs Name and all Symbols, Trademarks, and Service Marks: EIC reserves the right to control the
use of EICs name and all symbols, trademarks, and service marks presently existing or subsequently established.
Employer Group agrees that it will not use such name, symbols, trademarks, or service marks in advertising or
promotional materials or otherwise without EIC's prior written consent and will cease any and all usage immediately
upon EICs request or upon termination of this Employer Group Agreement.
8.18 Dispute Resolution
Page 15 of 29
8.18.1 Mediation: If either party to this Employer Group Agreement should declare a breach of this Employer
Group Agreement, or if any dispute arises from this Employer Group Agreement or the subject of this Employer Group
Agreement, the parties shall first submit the matter to non - binding mediation (not arbitration) and attempt to resolve
the matter, in good faith, prior to the institution of any arbitration or any other legal action. The parties agree that
arbitration or any other legal action may be initiated only after each party has presented its case to a qualified mediator
associated with a professional mediation firm and such mediator has declared an impasse. Any statements made at
such mediation shall be for settlement purposes only and shall not be construed to be an admission. A party demanding
mediation shall be entitled to obtain a court order mandating mediation if the other party does not agree to commence
mediation within thirty (30) days after written demand. The fees and costs incurred by the party seeking such court
order shall be reimbursed by the other party; otherwise, each party shall pay its own costs of mediation. All such
mediation proceedings shall be conducted on a confidential basis. The mediation shall be conducted in Monroe County,
Florida.
8.19 CMS Contract: This Employer Group Agreement is subject to the annual renewal of EIC's Medicare Part D
contract with CMS. Covered Benefits and/or the Administrative Fee and Expenses are also subject to change at the
beginning of any subsequent Term of Coverage under this Employer Group Agreement. Except as otherwise provided
herein, increases in the Administrative Fee and Expenses and /or decreases in Covered Benefits are only permitted at
the beginning of a subsequent Term of Coverage under this Employer Group Agreement. Should CMS cancel EIC's
contract as a Medicare Part D contractor or should EIC decide not to continue as a Medicare Part D contractor,
Members shall be given notice of such termination in accordance with the EOC and any applicable laws, rules and
regulations, including, without limitation, CMS requirements.
8.20 Force Maleure: EIC shall not be deemed to have breached this Employer Group Agreement or be held liable
for any failure or delay in the performance of all or any portion of its obligations under this Employer Group Agreement
if prevented from doing so by a cause or causes beyond its control. Without limiting the generality of the foregoing,
such causes include acts of God or the public enemy, fires, floods, storms, earthquakes, riots, strikes, boycotts, lock-
outs, acts of terrorism, acts of war or war - operations, restraints of government, power or communications line failure
or other circumstances beyond such party's control, or by reason of the judgment, ruling or order of any court or agency
of competent jurisdiction, or change of law or regulation (or change in the interpretation thereof) subsequent to the
execution of this Employer Group Agreement. If due to circumstances not within EICs reasonable control, including but
not limited to major disaster, epidemic, complete or partial destruction of facilities, riot, civil insurrection, disability of a
significant part of EIC's Network Providers or entities with whom EIC has contracted for services under this Employer
Group Agreement, or similar causes, the provision of benefits provided under this Employer Group Agreement is
delayed or rendered impractical, EIC shall not have any liability or obligation on account of such delay or failure to
provide services, except to refund the amount of the unearned prepaid Administrative Fee held by EIC on the date
such event occurs. EIC is required only to make a good -faith effort to provide or arrange for the provision of services,
taking into account the impact of the event. This Section 8.20 shall not be considered to be a waiver of any continuing
obligations under this Employer Group Agreement, including, without limitation, the obligation to make payments.
8.21 Notices: Any notice required or permitted under this Employer Group Agreement shall be in writing and shall
be deemed to have been given on the date when delivered in person; or, if delivered by first -class United States mail,
on the date mailed, proper postage prepaid, and properly addressed to the address set forth in the Employer Group
Application or Cover Sheet, or to any more recent address of which the sending party has received written notice or, if
delivered by facsimile or other electronic means, on the date sent by facsimile or other electronic means.
8.22 Representations: Employer Group represents and warrants that to the best of its knowledge (i) it is self -
insured for benefits covered under its Retiree Benefit Plan and the Wrap; (ii) the entering into this Employer Group
Agreement is not in violation of any other agreement; (iii) has no undisclosed conflicts of interest; and (iv) it maintains,
and shall continue to maintain throughout the term of this Employer Group Agreement, any and all applicable licenses,
governmental authority, or other authorization required to operate an entity of its type. EIC represents that (i) there are
no organizational arrangements that could potentially create a conflict of interest that affects clinical or financial
Page 16 of 29
decisions; and (ii) it maintains, and shall continue to maintain throughout the term of this Employer Group Agreement,
any and all applicable licenses, governmental authority, or other authorization required to operate an entity of its type.
8.23 Federal Contract Requirements: EIC and Employer Group agree to comply with the federal contractual
provisions required under 2 CFR part 200 et seq. and specified in Exhibit D.
The following are approved Exhibits to this Employer Group Agreement:
Exhibit A: Summary of Benefits
Exhibit B: Explanation of Coverage
Exhibit C: Administrative Expenses and Drug Pricing Fees and Financial Guarantees
Exhibit D: Federal Contract Requirements
[SIGNATURE PAGE FOLLOWS]
Page 17of
2018 MEDICARE EMPLOYER GROUP AGREEMENT
(EGWP /wrap ASO)
SIGNATURE PAGE
IN WITNESS WHEREOF, EIC and Employer Group have caused this Employer Group Agreement to be executed by their respective
authorized officers.
EIC: EMPLOYER GROUP:
BOARD OF COUNTY COMMISSIONERS
OF MONROE COUNTY FLORIDA
By: By:
William C. Epling, Presiden, •
David Rice, Mayor
Print Name and Title
Address: Address:
Envision Insurance Company 1100 Simonton Street
2181 East Aurora Road Key West, FL 33040
Twinsburg, OH 44087
PH:330- 405 -8080 PH: (305)292 -4458
FX: 330-405-8081 FX: (305)292 -4564
r ° E= MAIL. cook -bryan @monroecounty -f 1. gov
§ �v` = ::FEIN:; _`59- 6000749
ATTEST ;�
� KEVIN. t MADOK, CLERK 'R
p ..
Mao a,
By : c� N
Deputy Clerk nom`
• =e m
ri
MONROE COUNTY ATTORNEY
Ar RO . D-AS TO 0
r 1V/
_ _ • YNTHIA L. HALL
ASSTS` i NT COUNTY ATTORNEY
Date
Page 18 of 29
EXHIBIT C
Fees and Financial Guarantees*
Fees for Additional Services and Miscellaneous Expenses
Manual Claims Processing (including DMRs) $1.50 per Claim processed
Claim Adjustment Checks (charged to Employer Group for
reimbursements made to Members for Claim adjustments $8.50 per check
requested by Employer Group.)
Manually create or update the Eligibility File $1.00 per Covered Individual data entry
Ad Hoc Computer or Report Programming (Recurring Report) $2,500.00 for the development of a recurring, non - standard report
(one time standard ad -hoc report included in administrative fee)
Clinical Prior Authorizations (Initial Coverage Determinations) $35.00 per authorization
Redeterminations (Internal Appeals) $125.00 per determination
Independent Review Organization (IRO) Coordination Pass - through of cost of IRO
Member Communications Cost of production and postage
Customized Formulary $0.20 PMPM with a minimum of $2,000.00 per month
Custom Eligibility File layouts (accommodation or development) $1,000.00 per layout
Custom Website or Private Label Portal Quoted upon request
Replacement by Envision of lost or stolen ID Cards $1.15 per card plus cost of postage
Explanation of Benefits (EOB) production and distribution $1.00 per EOB plus postage
Medicaid Subrogation Claim Adjudication $3.50 per claim
Enhanced Fraud, Waste and Abuse /Benefit Integrity Services Quoted upon request
Pharmacy Audits (On -site) $1,500.00 per on -site audit
Drug Therapy Care Gap Management $1.50 per Member, per month
Medication Adherence and Persistency (up to three disease
states) $1.50 per Member, per month
e- Prescribing $0.30 per transaction, minimum of $250.00 per month
Standard Online Reporting includes access for 3 client users and
Standard Online Reporting User Access 1 consultant user. A licensing fee is charged for each user
account not accessed over a 60 -day period. $1,200.00 per
additional unique user
Data transfer files (Industry- standard files) $250.00 per transfer
$5,000.00 for identified reports:
A. Claims History
B. PA files
Contract Termination Report Fees C. Open Refill files (mail and specialty)
D. Accumulator files
E. Related Participant Data files
Post Termination Run -off Claims $2.24 per prescription
Page 19 of 29
Drug Pricing and Dispensing Fees(A)
Supply /Source BRAND GENERIC
Drug Price (B)(C) Dispensing Fee (C) Drug Price (B)(C) Dispensing Fee (C)
For Contract Year 2018 (Annual Average (Annual Average (Annual Average (Annual Average
Effective Rate Guarantee) Effective Rate Guarantee)
Guarantee) Guarantee)
Retail Pharmacy (Up to 30 AWP minus 17.00% $1.00 AWP minus 80.00% $1,00
Days' Supply)
Retail Pharmacy (31 AWP minus 17.00% $1.00 AWP minus 80.00% $1.00
Days' to 83 Days' Supply)
Retail Pharmacy (84 AWP minus 22.00% $1.00 AWP minus 84.00% $1.00
Days' to 89 Days' Supply)
Retail Pharmacy (90
Days' Supply or greater) AWP minus 22.00% N/A AWP minus 84.00% N/A
(non -Mail Order) (D)
Mail Order Pharmacy (Up AWP minus 17.00% N/A AWP minus 80.00% N/A
to 45 Days' Supply)
Mail Order Pharmacy (46 AWP minus 23.00% N/A AWP minus 85.00% N/A
Days' Supply or greater)
Specialty Pharmacy (Pass- Through of Contract Rate with Dispensing Pharmacy)
Supply /Source BRAND GENERIC
Drug Price Dispensing Fee (C) Drug Price (B)(C) (Annual Dispensing Fee (C> (Annual
(B)(c) (Annual (Annual Average Average Effective Rate Average Guarantee)
For Contract Year 2019 Average Guarantee) Guarantee)
Effective
Rate
Guarantee)
Retail Pharmacy (Up to 30 AWP minus
Days' Supply) 17.00% $1.00 AWP minus 80.25% $1.00
Retail Pharmacy (31 AWP minus
$1.00 AWP minus 80.25% $1.00
Days' to 83 Days' Supply) 17.00%
Retail Pharmacy (84 AWP minus
$1.00 AWP minus 84.00% $1.00
Days' to 89 Days' Supply) 22.00%
Retail Pharmacy (90 AWP minus AWP minus 84.00%
Days' Supply or greater)
22.00% N/A N/A
(non -Mail Order) (D)
Mail Order Pharmacy (Up AWP minus N/A AWP minus 80.25% N/A
to 45 Days' Supply) 17.00%
Mail Order Pharmacy (46 AWP minus N/A AWP minus 85.00% N/A
Days' Supply or greater) 23.00%
Specialty Pharmacy (Pass- Through of Contract Rate with Dispensing Pharmacy)
Page 20 of 29
Supply /Source BRAND GENERIC
Drug Price Dispensing Fee(c) Drug Price ( MP ) (Annual Dispensing Fee(c) (Annual
(B)(C) (Annual (Annual Average Average Effective Rate Average Guarantee)
For Contract Year 2020 Average Guarantee) Guarantee)
Effective
Rate
Guarantee)
Retail Pharmacy (Up to 30 AWP minus $1.00 AWP minus 80.50% $1.00
Days' Supply) 17.00%
Retail Pharmacy (31 AWP minus $1 00 AWP minus 80.50% $1.00
Days' to 83 Days' Supply) 17.00%
Retail Pharmacy (84 AWP minus $1 00 AWP minus 84.00% $1.00
Days' to 89 Days' Supply) 22.00%
Retail Pharmacy (90 AWP minus AWP minus 84.00%
Days' Supply or greater)
22.00% N/A N/A
(non -Mail Order) (D)
Mail Order Pharmacy (Up AWP minus N/A AWP minus 80.50% N/A
to 45 Days' Supply) 17.00%
Mail Order Pharmacy (46 AWP minus N/A AWP minus 85.00% N/A
Days' Supply or greater) 23.00%
Specialty Pharmacy (Pass- Through of Contract Rate with Dispensing Pharmacy)
(A) For purposes of this Agreement the "Average Wholesale Price" or "AWP" means the average wholesale price of a Covered Drug
indicated on the most current pricing file provided to Envision by Medi -Span® (or other applicable industry standard reference on which
pricing hereunder is based) for the actual drug dispensed using the 11 digit National Drug Code (NDC) number provided by the
dispensing pharmacy. Envision uses a single source for determining AWP and updates the AWP source file at least once weekly.
(B) For purposes of this Agreement, the "Annual Average Effective Rate" means, for the category of drugs being reviewed, the result
calculated by the following formula:
1. (IC /AWP) -1, where IC (the "Ingredient Cost ") is the sum of all amounts paid by Employer Group for the ingredient costs of the
Covered Drugs paid to Participating Pharmacies in the designated Network during the Contract Year, before deducting
applicable Manufacturer Derived Revenue; and
2. AWP is the sum of the Average Wholesale Price amounts associated with the same Covered Drugs during the Contract Year.
If the calculated price is lower than the allowable amount under any state Medicaid "Favored Nations" rule, Envision shall
pass- through, and Employer Group shall pay, the Medicaid allowable amount.
(C) The Annual Average Effective Rate and Annual Average Dispensing Fee is calculated using actual price paid by Envision to
Participating Pharmacies in the designated Network, plus any Cost Share, (the Ingredient Cost) for all Claims for the applicable category
above (including Claims paid at the U &C Price) during a Contract Year, excluding (i) compound drugs; (ii) Limited Distribution Drugs;
(iii) drugs dispensed at a Specialty Pharmacy; (iv) Claims from non - Participating Pharmacies, LTC pharmacies, home infusion or
government owned or operated pharmacies (e.g. Veterans Administration); (v) Claims paid at government required amounts (e.g.
Medicaid); (vi) 340B Claims; (vii) vaccines; (viii) non - Prescription Drugs (including OTC); (ix) drugs in limited supply; and (x) Claims
from any Employer Group owned or affiliated pharmacy which is not a Participating Pharmacy.
( 84 Days' supply or greater at retail pharmacy guarantees apply only if Employer Group's Covered Benefits includes a 90 days' supply
at retail benefit for the entire Contract Year.
Annual Average Effective Rate and Annual Average Dispensing Fee Guarantee
Employer Group acknowledges that the Annual Average Effective Rates and Annual Average Dispensing Fees specified in this Exhibit
C are conditioned upon Employer Group's adherence to certain conditions under this Agreement and that the actual Annual Average
Effective Rates and Annual Average Dispensing Fees will also depend on Employer Group's drug utilization and mix of Participating
Page 21 of 29
Pharmacies. The Annual Average Effective Rates and Annual Average Dispensing Fees guarantees set forth in Exhibit C shall be
deemed to have been satisfied if the discounts passed through to Employer Group for all Claims during the Contract Year are equal to
or more favorable, in the aggregate, than the drug pricing and dispensing fee guarantees stated for each drug type or category
individually. If the amounts paid by Employer Group for all Claims during the Contract Year are less favorable, in the aggregate and
after application of any additional offsets allowed under this Agreement, than the combined Annual Average Effective Rates and Annual
Average Dispensing Fees stated in Exhibit C, Envision shall credit Employer Group with the difference as set forth below. Envision
shall not be liable to Employer Group for shortfalls in guaranteed Annual Average Effective Rates or Annual Average Dispensing Fees
if (i) Employer Group makes a change to the Covered Benefits at any time (regardless of whether or not such change is required by
law); (ii) the configuration of System edits is modified by Employer Group; (iii) Employer Group does not adhere to the Formulary; (iv)
the utilization data provided by Employer Group (or Employer Group's agent) upon which the calculation of guarantees were based is
inaccurate, incomplete; (v) there is a change +I- 20% in drug utilization patterns of Members; or (vi) Employer Group terminates before
completion of the applicable, full Contract Year. In addition, Employer Group agrees that Envision's liability to Employer Group for
shortfalls in financial guarantees, in the aggregate, for any Contract Year shall be limited to amounts paid by Plan Sponsor to Envision
for Administrative Fees during the applicable Contract Year, and Employer Group has no right of offset to withhold any payment due
Envision under this Agreement for any amounts Employer Group believes are owed by Envision for financial guarantee.
Annual Average Manufacturer Derived Revenue Guarantee (E),(F),(G),(H)
For Contract Year 2018:
• For up to 83 days' supply of Brand Drugs at a Retail Pharmacy - $23.15 per paid Brand Drug Claim
• For 84 days' supply or greater of Brand Drugs at a Retail Pharmacy- $ 85.63 per paid Brand Drug Claim
• For up to 45 days' supply of Brand Drugs at the Mail Order Pharmacy- $23.15 per paid Brand Drug Claim
• For 46 days' supply or greater of Brand Drugs at the Mail Order Pharmacy- $118.34 per paid Brand Drug Claim
• For Specialty Brand Drugs - $234.46 per paid Specialty Brand Drug Claim
(E) Manufacturer Derived Revenue guarantees are stated as annual average amounts per Contract Year.
(F) Guarantees require Employer Group to maintain Covered Benefits that has a tier structure with a minimum $20 differential in Cost
Share between preferred Brand Drugs and non - preferred Brand Drugs.
(G) 340B Claims, Claims not eligible for Manufacturer Derived Revenue (e.g. Vaccines, Compounds, Direct Member Reimbursement
Claims, etc.), OTC drug Claims (with the exception of diabetic testing strips and meters), and Claims from any Employer Group owned
or affiliated pharmacy which is not a Participating Pharmacy, shall be excluded from the calculation of the guarantees above.
0 "0 Guarantees require Employer Group to utilize current EIC Formulary.
Employer Group acknowledges that the annual average Manufacturer Derived Revenue guaranteed amounts specified in this Exhibit
C are conditioned upon Employer Group's adherence to certain conditions under this Agreement.
(a) If the Manufacturer Derived Revenue advanced to Employer Group for the Contract Year is, overall, lower than the overall
Manufacturer Derived Revenue earned by Employer Group for the Contract Year, Envision shall pay the difference to Employer Group,
after application of any additional offset allowed under this Agreement.
(b) If the Manufacturer Derived Revenue earned by Employer Group for the Contract Year is, overall, lower than the annual
average Manufacturer Derived Revenue guaranteed amounts specified above, in the aggregate, Envision shall pay the difference to
Employer Group, after application of any additional offset allowed under this Agreement.
Notwithstanding anything herein to the contrary, Envision shall not be liable to Employer Group for any shortfall in guaranteed
Manufacturer Derived Revenue if: (i) Plan Sponsor makes a change to the Covered Benefits at any time (regardless of whether or not
such change is required by law); (ii) the configuration of System edits is modified by Employer Group; (iii) Employer Group does not
adhere to the Formulary; (iv) the utilization data provided by Employer Group (or Employer Group's agent) upon which the calculation
of guarantees were based is inaccurate, incomplete; (v) there is a change +I- 20% in drug utilization patterns of Members; (vi) there
is a loss of rebates due to pharmaceutical manufacturer drug patent expirations, manufacturer bankruptcy, or removal of a drug from
the market; (vii) there are changes in pharmaceutical manufacturer rebate contracting terms or policies; (viii) Employer Group's
Covered Benefits does not meet the conditions for rebates of pharmaceutical manufacturer contracts including market share rebates;
(ix) if Employer Group has been excluded by a manufacturer; (x) there is any governmental regulation, ruling, or guidance that impacts
Envision's ability to maintain current Manufacturer Derived Revenue yields; or (xi) Employer Group terminates before completion of
the applicable, Contract Year. Employer Group agrees that Envision's liability to Employer Group for shortfalls in financial guarantees,
in the aggregate, for any Contract Year shall be limited to amounts paid by Employer Group to Envision for Administrative Fees during
Page 22 of 29
the applicable Contract Year, and Employer Group has no right of offset to withhold any payment due Envision under this Agreement
for any amounts Employer Group believes are owed by Envision for financial guarantees.
Envision reserves the right to modify the pricing if the actual enrollment on the EGWP /wrap decreases by 20% or more from total
enrollment on the effective date of this Agreement.
Page 23 of 29
EXHIBIT D
Federal Contractual Requirements
For the purposes of this Exhibit only, Employer Group shall be known as the COUNTY and EIC as the CONTRACTOR.
1. SMALL AND MINORITY BUSINESSES, WOMEN'S BUSINESS ENTERPRISES, AND LABOR SURPLUS AREA FIRMS.
The COUNTY strongly encourages the use of women -, minority- and veteran -owned business enterprises (SBEs) and wishes to see a
minimum of 25% of the contract or subcontracts awarded pursuant to this RFP go to SBEs. Contractors may search for Florida registered
SBEs at: http: / /www.dms.mvflorida.com /agency administration /office of supplier diversity osd
Any proposal submitted in which the vendor is certified as an SBE, or in which the vendor proposes to use subcontractors that are certified
as SBEs, in Florida or another jurisdiction, must submit proof of the registration or certification from the local authority in order to receive
credit for the use of the SBE.
2. AUDIT OF RECORDS
CONTRACTOR shall grant to the COUNTY, DEM, FEMA, the Federal Government, and any other duly authorized agencies of the
Federal Government or the COUNTY where appropriate the right to inspect and review all books and records directly pertaining to the
Contract for a period of five (5) years after final grant close -out by FEMA or DEM, or as required by applicable County, State and Federal
law. Records shall be made available during normal working hours for this purpose and in accordance with Section 5 of this Agreement.
In the event that FEMA. DEM, or any other Federal or State agency, or the COUNTY, issues findings or rulings that the amounts charged
by the CONTRACTOR, or any portions thereof, were ineligible or were non - allowable under federal or state Law or regulation,
CONTRACTOR may appeal any such finding or ruling. If such appeal is unsuccessful, the CONTRACTOR shall agree that the amounts
paid to the Contractor shall be adjusted accordingly, and that the CONTRACTOR shall, within thirty (30) days thereafter, issue a
remittance to the COUNTY of any payments declared to be ineligible or non - allowable.
CONTRACTOR shall comply with federal and/or state laws authorizing an audit of CONTRACTOR's operation as a whole, or of specific
Project activities.
Under no circumstances shall advertising or other communications with the media be presented in such a manner as to COUNTY or
imply that the CONTRACTOR or the CONTRACTOR's services are endorsed by the COUNTY.
3. TERMINATION
In the event that the CONTRACTOR shall be found to be negligent in any aspect of service, the COUNTY shall have the right to terminate
this agreement after five days written notification to the CONTRACTOR. Either of the parties hereto may cancel this Agreement without
cause by giving the other party sixty (60) days written notice of its intention to do so.
A. Termination for Cause and Remedies: In the event of breach of any material contract terms, the COUNTY retains the right to
terminate this Agreement. The COUNTY may also terminate this agreement for cause with CONTRACTOR should
CONTRACTOR materially fail to perform the covenants herein contained at the time and in the manner herein provided. In the
event of such termination, prior to termination, the COUNTY shall provide CONTRACTOR with thirty (30) calendar days' notice
and provide the CONTRACTOR with an opportunity to cure the breach that has occurred. If the breach is not cured within thirty
(30) days of notice, the Agreement will be terminated for cause. The maximum amount due to CONTRACTOR shall not in any
event exceed the spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid
under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of
the COUNTY's False Claims Ordinance, located at Section 2 -721 et al. of the Monroe County Code.
B. Termination for Convenience: After the first Contract Year, the COUNTY may terminate this Agreement for convenience, at any
time, upon ninety (90) days' notice to CONTRACTOR. . The maximum amount due to CONTRACTOR shall not exceed the
spending cap in this Agreement. In addition, the COUNTY reserves all rights available to recoup monies paid under this
Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the COUNTY's
False Claims Ordinance, located at Section 2 -721 et al. of the Monroe County Code.
Page 24 of 29
4. PUBLIC ENTITIES CRIMES AND DEBARMENT
A person or affiliate who has been placed on the convicted vendor list following a conviction for public entity crime may not submit a bid
on contracts to provide any goods or services to a public entity, may not submit a bid on a contract with a public entity for the construction
or repair of a public building or public work, may not submit bids on leases of real property to public entity, may not be awarded or perform
work as a contractor, supplier, subcontractor, or CONTRACTOR under a contract with any public entity, and may not transact business
with any public entity in excess of the threshold amount provided in Section 287.017 of the Florida Statutes, for CATEGORY TWO for a
period of 36 months from the date of being placed on the convicted vendor list.
By signing this Agreement, CONTRACTOR represents that the execution of this Agreement will not violate the Public Entity Crimes Act
(Section 287.133, Florida Statutes).
Violation of terms of this contract shall result in termination of this Agreement and recovery of all monies paid hereto, suspension of the
ability to bid on and perform County contracts, and may result in debarment from COUNTY's competitive procurement activities.
In addition to the foregoing, CONTRACTOR further represents that there has been no determination, based on an audit, that it or any
subcontractor has committed an act defined by Section 287.133, Florida Statutes, as a "public entity crime" and that it has not been
formally charged with committing an act defined as a "public entity crime" regardless of the amount of money involved or whether
CONUSULTANT has been placed on the convicted vendor list.
CONTRACTOR will promptly notify the COUNTY if it or any subcontractor or CONTRACTOR is formally charged with an act
defined as a "public entity crime" or has been placed on the convicted vendor list.
5. NONDISCRIMINATION
During the performance of this Agreement, the CONTRACTOR agrees as follows:
A. The contractor will not discriminate against any employee or applicant for employment because of race, color, religion, sex,
sexual orientation, gender identity, or national origin. The contractor will take affirmative action to ensure that applicants are
employed, and that employees are treated during employment, without regard to their race, color, religion, sex, sexual
orientation, gender identity, or national origin. Such action shall include, but not be limited to the following: Employment,
upgrading, demotion, or transfer, recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of
compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places,
available to employees and applicants for employment, notices to be provided by the contracting officer setting forth the
provisions of this nondiscrimination clause.
B. The contractor will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all
qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation,
gender identity, or national origin.
C. The contractor will not discharge or in any other manner discriminate against any employee or applicant for employment because
such employee or applicant has inquired about, discussed, or disclosed the compensation of the employee or applicant or
another employee or applicant. This provision shall not apply to instances in which an employee who has access to the
compensation information of other employees or applicants as a part of such employee's essential job functions discloses the
compensation of such other employees or applicants to individuals who do not otherwise have access to such information,
unless such disclosure is in response to a formal complaint or charge, in furtherance of an investigation, proceeding, hearing,
or action, including an investigation conducted by the employer, or is consistent with the contractor's legal duty to furnish
information.
D. The contractor will send to each labor union or representative of workers with which it has a collective bargaining agreement or
other contract or understanding, a notice to be provided by the agency contracting officer, advising the labor union or workers'
representative of the contractor's commitments under section 202 of Executive Order 11246 of September 24, 1965, and shall
post copies of the notice in conspicuous places available to employees and applicants for employment.
E. The contractor will comply with all provisions of Executive Order 11246 of September 24, 1965, and of the rules, regulations,
and relevant orders of the Secretary of Labor.
F. The contractor will furnish all information and reports required by Executive Order 11246 of September 24, 1965, and by the
rules, regulations, and orders of the Secretary of Labor, or pursuant thereto, and will permit access to his books, records, and
Page 25 of 29
accounts by the contracting agency and the Secretary of Labor for purposes of investigation to ascertain compliance with such
rules, regulations, and orders.
G. In the event of the contractor's non - compliance with the nondiscrimination clauses of this contract or with any of such rules,
regulations, or orders, this contract may be canceled, terminated or suspended in whole or in part and the contractor may be
declared ineligible for further Government contracts in accordance with procedures authorized in Executive Order 11246 of
September 24, 1965, and such other sanctions may be imposed and remedies invoked as provided in Executive Order 11246
of September 24, 1965, or by rule, regulation, or order of the Secretary of Labor, or as otherwise provided by law.
6. COVENANT OF NO INTEREST
CONTRACTOR and COUNTY covenant that neither presently has any interest, and shall not acquire any interest, which would conflict
in any manner or degree with its performance under this Agreement, and that only interest of each is to perform and receive benefits as
recited in this Agreement.
7. CODE OF ETHICS
The parties recognize and agree that officers and employees of the COUNTY recognize and will be required to comply with the standards
of conduct for public officers and employees as delineated in Section 112.313, Florida Statutes, regarding, but not limited to, solicitation
or acceptance of gifts; doing business with one's agency; unauthorized compensation; misuse of public position, conflicting employment
or contractual relationship; and disclosure or use of certain information.
8. NO SOLICITATION/PAYMENT
The CONTRACTOR and COUNTY warrant that, in respect to itself, it has neither employed nor retained any company or person, other
than a bona fide employee working solely for it, to solicit or secure this Agreement and that it has not paid or agreed to pay any person,
company, corporation, individual, or firm, other than a bona fide employee working solely for it, any fee, commission, percentage, gift, or
other consideration contingent upon or resulting from the award or making of this Agreement. For the breach or violation of the provision,
the CONTRACTOR agrees that the COUNTY shall have the right to terminate this Agreement without liability and, at its discretion, to
offset from monies owed, or otherwise recover, the full amount of such fee, commission, percentage, gift, or consideration.
9. PUBLIC RECORDS.
Public Records Compliance.
Pursuant to F.S. 119.0701 and the terms and conditions of this contract, if the Contractor is an individual, partnership, corporation or
business entity that enters into a contract for services with a public agency and is acting on behalf of the public agency as provided under
F.S. 119.011(2), the CONTRACTOR is required to:
A. Keep and maintain public records that would be required by the County to perform the service.
B. Upon receipt from the County's custodian of records, provide the County with a copy of the requested records or allow the
records to be inspected or copied within a reasonable time at a cost that does not exceed the cost provided in this chapter or
as otherwise provided by law.
C. Ensure that public records that are exempt or confidential and exempt from public records disclosure requirements are not
disclosed except as authorized by law for the duration of the contract term and following completion of the contract if the
CONTRACTOR does not transfer the records to the County.
D. Upon completion of the contract, transfer, at no cost, to the County all public records in possession of the CONTRACTOR or
keep and maintain public records that would be required by the County to perform the service. If the CONTRACTOR transfers
all public records to the County upon completion of the contract, the CONTRACTOR shall destroy any duplicate public records
that are exempt or confidential and exempt from public records disclosure requirements. If the CONTRACTOR keeps and
maintains public records upon completion of the contract, the CONTRACTOR shall meet all applicable requirements for retaining
public records. All records stored electronically must be provided to the County, upon request from the County's custodian of
records, in a format that is compatible with the information technology systems of the County.
E. A request to inspect or copy public records relating to a County contract must be made directly to the County, but if the County
does not possess the requested records, the County shall immediately notify the CONTRACTOR of the request, and the
CONTRACTOR must provide the records to the County or allow the records to be inspected or copied within a reasonable time.
Page 26 of 29
If the CONTRACTOR does not comply with the County's request for records, the County shall enforce the public records contract
provisions in accordance with the contract, notwithstanding the County's option and right to unilaterally cancel this contract upon violation
of this provision by the CONTRACTOR. A CONTRACTOR who fails to provide the public records to the County or pursuant to a valid
public records request within a reasonable time may be subject to penalties under section119.10, Florida Statutes.
The CONTRACTOR shall not transfer custody, release, alter, destroy or otherwise dispose of any public records unless or otherwise
provided in this provision or as otherwise provided by law.
IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE
CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS CONTRACT, CONTACT THE CUSTODIAN OF
PUBLIC RECORDS, BRIAN BRADLEY AT PHONE# 305 - 292 -3470 BRADLEY - BRIAN @MONROECOUNTY - FL.GOV, MONROE
COUNTY ATTORNEY'S OFFICE 1111 12T" Street, SUITE 408, KEY WEST, FL 33040.
10. FEDERAL CONTRACT REQUIREMENTS
The CONTRACTOR and its subcontractors must follow the provisions as set forth in Appendix II to Part 200, as amended, including but
not limited to:
A. Contractor agrees to comply with all applicable standards, orders or regulations issued pursuant to the Clean Air Act (42 U.S.C.
7401- 7671q) and the Federal Water Pollution Control Act as amended (33 U.S.C. 1251 -1387) and will reports violations to
FEMA and the Regional Office of the Environmental Protection Agency (EPA).
B. Davis -Bacon Act, as amended (40 U.S.C. 3141 - 3148). When required by Federal program legislation, all prime construction
contracts in excess of $2,000 awarded by non - Federal entities must comply with the Davis -Bacon Act (40 U.S.C. 3141 -3144,
and 3146 -3148) as supplemented by Department of Labor regulations (29 CFR Part 5, "Labor Standards Provisions Applicable
to Contracts Covering Federally Financed and Assisted Construction "). In accordance with the statute, contractors must be
required to pay wages to laborers and mechanics at a rate not less than the prevailing wages specified in a wage determination
made by the Secretary of Labor. In addition, contractors must be required to pay wages not less than once a week. The COUNTY
must place a copy of the current prevailing wage determination issued by the Department of Labor in each solicitation. The
decision to award a contract or subcontract must be conditioned upon the acceptance of the wage determination. The COUNTY
must report all suspected or reported violations to the Federal awarding agency. The contractors must also comply with the
Copeland "Anti- Kickback" Act (40 U.S.C. 3145), as supplemented by Department of Labor regulations (29 CFR Part 3,
"Contractors and Subcontractors on Public Building or Public Work Financed in Whole or in Part by Loans or Grants from the
United States "). As required by the Act, each contractor or subrecipient is prohibited from inducing, by any means, any person
employed in the construction, completion, or repair of public work, to give up any part of the compensation to which he or she
is otherwise entitled. The COUNTY must report all suspected or reported violations to the Federal awarding agency.
C. Contract Work Hours and Safety Standards Act (40 U.S.C. 3701 - 3708). Where applicable, all contracts awarded by the
COUNTY in excess of $100,000 that involve the employment of mechanics or laborers must comply with 40 U.S.C. 3702 and
3704, as supplemented by Department of Labor regulations (29 CFR Part 5). Under 40 U.S.C. 3702 of the Act, each contractor
must compute the wages of every mechanic and laborer on the basis of a standard work week of 40 hours. Work in excess of
the standard work week is permissible provided that the worker is compensated at a rate of not less than one and a half times
the basic rate of pay for all hours worked in excess of 40 hours in the work week. The requirements of 40 U.S.C. 3704 are
applicable to construction work and provide that no laborer or mechanic must be required to work in surroundings or under
working conditions which are unsanitary, hazardous or dangerous. These requirements do not apply to the purchases of supplies
or materials or articles ordinarily available on the open market, or contracts for transportation or transmission of intelligence.
D. Rights to Inventions Made Under a Contract or Agreement. If the Federal award meets the definition of "funding agreement"
under 37 CFR §401.2 (a) and the recipient or subrecipient wishes to enter into a contract with a small business firm or nonprofit
organization regarding the substitution of parties, assignment or performance of experimental, developmental, or research work
under that "funding agreement," the recipient or subrecipient must comply with the requirements of 37 CFR Part 401, "Rights to
Inventions Made by Nonprofit Organizations and Small Business Firms Under Government Grants, Contracts and Cooperative
Agreements," and any implementing regulations issued by the awarding agency.
E. Clean Air Act (42 U.S.C. 7401- 7671q.) and the Federal Water Pollution Control Act (33 U.S.C. 1251 - 1387), as amended —
Contracts and subgrants of amounts in excess of $150,000 must comply with all applicable standards, orders or regulations
issued pursuant to the Clean Air Act (42 U.S.C. 7401- 7671q) and the Federal Water Pollution Control Act as amended (33
U.S.C. 1251 - 1387). Violations must be reported to the Federal awarding agency and the Regional Office of the Environmental
Protection Agency (EPA).
Page 27 of 29
F. Debarment and Suspension (Executive Orders 12549 and 12689) —A contract award (see 2 CFR 180.220) must not be made
to parties listed on the governmentwide exclusions in the System for Award Management (SAM), in accordance with the OMB
guidelines at 2 CFR 180 that implement Executive Orders 12549 (3 CFR part 1986 Comp., p. 189) and 12689 (3 CFR part 1989
Comp., p. 235), "Debarment and Suspension." SAM Exclusions contains the names of parties debarred, suspended, or
otherwise excluded by agencies, as well as parties declared ineligible under statutory or regulatory authority other than Executive
Order 12549.
G. Byrd Anti - Lobbying Amendment (31 U.S.C. 1352)— Contractors that apply or bid for an award exceeding $100,000 must file the
required certification. Each tier certifies to the tier above that it will not and has not used Federal appropriated funds to pay any
person or organization for influencing or attempting to influence an officer or employee of any agency, a member of Congress,
officer or employee of Congress, or an employee of a member of Congress in connection with obtaining any Federal contract,
grant or any other award covered by 31 U.S.C. 1352. Each tier must also disclose any lobbying with non - Federal funds that
takes place in connection with obtaining any Federal award. Such disclosures are forwarded from tier to tier up to the non -
Federal award.
H. Procurement of recovered materials as set forth in 2 CFR § 200.322.
I. Americans with Disabilities Act of 1990 (ADA) – The CONTRACTOR will comply with all the requirements as imposed by the
ADA, the regulations of the Federal government issued thereunder, and the assurance by the CONTRACTOR pursuant thereto.
J. Disadvantaged Business Enterprise (DBE) Policy and Obligation - It is the policy of the COUNTY that DBE's, as defined in 49
C.F.R. Part 26, as amended, shall have the opportunity to participate in the performance of contracts financed in whole or in
part with COUNTY funds under this Agreement. The DBE requirements of applicable federal and state laws and regulations
apply to this Agreement. The COUNTY and its CONTRACTOR agree to ensure that DBE's have the opportunity to participate
in the performance of this Agreement. In this regard, all recipients and contractors shall take all necessary and reasonable steps
in accordance with applicable federal and state laws and regulations to ensure that the DBE's have the opportunity to compete
for and perform contracts. The COUNTY and the CONTRACTOR and subcontractors shall not discriminate on the basis of race,
color, national origin or sex in the award and performance of contracts, entered pursuant to this Agreement.
K. The Contractor shall utilize the U.S. Department of Homeland Security's E- Verify system to verify the employment eligibility of
all new employees hired by the Contractor during the term of the Contract and shall expressly require any subcontractors
performing work or providing services pursuant to the Contract to likewise utilize the U.S. Department of Homeland Security's
E- Verify system to verify the employment eligibility of all new employees hired by the subcontractor during the Contract term.
L. No Obligation by Federal Government. The federal government is not a party to this contract and is not subject to any obligations
or liabilities to the non - Federal entity, contractor, or any other party pertaining to any matter resulting from the contract.
M. Program Fraud and False or Fraudulent Statements or Related Acts. The Contractor acknowledges that 31 U.S.C. Chapter 38
(Administrative Remedies for False Claims and Statements) applies to the Contractor's actions pertaining to this contract.
Page 28 of 29
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Understanding Your Medicare - Approved Prescription Drug Plan (PDP)
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EXHIBIT
(9 EnvisionRxPlus
S7694_17-1722_2018 EGWP SB A MEDICARE APPROVED PRESCRIPTION DRUG PLAN
GET ANSWERS TO QUESTIONS
14 410 .
Contact your 1- 844 - 293 -4760 (TTY: 711) Log in at envisionrxplus.com,
employer 24 hours a day, 7 days a week select Member and choose
Group Retiree Members
NOTES
ENVISIONRXPLUS • SUMMARY OF BENEFITS 1
A PART D PRESCRIPTION DRUG (fEnvisionRxPlus
PLAN D P) DESIGNED FOR YOU A MEDICARE APPROVED PRESCRIPTION DRUG PLAN
DEDUCTIBLE
COPAYS AND COINSURANCE
INITIAL COVERAGE STA Amount -you, pay until you and the plan pay- a of $3,750
includes deductible) for covered Part D p p
: rescri p tion drug expenses
• ,
90 dayrSupply
Drug Coverage ?Tiers 30 -day Supply for Retail '
for for or Mail Order Y...
Tier 1 — :Preferred Generic $15 $37;50
Tier 2. ;Generic $15: $37:50
Tier 3 —.Preferred Brand $50" $125 •
Tier 4 — Non- preferred Drug :$90 $225
Tier
5 — Specialty , 20 % Not Applicable (30 -day supply, only)
The.above are applicable for both, retail and mail -order pharmacies. If you reside in a long term care facility, you pay the_same
AS at a standardx,pharmacy and may receive up -day supply. WO may get drugs from an out -of- network. pharmacy,: but
may pay more than you- pay at an in- network pharmacy. Your Plan includes a maximum out -of- pocket of $3,750."
COVERAGE;GAP STAGE Amount of out of pocket costs pay between
$3,750 and $5,000;in total prescription drug expenses
Your plan provides additional coverage during this stage:
The. Initial'Coverage Stage; s ection above "details how much you pay:
You pay, 44% of the cost
!Brand • .You pay 35% Of the negotiated price and a portion of the. dispensing fee
CATASTROPHI STAGE r $5,000 in•annual•. out - of - pocket =` •
Amount pay afte ,
covered, prescription drug expenses
You will Pay the lesser of either the cost -share listed in' the Initial
Coverage Stage section above or the greater of the anamounts below:
rGeneric 5% coinsurance or $3.35 copay
B rand 5% coinsurance or $8.35 copay
EnvisionRxPlus is a Prescription Drug Plan with a Medicare contract. Enrollment in EnvisionRxPlus depends on contract renewal.
The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or
list every limitation or exclusion. To get a complete list of services we cover, please request an Evidence of Coverage by calling
Member Services or visit envisionrxplus.com. Cost - Sharing may change depending on the pharmacy you choose and when you
enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost - sharing and the phases
of the benefit, please call us or access our Evidence of Coverage online. For information about your Supplemental Benefits from
your employer, please referto your Supplemental Summary Plan Description.
ENVISIONRXPLUS • SUMMARY OF BENEFITS 1 2
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 copayments /coinsurance may change on January 1 of each year.
You must continue to pay your Medicare Part B premium.
This information is available for free in other languages. Please call our customer service number at 1- 844 - 293 -4760
(TTY: 711) 24 hours a day, 7 days a week. Esta informacion esta disponible gratuitamente en otros idiomas. Llame a
nuestro Cuidado al Cliente, al 1- 844 -293 -4760 (telefono de texto/TTY: 711), las 24 horas del dia, los 7 dias de la semana.
Other pharmacies are available in our network. The formulary or pharmacy network may change at any time. You will receive
notice when necessary.
•
If you want to know more about the coverage and costs of Original Medicare or to compare plans, look in your current
"Medicare & You" handbook. You can also view it online at http: / /www.medicare.gov. You can also call 1- 800 - MEDICARE
to order your booklet.
You can see the complete plan formulary (list of Part D covered prescription drugs) and any restrictions, as well as view
the pharmacy directory on our website at envisionrxplus.com.
If you qualify for Extra Help, you get help paying for any Medicare drug plan's monthly premium, yearly deductible, and
prescription coinsurance. This "Extra Help" also counts toward your out -of- pocket costs. People with limited income and
resources may qualify for "Extra Help." Some people automatically qualify for "Extra Help" and don't need to apply.
Medicare mails a letter to people who automatically qualify for "Extra Help."
You may be able to get "Extra Help" to pay for your prescription drug premiums and costs. To see if you qualify for getting
"Extra Help," call:
• 1- 800 - MEDICARE (1- 800 - 633- 4227). TTY users should call 1- 877- 486 -2048, 24 hours a day, 7 days a week;
• The Social Security Office at 1- 800 - 772 -1213, between 7 am to 7 pm, Monday through Friday. TTY users should call
1- 800 - 325 -0778.
EnvisionRxPlus complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color,
national origin, age, disability, or sex. EnvisionRxPlus does not exclude people or treat them differently because of race,
color, national origin, age, disability, or sex. EnvisionRxPlus:
• Provides free aids and services to people with disabilities to communicate effectively with us, such as:
o Written information in other formats (large print and accessible electronic formats)
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Member Services.lf you believe that EnvisionRxPlus has failed to provide these
services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with: EnvisionRxPlus, mailing address: 2181 E. Aurora Rd, Ste. 201, Twinsburg, OH, 44087, Member Services:
1- 844 - 293 -4760, TTY: 711, fax: 1- 877 - 503 -7231, email: clinicalservices @ envisionrxplus.com. If you need help filing a
grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department
of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal,
available at https : / /ocrportal.hhs.gov /ocr /portal /lobby.jsf, or by mail or phone at: U.S. Department of Health and
Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201,1- 800 - 368 -1019,
1- 800 - 537 -7697 (TDD). Complaint forms are available at http: / /www.hhs.gov /ocr /office /file /index.html.
ENVISIONRXPLUS • SUMMARY OF BENEFITS 1
YE d CI
, I .
A MEDICARE APPROVED PRESCRIPTION DRUG PLAN
January 1— December 31, 2018
Evidence of Coverage:
Your Medicare Prescription Drug Coverage as a Member of EnvisionRxPlus
Employer Group Retiree PDP
This booklet gives you the details about your Medicare prescription drug coverage from January
1 — December 31, 2018. It explains how to get coverage for the prescription drugs you need.
This is an important legal document. Please keep it in a safe place.
This plan, EnvisionRxPlus Employer Group Retiree PDP, is offered by Envision Insurance
Company. (When this Evidence of Coverage says "we," "us," or "our," it means means Envision
Insurance Company. When it says "plan" or "our plan," it means EnvisionRxPlus Employer
Group Retiree PDP.)
EnvisionRxPlus is a PDP with a Medicare contract. Enrollment in EnvisionRxPlus depends on
contract renewal.
This document is available for free in Spanish.
Please contact our Member Services number at 1- 844 - 293 -4760 for additional information. (TTY
users should call 711.) Hours are 24 hours a day, 7 days a week.
ATTENTION: If you speak Spanish, language assistance services, free of charge, are available
to you. Call 1- 844 - 293 -4760 (TTY: 711).
ATENCION: Si habla espafiol, tiene a su disposicion servicios gratuitos de asistencia lingiiistica.
Llame al 1- 844 - 293 -4760 (TTY 711).
This information is available in a different format, including large print.
Benefits, premium, deductible, and/or copayments /coinsurance may change on January 1, 2019.
The formulary and pharmacy network may change at any time. You will receive notice when
necessary.
S7694_2018 EGWP EOC CE Reviewed 10/30/17
Form CMS 10260 - ANOC /EOC OMB Approval 0938 -1051 (Expires: May 31, 2020)
(Approved 05/2017)
EXHIBIT
I 8
8
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 2
Table of Contents
2018 Evidence of Coverage
Table of Contents
This list of chapters and page numbers is your starting point. For more help in fmding
information you need, go to the first page of a chapter. You will find a detailed list of topics at
the beginning of each chapter.
Chapter 1. Getting started as a member 5
Explains what it means to be in a Medicare prescription drug plan and how
to use this booklet. Tells about materials we will send you, your plan
premium, the Part D late enrollment penalty, your plan membership card,
and keeping your membership record up to date.
Chapter 2. Important phone numbers and resources 22
Tells you how to get in touch with our plan (EnvisionRxPlus Employer
Group Retiree PDP) and with other organizations including Medicare, the
State Health Insurance Assistance Program (SHIP), the Quality
Improvement Organization, Social Security, Medicaid (the state health
insurance program for people with low incomes), programs that help people
pay for their prescription drugs, and the Railroad Retirement Board.
Chapter 3. Using the plan's coverage for your Part D prescription drugs 35
Explains rules you need to follow when you get your Part D drugs. Tells
how to use the plan's List of Covered Drugs (Formulary) to find out which
drugs are covered. Tells which kinds of drugs are not covered. Explains
several kinds of restrictions that apply to coverage for certain drugs.
Explains where to get your prescriptions filled. Tells about the plan's
programs for drug safety and managing medications.
Chapter 4. What you pay for your Part D prescription drugs 58
Tells about the 4 stages of drug coverage (Deductible Stage (if applicable),
Initial Coverage Period, Coverage Gap Stage, Catastrophic Coverage
Stage) and how these stages affect what you pay for your drugs. Explains
the 5 cost - sharing tiers for your Part D drugs and tells what you must pay for
a drug in each cost - sharing tier.
Chapter 5. Asking us to pay our share of the costs for covered drugs 74
Explains when and how to send a bill to us when you want to ask us to pay
you back for our share of the cost for your covered drugs.
Chapter 6. Your rights and responsibilities 81
Explains the rights and responsibilities you have as a member of our plan.
Tells what you can do if you think your rights are not being respected.
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 3
Table of Contents
Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints) 91
Tells you step -by -step what to do if you are having problems or concerns as a
member of our plan.
• Explains how to ask for coverage decisions and make appeals if you are
having trouble getting the prescription drugs you think are covered by our
plan. This includes asking us to make exceptions to the rules and/or extra
restrictions on your coverage.
• Explains how to make complaints about quality of care, waiting times,
customer service, and other concerns.
Chapter 8. Ending your membership in the plan 116
Explains when and how you can end your membership in the plan. Explains
situations in which our plan is required to end your membership.
Chapter 9. Legal notices 126
Includes notices about governing law and about non - discrimination.
Chapter 10. Definitions of important words 134
Explains key terms used in this booklet.
CHAPTER 1
Getting started as a member
2018 Evidence of Coverage for EnvisionRxPlus Employer Group. Retiree PDP 5
Chapter 1. Getting started as a member
Chapter 1. . Getting started as a member
SECTION 1 Introduction 7
Section 1.1 You are enrolled in EnvisionRxPlus Employer Group Retiree PDP,
which is a Medicare Prescription Drug Plan 7
Section 1.2 What is the Evidence of Coverage booklet about? 7
Section 1.3 Legal information about the Evidence of Coverage 7
SECTION 2 What makes you eligible to be a plan member? 8
Section 2.1 Your eligibility requirements 8
Section 2.2 What are Medicare Part A and Medicare Part B? 8
Section 2.3 Here is the plan service area for EnvisionRxPlus Employer Group
Retiree PDP 9
Section 2.4 U.S. Citizen or Lawful Presence 9
SECTION 3 What other materials will you get from us? 10
Section 3.1 Your plan membership card = Use it to get all covered prescription drugs 10
Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network 10
Section 3.3 The plan's List of Covered Drugs (Formulary) 11
Section 3.4 The Part D Explanation of Benefits (the "Part D EOB "): Reports with a
summary of payments made for your Part D prescription drugs 11
SECTION 4 Your monthly premium for EnvisionRxPlus Employer
Group Retiree PDP 12
Section 4.1 How much is your plan premium? 12
SECTION 5 Do you have to pay the Part D "late enrollment penalty "? 13
Section 5.1 What is the Part D "late enrollment penalty "? 13
Section 5.2 How much is the Part D late enrollment penalty? 13
Section 5.3 In some situations, you can enroll late and not have to pay the penalty 14
Section 5.4 What can you do if you disagree about your Part D late enrollment
penalty? 15
SECTION 6 Do you have to pay an extra Part D amount because of your
income? 15
Section 6.1 Who pays an extra Part D amount because of income? 15
Section 6.2 How much is the extra Part D amount? 16
Section 6.3 What can you do if you disagree about paying an extra Part D amount? 16
Section 6.4 What happens if you do not pay the extra Part D amount? 17
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 6 '
Chapter 1. Getting started as a member
SECTION 7 More information about your monthly premium 17
Section 7.1 There are several ways you can pay your plan premium 17
Section 7.2 Can we change your monthly plan premium during the year? 18
SECTION 8 Please keep your plan membership record up to date 18
Section 8.1 How to help make sure that we have accurate information about you 18
SECTION 9 We protect the privacy of your personal health information 19
Section 9.1 We make sure that your health information is protected 19
SECTION 10 How other insurance works with our plan 19
Section 10.1 Which plan pays first when you have other insurance? 19
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 7
Chapter 1. Getting started as a member
SECTION 1 Introduction
Section 1.1 You are enrolled in EnvisionRxPlus Employer Group Retiree
PDP, which is a Medicare Prescription Drug Plan
You are covered by Original Medicare for your health care coverage, and you have chosen to get
your Medicare prescription drug coverage through our plan, EnvisionRxPlus Employer Group
Retiree PDP.
There are different types of Medicare plans. EnvisionRxPlus Employer Group Retiree PDP
is a Medicare prescription drug plan (PDP). Like all Medicare plans, this Medicare
prescription drug plan is approved by Medicare and run by a private company.
Section 1.2 What is the Evidence of Coverage booklet about?
This Evidence of Coverage booklet tells you how to get your Medicare prescription drug
coverage through our plan. This booklet explains your rights and responsibilities, what is
covered, and what you pay as a member of the plan.
The word "coverage" and "covered drugs" refers to the prescription drug coverage available to
you as a member of EnvisionRxPlus Employer Group Retiree PDP.
It's important for you to learn what the plan's rules are and what coverage is available to you.
We encourage you to set aside some time to look through this Evidence of Coverage booklet.
If you are confused or concerned or just have a question, please contact our plan's Member
Services (phone numbers are printed on the back cover of this booklet).
Section 1.3 Legal information about the Evidence of Coverage
It's part of our contract with you
This Evidence of Coverage is part of our contract with you about how EnvisionRxPlus
Employer Group Retiree PDP covers your care. Other parts of this contract include your
enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us
about changes to your coverage or conditions that affect your coverage. These notices are
sometimes called "riders" or "amendments."
The contract is in effect for months in which you are enrolled in EnvisionRxPlus Employer
Group Retiree PDP between January 1, 2018, and December 31, 2018.
Each calendar year, Medicare allows us to make changes to the plans that we offer. This means
we can change the costs and benefits of EnvisionRxPlus Employer Group Retiree PDP after
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 8
Chapter 1. Getting started as a member
December 31, 2018. We can also choose to stop offering the plan, or to offer it in a different
service area, after December 31, 2018.
Medicare must approve our plan each year
Medicare (the Centers for Medicare & Medicaid Services) must approve EnvisionRxPlus
Employer Group Retiree PDP each year. You can continue to get Medicare coverage as a
member of our plan as long as we choose to continue to offer the plan and Medicare renews its
approval of the plan.
SECTION 2 What makes you eligible to be a plan member?
I Section 2.1 Your eligibility requirements
You are eligible for membership in our plan as long as:
• You have Medicare Part A or Medicare Part B (or you have both Part A and Part B)
(Section 2.2 tells you about Medicare Part A and Medicare Part B)
• -- and -- you are a United States citizen or are lawfully present in the United States
• -- and -- you live in our geographic service area (Section 2.3 below describes our service
area)
Section 2.2 What are Medicare Part A and Medicare Part B?
As discussed in section 1.1 above, you have chosen to get your prescription drug coverage
(sometimes called Medicare Part D) through our plan. Our plan has contracted with Medicare to
provide you with most of these Medicare benefits. We describe the drug coverage you receive
under your Medicare Part D coverage in Chapter 3.
When you first signed up for Medicare, you received information about what services are
covered under Medicare Part A and Medicare Part B. Remember:
• Medicare Part A generally helps cover services provided by hospitals for inpatient
services, skilled nursing facilities, or home health agencies.
• Medicare Part B is for most other medical services (such as physician's services and
other outpatient services) and certain items (such as durable medical equipment (DME)
and supplies).
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 9
Chapter 1. Getting started as a member
Section 2.3 Here is the plan service area for EnvisionRxPlus Employer
Group Retiree PDP
Although Medicare is a Federal program, EnvisionRxPlus Employer Group Retiree PDP is
available only to individuals who live in our plan service area. To remain a member of our plan,
you must continue to reside in the plan service area. The service area is described below.
Our service area includes all 50 states, the District of Columbia, Puerto Rico, and Guam.
We offer coverage in all states, Puerto Rico and Guam. However, there may be cost or other
differences between the plans we offer in each state. If you move out of state or territory and into
a state or territory that is still within our service area, you must call Member Services in order to
update your information.
It is also important that you call Social Security if you move or change your mailing address.
You can find phone numbers and contact information for Social Security in Chapter 2, Section 5.
Section 2.4 U.S. Citizen or Lawful Presence
A member of a Medicare health plan must be a U.S. citizen or lawfully present in the United
States. Medicare (the Centers for Medicare & Medicaid Services) will notify EnvisionRxPlus
Employer Group Retiree PDP if you are not eligible to remain a member on this basis.
EnvisionRxPlus Employer Group Retiree PDP must disenroll you if you do not meet this
requirement.
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 10
Chapter 1. Getting started as a member
SECTION 3 What other materials will you get from us?
Section 3.1 Your plan membership card — Use it to get all covered
prescription drugs
While you are a member of our plan, you must use your membership card for our plan for
prescription drugs you get at network pharmacies. You should also show the provider your
Medicaid card, if applicable. Here's a sample membership card to show you what yours will look
like:
efEnvisionRxPlus Submit Paw Claims to: Customer Service:
AJS' fit§ tt".FxPFifft'E'DPa ii>i} tltfllGPLAN Euv'i 14344-293-4760 Rx Br 012312 2181 EastAuraxa Rd. TTY7IDD: 711
Rx PC N: PARTD SAMPLE Suite 201 SAMPLE
�s
Rx GRP.: : ):91 � p9 9 1 1 014 609 Ruins burg, Ohio 44087
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ID: <EIC OODOC X
Name: <Varle> urvirvienvisicimmolus.com
M . td3C EiB °c Claims administered by
57694FeV b i r. ,.,,.;,u is. ` X Rx Options, LUC, a subsidiary of Rite Aid C.mparatron
1
Please carry your card with you at all times and remember to show your card when you get
covered drugs. If your plan membership card is damaged, lost, or stolen, call Member Services
right away and we will send you a new card. (Phone numbers for Member Services are printed
on the back cover of this booklet.)
You may need to use your red, white, and blue Medicare card to get covered medical care and
services under Original Medicare.
Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our
network
What are "network pharmacies "?
Network pharmacies are all of the pharmacies that have agreed to fill covered prescriptions for
our plan members.
Why do you need to know about network pharmacies?
You can use the Pharmacy Directory to find the network pharmacy you want to use. We
included a copy of our Pharmacy Directory in the envelope with this booklet. An updated
Pharmacy Directory is located on our website at www.envisionrxplus.com. To access this online
directory, go to www.envisionrxplus.com and click "sign in" in the top right corner (if you have
not yet registered, you will need to click "register now" and follow the registration steps to
proceed). You may also call Member Services for updated provider information or to ask us to
•
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 11
Chapter 1. Getting started as a member
mail you a Pharmacy Directory. We strongly suggest that you review our current Pharmacy
Directory to see if your pharmacy is still in our network. This is important because, with few
exceptions, you must get your prescriptions filled at a network pharmacy if you want our plan to
cover (help you pay for) them.
If you don't have the Pharmacy Directory, you can get a copy from Member Services (phone
numbers are printed on the back cover of this booklet). At any time, you can call Member
Services to get up -to -date information about changes in the pharmacy network. You can also fmd
this information on our website at www.envisionrxplus.com. To access this online directory, go
to www.envisionrxplus.com and click "sign in" in the top right corner (if you have not yet
registered, you will need to click "register now" and follow the registration steps to proceed).
Section 3.3 The plan's List of Covered Drugs (Formulary)
The plan has a List of Covered Drugs (Formulary). We call it the "Drug List" for short. It tells
which Part D prescription drugs are covered by EnvisionRxPlus Employer Group Retiree
PDP. The drugs on this list are selected by the plan with the help of a team of doctors and
pharmacists. The list must meet requirements set by Medicare. Medicare has approved the
EnvisionRxPlus Employer Group Retiree PDP Drug List.
The Drug List also tells you if there are any rules that restrict coverage for your drugs. In
addition to the Drug List, your Employer Group may provide coverage for some additional drugs
as a supplemental benefit. If so, you will receive a Supplemental Formulary addendum from us.
We will send you a copy of the Drug List and your Group's Supplemental Formulary addendum
(if applicable). The Drug List we send to you includes information for the covered drugs that are
most commonly used by our members. However, we cover additional drugs that are not included
in the printed Drug List. If one of your drugs is not listed in the Drug List, you should visit our
website or contact Member Services to fmd out if we cover it. To get the most complete and
current information about which drugs are covered, you can visit the plan's website
(www.envisionrxplus.com) or call Member Services (phone numbers are printed on the back
cover of this booklet).
Section 3.4 The Part D Explanation of Benefits (the "Part D EOB "): Reports
with a summary of payments made for your Part D prescription
drugs
When you use your Part D prescription drug benefits, we will send you a summary report to help
you understand and keep track of payments for your Part D prescription drugs. This summary
report is called the Part D Explanation of Benefits (or the "Part D EOB ").
The Part D Explanation of Benefits tells you the total amount you, or others on your behalf, have
spent on your Part D prescription drugs and the total amount we have paid for each of your Part
D prescription drugs during the month. Chapter 4 (What you pay for your Part D prescription
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 12
Chapter 1. Getting started as a member
drugs) gives more information about the Part D Explanation of Benefits and how it can help you
keep track of your drug coverage.
A Part D Explanation of Benefits summary is also available upon request. To get a copy, please
contact Member Services (phone numbers are printed on the back cover of this booklet).
You can also get your Explanation of Benefits on our website at www.envisionrxplus.com. To
access this information online, go to www.envisionrxplus.com and click "sign in" in the top right
corner (if you have not yet registered, you will need to click "register now" and follow the
registration steps to proceed).
SECTION 4 Your monthly premium for EnvisionRxPlus Employer
Group Retiree PDP
Section 4.1 How much is your plan premium?
Your coverage is provided through a contract with your current employer or former employer or
union. Your current employer or former employer or union will pay monthly premiums to the
plan. You may be required to contribute a portion of the premium. If so, this amount is collected
by your employer (or former employer or union). Please contact the employer's or union's
Benefits Administrator for information about your plan premium.
In some situations, your plan premium could be Tess
There are programs to help people with limited resources pay for their drugs. These include
"Extra Help" and State Pharmaceutical Assistance Programs. Chapter 2, Section 7 tells more
about these programs. If you qualify, enrolling in the program might lower your monthly plan
premium.
If you are already enrolled and getting help from one of these programs, the information about
premiums in this Evidence of Coverage may not apply to you. We have included a separate
insert, called the "Evidence of Coverage Rider for People Who Get Extra Help Paying for
Prescription Drugs" (also known as the "Low Income Subsidy Rider" or the "LIS Rider "), which
tells you about your drug coverage. If you don't have this insert, please call Member Services
and ask for the "LIS Rider." (Phone numbers for Member Services are printed on the back cover
of this booklet.)
In some situations, your plan premium could be more
In some situations, your plan premium could be more than the amount listed above in
Section 4.1. Some members are required to pay a Part D late enrollment penalty because they
did not join a Medicare drug plan when they first became eligible or because they had a
continuous period of 63 days or more when they didn't have "creditable" prescription drug
coverage. ( "Creditable" means the drug coverage is expected to pay, on average, at least as much
as Medicare's standard prescription drug coverage.) For these members, the Part D late
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 13
Chapter 1. Getting started as a member
enrollment penalty is added to the plan's monthly premium. Their premium amount will be the
monthly plan premium plus the amount of their Part D late enrollment penalty.
• If you are required to pay the Part D late enrollment penalty, the amount of your penalty
depends on how long you waited before you enrolled in drug coverage or how many
months you were without drug coverage after you became eligible. Chapter 1, Section 5
explains the Part D late enrollment penalty.
• If you have a Part D late enrollment penalty and do not pay it, you could be disenrolled
from the plan.
• If you have a late enrollment penalty but have had creditable coverage through your
employer or Group as a retiree or working aged, please contact your Benefit
Administrator for proof of coverage. Upon submission of creditable coverage
documentation to the plan your Late Enrollment Penalty will be either be reduced or
eliminated.
SECTION 5 Do you have to pay the Part D "late enrollment
penalty "?
Section 5.1 What is the Part D "late enrollment penalty "?
Note: If you receive "Extra Help" from Medicare to pay for your prescription drugs, you will not
pay a late enrollment penalty.
The late enrollment penalty is an amount that is added to you Part D premium. You may owe a
Part D late enrollment penalty if at any time after your initial enrollment period is over, there is a
period of 63 days or more in a row when you did not have Part D or other creditable prescription
drug coverage. "Creditable prescription drug coverage" is coverage that meets Medicare's
minimum standards since it is expected to pay, on average, at least as much as Medicare's
standard prescription drug coverage. The amount of the penalty depends on how long you waited
to enroll in a creditable prescription drug coverage plan any time after the end of your initial
enrollment period or how many full calendar months you went without creditable prescription
drug coverage. You will have to pay this penalty for as long as you have Part D coverage.
The Part D late enrollment penalty is added to your monthly premium. When you first enroll in
EnvisionRxPlus Employer Group Retiree PDP, we let you know the amount of the penalty.
Your Part D late enrollment penalty is considered part of your plan premium. Your employer (or
former employer or union) will pay your monthly premiums, but they may bill you for the late
enrollment penalty.
Section 5.2 How much is the Part D late enrollment penalty?
Medicare determines the amount of the penalty. Here is how it works:
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• First count the number of full months that you delayed enrolling in a Medicare drug plan
after you were eligible to enroll. Or count the number of full months in which you did not
have creditable prescription drug coverage, if the break in coverage was 63 days or more.
The penalty is 1% for every month that you didn't have creditable coverage. For
example, if you go 14 months without coverage, the penalty will be 14 %.
• Then Medicare determines the amount of the average monthly premium for Medicare
drug plans in the nation from the previous year. For 2018, this average premium amount
is $35.02.
• To calculate your monthly penalty, you multiply the penalty percentage and the average
monthly premium and then round it to the nearest 10 cents. In the example here it would
be 14% times $35.02, which equals $39.92. This rounds to $39.90. This amount would be
added to the monthly premium for someone with a Part D late enrollment penalty.
There are three important things to note about this monthly Part D late enrollment penalty:
• First, the penalty may change each year, because the average monthly premium can
change each year. If the national average premium (as determined by Medicare)
increases, your penalty will increase.
• Second, you will continue to pay a penalty every month for as long as you are enrolled
in a plan that has Medicare Part D drug benefits.
• Third, if you are under 65 and currently receiving Medicare benefits, the Part D late
enrollment penalty will reset when you turn 65. After age 65, your Part D late enrollment
penalty will be based only on the months that you don't have coverage after your initial
enrollment period for aging into Medicare.
Section 5.3 In some situations, you can enroll late and not have to pay the
penalty
Even if you have delayed enrolling in a plan offering Medicare Part D coverage when you were
first eligible, sometimes you do not have to pay the Part D late enrollment penalty.
You will not have to pay a penalty for late enrollment if you are in any of these situations:
• If you already have prescription drug coverage that is expected to pay, on average, at
least as much as Medicare's standard prescription drug coverage. Medicare calls this
"creditable drug coverage." Please note:
o Creditable coverage could include drug coverage from a former employer or
union, TRICARE, or the Department of Veterans Affairs. Your insurer or your
human resources department will tell you each year if your drug coverage is
creditable coverage. This information may be sent to you in a letter or included in
a newsletter from the plan. Keep this information, because you may need it if you
join a Medicare drug plan later.
•
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Chapter 1. Getting started as a member
• Please note: If you receive a "certificate of creditable coverage" when
your health coverage ends, it may not mean your prescription drug
coverage was creditable. The notice must state that you had "creditable"
prescription drug coverage that expected to pay as much as Medicare's
standard prescription drug plan pays.
o The following are not creditable prescription drug coverage: prescription drug
discount cards, free clinics, and drug discount websites.
o For additional information about creditable coverage, please look in your
Medicare & You 2018 Handbook or call Medicare at 1- 800 - MEDICARE (1 -800-
633- 4227). TTY users call 1- 877 - 486 -2048. You can call these numbers for free,
24 hours a day, 7 days a week.
• If you were without creditable coverage, but you were without it for less than 63 days in a
row.
• If you are receiving "Extra Help" from Medicare.
Section 5.4 What can you do if you disagree about your Part D late
enrollment penalty?
If you disagree about your Part D late enrollment penalty, you or your representative can ask for
a review of the decision about your late enrollment penalty. Generally, you must request this
review within 60 days from the date on the letter you receive stating you have to pay a late
enrollment penalty. Call Member Services to find out more about how to do this (phone numbers
are printed on the back cover of this booklet).
Important: Do not stop paying your Part D late enrollment penalty while you're waiting for a
review of the decision about your late enrollment penalty. If you do, you could be disenrolled for
failure to pay your plan premiums.
SECTION 6 Do you have to pay an extra Part D amount because of
your income?
Section 6.1 Who pays an extra Part D amount because of income?
Most people pay a standard monthly Part D premium. However, some people pay an extra
amount because of their yearly income. If your income is $85,000 or above for an individual (or
married individuals filing separately) or $170,000 or above for married couples, you must pay an
extra amount directly to the government for your Medicare Part D coverage.
If you have to pay an extra amount, Social Security, not your Medicare plan, will send you a
letter telling you what that extra amount will be and how to pay it. The extra amount will be
withheld from your Social Security, Railroad Retirement Board, or Office of Personnel
Management benefit check, no matter how you usually pay your plan premium, unless your
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Chapter 1. Getting started as a member
monthly benefit isn't enough to cover the extra amount owed. If your benefit check isn't enough
to cover the extra amount, you will get a bill from Medicare. You must pay the extra amount
to the government. It cannot be paid with your monthly plan premium.
Section 6.2 How much is the extra Part D amount?
If your modified adjusted gross income(MAGI) as reported on your IRS tax return is above a
certain amount, you will pay an extra amount in addition to your monthly plan premium.
The chart below shows the extra amount based on your income.
If you filed an If you were If you filed a joint tax This is the monthly
individual tax married but return and your cost of your extra
return and your filed a separate income in 2016 was: Part D amount(to be
income in 2016 tax return and paid in addition to
was: your income in your plan premium)
2016 was:
Less than or equal Less than or equal Less than or equal to $0
to $85,000 to $85,000 $170,000
Greater than Greater than$170,000
$85,000 and less and less than or equal to $13.00
than or equal to $214,000
$107,000
Greater than Greater than$214,000
$107,000 and less and less than or equal to $33.60
than or equal to $267,000
$133,500
Greater than Greater than$267,000
$133,500 and less and less than or equal to $54.20
than or equal to $320,000
$160,000
Greater than Greater than Greater than$320,000 $74.80
$160,000 $85,000
Section 6.3 What can you do if you disagree about paying an extra Part D
amount?
If you disagree about paying an extra amount because of your income, you can ask Social
Security to review the decision. To find out more about how to do this, contact Social Security at
1-800-772-1213 (TTY 1-800-325-0778).
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Chapter 1. Getting started as a member
Section 6.4 What happens if you do not pay the extra Part D amount?
The extra amount is paid directly to the government (not your Medicare plan) for your Medicare
Part D coverage. If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.
SECTION 7 More information about your monthly premium
Many members are required to pay other Medicare premiums
In addition to paying the monthly plan premium, many members are required to pay other
Medicare premiums. Some plan members (those who aren't eligible for premium -free Part A)
pay a premium for Medicare Part A. And most plan members pay a premium for Medicare
Part B.
Some people pay an extra amount for Part D because of their yearly income, this is known
Income Related Monthly Adjustment Amounts, also known as IRMAA. If your income is greater
than $85,000 for an individual (or married individuals filing separately) or greater than $170,000
for married couples, you must pay an extra amount directly to the government (not the
Medicare plan) for your Medicare Part D coverage.
• If you are required to pay the extra amount and you do not pay it, you will be
disenrolled from the plan and lose prescription drug coverage.
• If you have to pay an extra amount, Social Security, not your Medicare plan, will send
you a letter telling you what that extra amount will be.
• For more information about Part D premiums based on income, go to Chapter 1, Section
6 of this booklet. You can also visit https: / /www.medicare.gov on the Web or call 1-800 -
MEDICARE (1- 800 - 633 - 4227), 24 hours a day, 7 days a week. TTY users should call 1-
877- 486 -2048. Or you may call Social Security at 1- 800 - 772 -1213. TTY users should
call 1- 800 - 325 -0778.
Your copy of Medicare & You 2018 gives information about the Medicare premiums in the
section called "2018 Medicare Costs." This explains how the Medicare Part B and Part D
premiums differ for people with different incomes. Everyone with Medicare receives a copy of
Medicare & You each year in the fall. Those new to Medicare receive it within a month after first
signing up. You can also download a copy of Medicare & You 2018 from the Medicare website
(https: / /www.medicare.gov). Or, you can order a printed copy by phone at 1- 800 - MEDICARE
(1- 800 - 633 - 4227), 24 hours a day, 7 days a week. TTY users call 1- 877 - 486 -2048.
Section 7.1 There are several ways you can pay your plan premium
This section is not applicable to EnvisionRxPlus Employer Group Retiree PDP.
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Chapter 1. Getting started as a member
Section 7.2 Can we change your monthly plan premium during the year?
No. Please note that your employer (or former employer or union) will pay monthly
premiums to the plan. You may be required to contribute a portion of the premium.
If so, this amount is collected by your employer (or former employer or union).
However, in some cases the part of the premium that you have to pay can change during the year.
This happens if you become eligible for the "Extra Help" program or if you lose your eligibility
for the "Extra Help" program during the year. If a member qualifies for "Extra Help" with their
prescription drug costs, the "Extra Help" program will pay part of the member's monthly plan
premium. A member who loses their eligibility during the year will need to start paying their full
monthly premium. You can fmd out more about the "Extra Help" program in Chapter 2,
Section 7.
SECTION 8 Please keep your plan membership record up to date
Section 8.1 How to help make sure that we have accurate information
about you
Your membership record has information from your enrollment form, including your address and
telephone number. It shows your specific plan coverage.
The pharmacists in the plan's network need to have correct information about you. These
network providers use your membership record to know what drugs are covered and the
cost - sharing amounts for you. Because of this, it is very important that you help us keep your
information up to date.
Let us know about these changes:
• Changes to your name, your address, or your phone number
• Changes in any other medical or drug insurance coverage you have (such as from your
employer, your spouse's employer, workers' compensation, or Medicaid)
•
• If you have any liability claims, such as claims from an automobile accident
• If you have been admitted to a nursing home
• If your designated responsible party (such as a caregiver) changes
If any of this information changes, please let us know by calling Member Services (phone
numbers are printed on the back cover of this booklet).
It is also important to contact Social Security if you move or change your mailing address. You
can fmd phone numbers and contact information for Social Security in Chapter 2, Section 5.
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Chapter 1. Getting started as a member
Read over the information we send you about any other insurance coverage you
have
That's because we must coordinate any other coverage you have with your benefits under our
plan. (For more information about how our coverage works when you have other insurance, see
Section 10 in this chapter.)
Once each year, we will send you a letter that lists any other medical or drug insurance coverage
that we know about. Please read over this information carefully. If it is correct, you don't need to
do anything. If the information is incorrect, or if you have other coverage that is not listed, please
call Member Services (phone numbers are printed on the back cover of this booklet).
SECTION 9 We protect the privacy of your personal health
information
Section 9.1 We make sure that your health information is protected
Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
For more information about how we protect your personal health information, please go to
Chapter 6, Section 1.4 of this booklet.
SECTION 10 How other insurance works with our plan
Section 10.1 Which plan pays first when you have other insurance?
When you have other insurance (like employer group health coverage), there are rules set by
Medicare that decide whether our plan or your other insurance pays first. The insurance that pays
first is called the "primary payer" and pays up to the limits of its coverage. The one that pays
second, called the "secondary payer," only pays if there are costs left uncovered by the primary
coverage. The secondary payer may not pay all of the uncovered costs.
These rules apply for employer or union group health plan coverage:
• If you have retiree coverage, Medicare pays first.
• If your group health plan coverage is based on your or a family member's current
employment, who pays first depends on your age, the number of people employed by
your employer, and whether you have Medicare based on age, disability, or End -Stage
Renal Disease (ESRD):
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Chapter 1. Getting started as a member
•
o If you're under 65 and disabled and you or your family member is still working,
your group health plan pays first if the employer has 100 or more employees or at
least one employer in a multiple employer plan that has more than 100 employees.
o If you're over 65 and you or your spouse is still working, your group health plan
pays first if the employer has 20 or more employees or at least one employer in a
multiple employer plan that has more than 20 employees.
• If you have Medicare because of ESRD, your group health plan will pay first for the first
30 months after you become eligible for Medicare.
These types of coverage usually pay first for services related to each type:
• No -fault insurance (including automobile insurance)
• Liability (including automobile insurance)
• Black lung benefits
• Workers' compensation
Medicaid and TRICARE never pay first for Medicare - covered services. They only pay after
Medicare, employer group health plans, and/or Medigap have paid.
If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about
who pays first, or you need to update your other insurance information, call Member Services
(phone numbers are printed on the back cover of this booklet). You may need to give your plan
member ID number to your other insurers (once you have confirmed their identity) so your bills
are paid correctly and on time.
CHAPTER 2
Important phone numbers and
resources
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Chapter 2. Important phone numbers and resources
Chapter 2. Important phone numbers and resources
SECTION 1 EnvisionRxPlus Employer Group Retiree PDP contacts
(how to contact us, including how to reach Member Services at
the plan) 23
SECTION 2 Medicare (how to get help and information directly from the
Federal Medicare program) 26
SECTION 3 State Health Insurance Assistance Program (free help,
information, and answers to your questions about Medicare) 27
SECTION 4 Quality Improvement Organization (paid by Medicare to
check on the quality of care for people with Medicare) 27
SECTION 5 Social Security 28
SECTION 6 Medicaid (a joint Federal and state program that helps with
medical costs for some people with limited income and
resources) 29
SECTION 7 Information about programs to help people pay for their
prescription drugs 30
SECTION 8 How to contact the Railroad Retirement Board 32
SECTION 9 Do you have "group insurance" or other health insurance
from an employer? 33
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Chapter 2. Important phone numbers and resources
SECTION 1 EnvisionRxPlus Employer Group Retiree PDP
contacts
(how to contact us, including how to reach Member
Services at the plan)
How to contact our plan's Member Services
For assistance with claims,billing, or member card questions,please call or write to
EnvisionRxPlus Employer Group Retiree PDP Member Services. We will be happy to help
you.
Method Member Services —Contact Information
CALL 1-844-293-4760
Calls to this number are free. Member Services, including TTY/TDD,
is open 24 hours a day, 7 days a week.
Member Services also has free language interpreter services available
for non-English speakers.
TTY 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. The TTY/TDD is available 24 hours a
day, 7 days a week.
FAX 1-866-250-5178
WRITE EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
customerservice@envisionrxplus.com
WEBSITE www.envisionrxplus.com
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 24
Chapter 2. Important phone numbers and resources
How to contact us when you are asking for a coverage decision about your Part D
prescription drugs, or when you are making an appeal or complaint about your
Part D prescription drugs
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your prescription drugs covered under the Part D benefit included in your plan.
For more information on asking for coverage decisions about your Part D prescription drugs, see
Chapter 7 (What to do if you have a problem or complaint(coverage decisions, appeals,
complaints)).
You may call us if you have questions about our coverage decision process.
An appeal is a formal way of asking us to review and change a coverage decision we have made.
For more information on making an appeal about your Part D prescription drugs, see Chapter 7
(What to do if you have a problem or complaint (coverage decisions, appeals, complaints)).
You can make a complaint about us or one of our network pharmacies, including a complaint
about the quality of your care. This type of complaint does not involve coverage or payment
disputes. (If your problem is about the plan's coverage or payment, you should look at the
section above about making an appeal.) For more information on making a complaint about your
Part D prescription drugs, see Chapter 7 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
Method Coverage Decisions, Appeals and Complaints for Part D
Prescription Drugs —Contact Information
x
CALL 1- 844-293-4760
Calls to this number are free. Hours are 24 hours a day, 7 days a week.
TTY 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. Hours are 24 hours a day, 7 days a week.
FAX 1-877-503-7231
WRITE EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
WEBSITE www.envisionrxplus.com
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Chapter 2. Important phone numbers and resources
Method Coverage Decisions, Appeals and Complaints for Part D
Prescription Drugs—Contact Information
MEDICARE You can submit a complaint about EnvisionRxPlus Employer Group
WEBSITE Retiree PDP directly to Medicare. To submit an online complaint to
Medicare go to
www.medicare.gov/MedicareComplaintForm/home.aspx.
Where to send a request asking us to pay for our share of the cost of a drug you
have received
The coverage determination process includes determining requests to pay for our share of the
costs of a drug that you have received. For more information on situations in which you may
need to ask the plan for reimbursement or to pay a bill you have received from a provider,
see Chapter 5 (Asking us to pay our share of the costs for covered drugs).
Please note: If you send us a payment request and we deny any part of your request, you can
appeal our decision. See Chapter 7 (What to do if you have a problem or complaint(coverage
decisions, appeals, complaints)) for more information.
Method Payment Requests—Contact Information
CALL 1- 844-293-4760. Member Services is open 24 hours a day, 7 days a
week.
Calls to this number are free.
TTY 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. The TTY/TDD is open 24 hours a day, 7
days a week.
FAX 1-866-250-5178
WRITE EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Attn: Direct Member Reimbursement
WEBSITE www.envisionrxplus.com
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 26
Chapter 2. Important phone numbers and resources
SECTION 2 Medicare
(how to get help and information directly from the Federal
Medicare program)
Medicare is the Federal health insurance program for people 65 years of age or older, some
people under age 65 with disabilities, and people with End-Stage Renal Disease (permanent
kidney failure requiring dialysis or a kidney transplant).
The Federal agency in charge of Medicare is the Centers for Medicare &Medicaid Services
(sometimes called "CMS"). This agency contracts with Medicare Prescription Drug Plans,
including us.
Method Medicare—Contact Information
CALL 1-800-MEDICARE, or 1-800-633-4227
Calls to this number are free.
24 hours a day, 7 days a week.
TTY 1-877-486-2048
This number requires special telephone equipment and is only for people who
have difficulties with hearing or speaking.
Calls to this number are free.
WEBSITE https://www.medicare.gov
This is the official government website for Medicare. It gives you up-to-date
information about Medicare and current Medicare issues. It also has
information about hospitals, nursing homes,physicians, home health
agencies, and dialysis facilities. It includes booklets you can print directly
from your computer. You can also find Medicare contacts in your state.
The Medicare website also has detailed information about your Medicare
eligibility and enrollment options with the following tools:
• Medicare Eligibility Tool: Provides Medicare eligibility status
information.
• Medicare Plan Finder: Provides personalized information about
available Medicare prescription drug plans, Medicare health plans, and
Medigap (Medicare Supplement Insurance)policies in your area.
These tools provide an estimate of what your out-of-pocket costs
might be in different Medicare plans.
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 27
Chapter 2. Important phone numbers and resources
Method Medicare Contact Information
WEBSITE You can also use the website to tell Medicare about any complaints you have
(continued) about EnvisionRxPlus Employer Group Retiree PDP:
• Tell Medicare about your complaint: You can submit a complaint
about EnvisionRxPlus Employer Group Retiree PDP directly to
Medicare. To submit a complaint to Medicare, go to
https://www.medicare.gov/MedicareComplaintForrn/home.aspx.
Medicare takes your complaints seriously and will use this
information to help improve the quality of the Medicare program.
If you don't have a computer, your local library or senior center may be able
to help you visit this website using its computer. Or, you can call Medicare
and tell them what information you are looking for. They will find the
information on the website,print it out, and send it to you. (You can call
Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a
week. TTY users should call 1-877-486-2048.)
SECTION 3 State Health Insurance Assistance Program
(free help, information, and answers to your questions
about Medicare)
The State Health Insurance Assistance Program(SHIP) is a government program with trained
counselors in every state. You can find the name of your state SHIP in Appendix A at the end
of this document.
SHIP is independent (not connected with any insurance company or health plan). It is a state
program that gets money from the Federal government to give free local health insurance
counseling to people with Medicare.
SHIP counselors can help you with your Medicare questions or problems. They can help you
understand your Medicare rights, help you make complaints about your medical care or
treatment, and help you straighten out problems with your Medicare bills. SHIP counselors
can also help you understand your Medicare plan choices and answer questions about
switching plans.
SECTION 4 Quality Improvement Organization
(paid by Medicare to check on the quality of care for
people with Medicare)
There is a designated Quality Improvement Organization for serving Medicare beneficiaries in
each state. You can find the name of your state's Quality Improvement Organization in
Appendix B at the end of this document.
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Chapter 2. Important phone numbers and resources
A Quality Improvement Organization has a group of doctors and other health care
professionals who are paid by the Federal government. This organization is paid by Medicare
to check on and help improve the quality of care for people with Medicare. A Quality
Improvement Organization is an independent organization. It is not connected with our plan.
You should contact the Quality Improvement Organization if you have a complaint about the
quality of care you have received. For example, you can contact the Quality Improvement
Organization if you were given the wrong medication or if you were given medications that
interact in a negative way.
SECTION 5 Social Security
Social Security is responsible for determining eligibility and handling enrollment for
Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a
disability or End -Stage Renal Disease and meet certain conditions, are eligible for Medicare.
If you are already getting Social Security checks, enrollment into Medicare is automatic. If
you are not getting Social Security checks, you have to enroll in Medicare. Social Security
handles the enrollment process for Medicare. To apply for Medicare, you can call Social
Security or visit your local Social Security office.
Social Security is also responsible for determining who has to pay an extra amount for their
Part D drug coverage because they have a higher income. If you got a letter from Social
Security telling you that you have to pay the extra amount and have questions about the
amount or if your income went down because of a life- changing event, you can call Social
Security to ask for reconsideration.
If you move or change your mailing address, it is important that you contact Social Security to
let them know.
•
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 29
Chapter 2. Important phone numbers and resources
Method Social Security—ContactInformation
CALL 1-800-772-1213
Calls to this number are free.
Available 7:00 am to 7:00 pm, Monday through Friday.
You can use Social Security's automated telephone services to get
recorded information and conduct some business 24 hours a day.
TTY 1-800-325-0778
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free.
Available 7:00 am ET to 7:00 pm, Monday through Friday.
WEBSITE https://www.ssa.gov/
SECTION 6 Medicaid
(a joint Federal and state program that helps with medical
costs for some people with limited income and resources)
Medicaid is a joint Federal and state government program that helps with medical costs for
certain people with limited incomes and resources. Some people with Medicare are also
eligible for Medicaid.
In addition, there are programs offered through Medicaid that help people with Medicare pay
their Medicare costs, such as their Medicare premiums. These "Medicare Savings Programs"
help people with limited income and resources save money each year:
• Qualified Medicare Beneficiary(QMB): Helps pay Medicare Part A and Part B
premiums, and other cost-sharing(like deductibles, coinsurance, and copayments). (Some
people with QMB are also eligible for full Medicaid benefits (QMB+).)
• Specified Low-Income Medicare Beneficiary(SLMB): Helps pay Part B premiums.
(Some people with SLMB are also eligible for full Medicaid benefits (SLMB+).)
o Qualified Individual (QI): Helps pay Part B premiums.
o Qualified Disabled & Working Individuals (QDWI): Helps pay Part A
premiums.
To find out more about Medicaid and its programs, contact your state's Medicaid agency
listed at the end of this document in Appendix C.
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Chapter 2. Important phone numbers and resources
SECTION 7 Information about programs to help people pay for
their prescription drugs
Medicare's "Extra Help" Program
Medicare provides "Extra Help" to pay prescription drug costs for people who have limited
income and resources. Resources include your savings and stocks, but not your home or car. If
you qualify, you get help paying for any Medicare drug plan's monthly premium, yearly
deductible, and prescription copayments or coinsurance. This "Extra Help" also counts toward
your out -of- pocket costs.
People with limited income and resources may qualify for "Extra Help." Some people
automatically qualify for "Extra Help" and don't need to apply. Medicare mails a letter to people
who automatically qualify for "Extra Help."
You may be able to get "Extra Help" to pay for your prescription drug premiums and costs. To
see if you qualify for getting "Extra Help," call:
• 1- 800 - MEDICARE (1- 800 - 633 - 4227). TTY users should call 1- 877 - 486 -2048, 24 hours
a day, 7 days a week;
• The Social Security Office at 1- 800 - 772 -1213, between 7 am to 7 pm, Monday through
Friday. TTY users should call 1- 800 - 325 -0778 (applications); or
• Your State Medicaid Office (applications). (See Section 6 of this chapter for contact
information.)
If you believe you have qualified for "Extra Help" and you believe that you are paying an
incorrect cost - sharing amount when you get your prescription at a pharmacy, our plan has
established a process that allows you to either request assistance in obtaining evidence of your
proper copayment level, or, if you already have the evidence, to provide this evidence to us.
• For assistance obtaining evidence of your proper cost - sharing level, please contact
Member Services. We may be able to help you identify the documentation you need.
Once you have obtained the proper evidence, you may mail or fax the documentation to
our Member Services department for processing. The documentation that you send must
include an effective date for the current plan year.
• When we receive the evidence showing your copayment level, we will update our system
so that you can pay the correct copayment when you get your next prescription at the
pharmacy. If you overpay your copayment, we will reimburse you. Either we will
forward a check to you in the amount of your overpayment or we will offset future
copayments. If the pharmacy hasn't collected a copayment from you and is carrying your
copayment as a debt owed by you, we may make the payment directly to the pharmacy. If
a state paid on your behalf, we may make payment directly to the state. Please contact
Member Services if you have questions (phone numbers are printed on the back cover of
this booklet).
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Chapter 2. Important phone numbers and resources
There are programs in Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and
American Samoa to help people with limited income and resources pay their Medicare costs.
Programs vary in these areas. Call your local Medical Assistance (Medicaid) office to find out
more about their rules (phone numbers are in Section 6 of this chapter). Or call 1-800 -
MEDICARE (1- 800 - 633 -4227) 24 hours a day, 7 days a week and say "Medicaid" for more
information. TTY users should call 1- 877 - 486 -2048. You can also visit
https: / /www.medicare.gov for more information.
Medicare Coverage Gap Discount Program
The Medicare Coverage Gap Discount Program provides manufacturer discounts on brand name
drugs to Part D members who have reached the coverage gap and are not receiving "Extra Help."
For brand name drugs, the 50% discount provided by manufacturers excludes any dispensing fee
for costs in the gap. Members pay 35% of the negotiated price and a portion of the dispensing fee
for brand name drugs.
If you reach the coverage gap, we will automatically apply the discount when your pharmacy
bills you for your prescription and your Part D Explanation of Benefits (EOB) will show any
discount provided. Both the amount you pay and the amount discounted by the manufacturer
count toward your out -of- pocket costs as if you had paid them and move you through the
coverage gap. The amount paid by the plan (15 %) does not count toward your out -of- pocket
costs.
You also receive some coverage for generic drugs. If you reach the coverage gap, the plan pays
56% of the price for generic drugs and you pay the remaining 44% of the price. For generic
drugs, the amount paid by the plan (56 %) does not count toward your out -of- pocket costs. Only
the amount you pay counts and moves you through the coverage gap. Also, the dispensing fee is
included as part of the cost of the drug.
If you have any questions about the availability of discounts for the drugs you are taking or about
the Medicare Coverage Gap Discount Program in general, please contact Member Services
(phone numbers are printed on the back cover of this booklet).
What if you have coverage from a State Pharmaceutical Assistance Program (SPAP)?
If you are enrolled in a State Pharmaceutical Assistance Program (SPAP), or any other program
that provides coverage for Part D drugs (other than "Extra Help "), you still get the 50% discount
on covered brand name drugs. Also, the plan pays 15% of the costs of brand drugs in the
coverage gap. The 50% discount and the 15% paid by the plan are both applied to the price of the
drug before any SPAP or other coverage.
What if you have coverage from an AIDS Drug Assistance Program (ADAP)?
What is the AIDS Drug Assistance Program (ADAP)?
The AIDS Drug Assistance Program (ADAP) helps ADAP - eligible individuals living with
HIV /AIDS have access to life - saving HIV medications. Medicare Part D prescription drugs that
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 32
Chapter 2. Important phone numbers and resources
are also covered by ADAP qualify for prescription cost - sharing assistance. You can fmd the
name of your state ADAP in Appendix F at the end of this document. Note: To be eligible for the
ADAP operating in your State, individuals must meet certain criteria, including proof of State
residence and HIV status, low income as defined by the State, and uninsured /under- insured
status.
If you are currently enrolled in an ADAP, it can continue to provide you with Medicare Part D
prescription cost - sharing assistance for drugs on the ADAP formulary. In order to be sure you
'continue receiving this assistance, please notify your local ADAP enrollment worker of any
changes in your Medicare Part D plan name or policy number. You can fmd the name of your
state ADAP in Appendix F at the end of this document.
For information on eligibility criteria, covered drugs, or how to enroll in the program, please call
your state ADAP in Appendix F at the end of this document.
What if you get "Extra Help" from Medicare to help pay your prescription drug costs?
Can you get the discounts?
No. If you get "Extra Help," you already get coverage for your prescription drug costs during the
coverage gap.
What if you don't get a discount, and you think you should have?
If you think that you have reached the coverage gap and did not get a discount when you paid for
your brand name drug, you should review your next Part D Explanation of Benefits (Part D
EOB) notice. If the discount doesn't appear on your Part D Explanation of Benefits, you should
contact us to make sure that your prescription records are correct and up -to -date. If we don't
agree that you are owed a discount, you can appeal. You can get help filing an appeal from your
State Health Insurance Assistance Program (SHIP) (telephone numbers are in Section 3 of this
chapter) or by calling 1- 800 - MEDICARE (1- 800 - 633 - 4227), 24 hours a day, 7 days a week.
TTY users should call 1- 877 - 486 -2048.
State Pharmaceutical Assistance Programs
Many states have State Pharmaceutical Assistance Programs that help some people pay for
prescription drugs based on financial need, age, medical condition, or disabilities. Each state has
different rules to provide drug coverage to its members.
You can find out if your state has a State Pharmaceutical Assistance Program by looking in
Appendix D at the end of this document.
SECTION 8 How to contact the Railroad Retirement Board
The Railroad Retirement Board is an independent Federal agency that administers
comprehensive benefit programs for the nation's railroad workers and their families. If you have
questions regarding your benefits from the Railroad Retirement Board, contact the agency.
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Chapter 2. Important phone numbers and resources
If you receive your Medicare through the Railroad Retirement Board, it is important that you let
them know if you move or change your mailing address.
Method Railroad Retirement Board—Contact Information
CALL 1-877-772-5772
Calls to this number are free.
Available 9:00 am to 3:30 pm, Monday through Friday
If you have a touch-tone telephone,recorded information and
automated services are available 24 hours a day, including weekends
and holidays.
TTY 1-312-751-4701
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are not free.
WEBSITE https://secure.rrb.gov/
SECTION 9 Do you have "group insurance" or other health
insurance from an employer?
If you (or your spouse) get benefits from your(or your spouse's)employer or retiree group as
part of this plan, you may call the employer/union benefits administrator or Member Services if
you have any questions. You can ask about your(or your spouse's) employer or retiree health
benefits,premiums, or the enrollment period. (Phone numbers for Member Services are printed
on the back cover of this booklet.)You may also call 1-800-MEDICARE (1-800-633-4227;
TTY: 1-877-486-2048) with questions related to your Medicare coverage under this plan.
If you have other prescription drug coverage through your(or your spouse's) employer or retiree
group,please contact that group's benefits administrator. The benefits administrator can help
you determine how your current prescription drug coverage will work with our plan.
CHAPTER 3
Using the plan's coverage for your
Part D prescription drugs
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
Chapter 3. Using the plan's coverage for your Part D prescription
drugs
SECTION 1 Introduction 37
Section 1.1 This chapter describes your coverage for Part D drugs 3
Section 1.2 Basic rules for the plan's Part D drug coverage 37
SECTION 2 Fill your prescription at a network pharmacy or through the
plan's mail -order service 38
Section 2.1 To have your prescription covered, use a network pharmacy 38
Section 2.2 Finding network pharmacies 38
Section 2.3 Using the plan's mail -order services 39
Section 2.4 How can you get a long -term supply of drugs? 40
Section 2.5 When can you use a pharmacy that is not in the plan's network? 40
SECTION 3 Your drugs need to be on the plan's "Drug List" 41
Section 3.1 The "Drug List" tells which Part D drugs are covered 41
Section 3.2 There are 5 "cost- sharing tiers" for drugs on the Drug List 42
Section 3.3 How can you find out if a specific drug is on the Drug List? 42
SECTION 4 There are restrictions on coverage for some drugs 43
Section 4.1 Why do some drugs have restrictions? 43
Section 4.2 What kinds of restrictions? 43
Section 4.3 Do any of these restrictions apply to your drugs? 44
SECTION 5 What if one of your drugs is not covered in the way you'd
like it to be covered? 45
Section 5.1 There are things you can do if your drug is not covered in the way you'd
like it to be covered 45
Section 5.2 What can you do if your drug is not on the Drug List or if the drug is
restricted in some way? 45
Section 5.3 What can you do if your drug is in a cost - sharing tier you think is too
high? 48
SECTION 6 What if your coverage changes for one of your drugs? 48
Section 6.1 The Drug List can change during the year 48
Section 6.2 What happens if coverage changes for a drug you are taking? 49
SECTION 7 What types of drugs are not covered by the plan? 50
Section 7.1 Types of drugs we do not cover 50
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
SE CTION 8 Show your plan membership card when you fill a
prescription 51
Section 8.1 Show your membership card 51
Section 8.2 What if you don't have your membership card with you? 51
SECTION 9 Part D drug coverage in special situations 52
Section 9.1 What if you're in a hospital or a skilled nursing facility for a stay that is
covered by Original Medicare? 52
Section 9.2 What if you're a resident in a long -term care (LTC) facility? 52
Section 9.3 What if you are taking drugs covered by Original Medicare? 53
Section 9.4 What if you have a Medigap (Medicare Supplement Insurance) policy
with prescription drug coverage? 53
Section 9.5 What if you're also getting drug coverage from an employer or retiree
group plan? 54
Section 9.6 What if you are in Medicare - certified Hospice? 54
SECTION 10 Programs on drug safety and managing medications 55
Section 10.1 Programs to help members use drugs safely 55
Section 10.2 Medication Therapy Management (MTM) program to help members
manage their medications 55
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
Did you know there are programs to help people pay for their drugs?
There are programs to help people with limited resources pay for their drugs. These
include "Extra Help" and State Pharmaceutical Assistance Programs. For more
information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in this Evidence
of Coverage about the costs for Part D prescription drugs may not apply to you. We
have included a separate insert, called the "Evidence of Coverage Rider for People Who
Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy
Rider" or the "LIS Rider "), which tells you about your drug coverage. If you don't have
this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for
Member Services are printed on the back cover of this booklet.)
SECTION 1 Introduction
Section 1.1 This chapter describes your coverage for Part D drugs
This chapter explains rules for using your coverage for Part D drugs. The next chapter tells
what you pay for Part D drugs (Chapter 4, What you pay for your Part D prescription drugs).
In addition to your coverage for Part D drugs through our plan, Original Medicare (Medicare
Part A and Part B) also covers some drugs:
• Medicare Part A covers drugs you are given during Medicare - covered stays in the
hospital or in a skilled nursing facility.
• Medicare Part B also provides benefits for some drugs. Part B drugs include certain
chemotherapy drugs, certain drug injections you are given during an office visit, and
drugs you are given at a dialysis facility.
The two examples of drugs described above are covered by Original Medicare. (To fmd out more
about this coverage, see your Medicare & You Handbook.) Your Part D prescription drugs are
covered under our plan.
Section 1.2 Basic rules for the plan's Part D drug coverage
The plan will generally cover your drugs as long as you follow these basic rules:
• You must have a provider (a doctor, dentist, or other prescriber) write your prescription.
• Your prescriber must either accept Medicare or file documentation with CMS showing
that he or she is qualified to write prescriptions, or your Part D claim will be denied. You
should ask your prescribers the next time you call or visit if they meet this condition. If
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
not, please be aware it takes time for your prescriber to submit the necessary paperwork
to be processed.
• You generally must use a network pharmacy to fill your prescription. (See Section 2, Fill
your prescriptions at a network pharmacy or through the plan's mail -order service.)
• Your drug must be on the plan's List of Covered Drugs (Formulary) (we call it the "Drug
List" for short). (See Section 3, Your drugs need to be on the plan's "Drug List. ")
• Your drug must be used for a medically accepted indication. A "medically accepted
indication" is a use of the drug that is either approved by the Food and Drug
Administration or supported by certain reference books. (See Section 3 for more
information about a medically accepted indication.)
SECTION 2 Fill your prescription at a network pharmacy or
through the plan's mail -order service
Section 2.1 To have your prescription covered, use a network pharmacy
In most cases, your prescriptions are covered only if they are filled at the plan's network
pharmacies. (See Section 2.5 for information about when we would cover prescriptions filled
at out -of- network pharmacies.)
A network pharmacy is a pharmacy that has a contract with the plan to provide your covered
prescription drugs. The term "covered drugs" means all of the Part D prescription drugs that are
covered on the plan's Drug List.
Section 2.2 Finding network pharmacies l
How do you find a network pharmacy in your area?
To fmd a network pharmacy, you can look in your Pharmacy Directory, visit our website
(www.envisionrxplus.com) and click "sign in" in the top right comer (if you have not yet
registered, you will need to click "register now" and follow the registration steps to proceed),
or call Member Services (phone numbers are printed on the back cover of this booklet).
You may go to any of our network pharmacies. If you switch from one network pharmacy to
another, and you need a refill of a drug you have been taking, you can ask either to have a new
prescription written by a provider or to have your prescription transferred to your new network
pharmacy.
What if the pharmacy you have been using leaves the network?
If the pharmacy you have been using leaves the plan's network, you will have to find a new
pharmacy that is in the network. To fmd another network pharmacy in your area, you can get
help from Member Services (phone numbers are printed on the back cover of this booklet) or use
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
the Pharmacy Directory. You can also fmd information on our website at
www.envisionrxplus.com. To access the Pharmacy Directory online, go to
www.envisionrxplus.com and click "sign in" in the top right corner (if you have not yet
registered, you will need to click "register now" and follow the registration steps to proceed).
What if you need a specialized pharmacy?
Sometimes prescriptions must be filled at a specialized pharmacy. Specialized pharmacies
include:
• Pharmacies that supply drugs for home infusion therapy. The Infusion drugs may be
covered under Medicare Part D.
• Pharmacies that supply drugs for residents of a long -term care (LTC) facility. Usually, a
long -term care facility (such as a nursing home) has its own pharmacy. If you are in an
LTC facility, we must ensure that you are able to routinely receive your Part D benefits
through our network of LTC pharmacies, which is typically the pharmacy that the LTC
facility uses. If you have any difficulty accessing your Part D benefits in an LTC facility,
please contact Member Services. Prescriptions for formulary drugs are available up to 31
days in these types of pharmacies depending upon the dispensing increments of each
LTC facility.
• Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Program
(not available in Puerto Rico). Except in emergencies, only Native Americans or Alaska
Natives have access to these pharmacies in our network. Please contact Member Services
to ensure your pharmacy is contracted.
• Pharmacies that dispense drugs that are restricted by the FDA to certain locations or that
require special handling, provider coordination, or education on their use. (Note: This
scenario should happen rarely.)
To locate a specialized pharmacy, look in your Pharmacy Directory or call Member Services
(phone numbers are printed on the back cover of this booklet).
Section 2.3 Using the plan's mail -order services
Our plan's mail -order service allows you to order at least a 30 -day supply of the drug and a
90 -day supply if your benefit plan covers a 90 -day benefit.
To get order forms and information about filling your prescriptions by mail please call Members
Services at 1- 844 - 293 -4760. If you use a mail -order pharmacy not in the plan's network, your
prescription will not be covered.
Usually a mail -order pharmacy order will get to you in no more than 14 days. If your mail -order
is delayed, you may be able to receive a temporary supply at your local pharmacy. Please
contact Member Services at 1 -844- 293 -4760, 24 hours a day, 7 days a week for more
information.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
New prescriptions the pharmacy receives directly from your doctor's office.
After the pharmacy receives a prescription from a health care provider, it will contact you to see
if you want the medication filled immediately or at a later time. This will give you an
opportunity to make sure that the pharmacy is delivering the correct drug (including strength,
amount, and form) and, if needed, allow you to stop or delay the order before you are billed and
it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let
them know what to do with the new prescription and to prevent any delays in shipping.
Refills on mail - order prescriptions. For refills of your drugs, you have the option to sign up for
an automatic refill program. Under this program we will start to process your next refill
automatically when our records show you should be close to running out of your drug. The
pharmacy will contact you prior to shipping each refill to make sure you are in need of more
medication, and you can cancel scheduled refills if you have enough of your medication or if
your medication has changed. If you choose not to use our auto refill program, please contact
your pharmacy 14 days before you think the drugs you have on hand will run out to make sure
your next order is shipped to you in time.
To opt out of our program that automatically prepares mail -order refills, please contact us by
calling 1 -844- 296 -4760 (TTY/TDD 711) 24 hours a day, 7 days a week.
Section 2.4 How can you get a Tong -term supply of drugs?
If your plan allows you to obtain a long -term supply of drugs (i.e. up to 90 days), your cost
sharing may be lower. "Maintenance drugs" are the type of drugs that can be obtained for a long
term- supply. You are able to order your supply through the mail order service or perhaps from a
retail pharmacy. All retail pharmacies do not provide a prescription for a long -term supply. See
Section 2.3 on how to use the mail order service.
If you are uncertain if your plan allows for a long -term supply, please contact Member Services.
Section 2.,5 When can you use a pharmacy that is not in the plan's
network?
Your prescription may be covered in certain situations
Generally, we cover drugs filled at an out -of- network pharmacy only when you are not able to
use a network pharmacy. To help you, we have network pharmacies outside of our service area
where you can get your prescriptions filled as a member of our plan. If you cannot use a network
pharmacy, here are the circumstances when we would cover prescriptions filled at an out -of-
network pharmacy:
• If there are no participating pharmacies near you, we will cover prescriptions filled at an
out -of- network pharmacy in the event of an emergency as determined by the plan. We
will cover up to a 30 -day supply only.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
In these situations, please check first with Member Services to see if there is a network
pharmacy nearby. (Phone numbers for Member Services are printed on the back cover of this
booklet.) You may be required to pay the difference between what you pay for the drug at the
out -of- network pharmacy and the cost that we would cover at an in- network pharmacy.
How do you ask for reimbursement from the plan?
If you must use an out -of- network pharmacy, you will generally have to pay the full cost (rather
than your normal share of the cost) at the time you fill your prescription. You can ask us to
reimburse you for our share of the cost. (Chapter 5, Section 2.1 explains how to ask the plan to
pay you back.)
SECTION 3 Your drugs need to be on the plan's "Drug List"
Section 3.1 The "Drug List" tells which Part D drugs are covered
The plan has a "List of Covered Drugs (Formulary)." In this Evidence of Coverage, we call it
the "Drug List" for short.
The drugs on this list are selected by the plan with the help of a team of doctors and pharmacists.
The list must meet requirements set by Medicare. Medicare has approved the plan's Drug List.
The drugs on the Drug List are only those covered under Medicare Part D (earlier in this chapter,
Section 1.1 explains about Part D drugs).
We will generally cover a drug on the plan's Drug List as long as you follow the other coverage
rules explained in this chapter and the use of the drug is a medically accepted indication. A
"medically accepted indication" is a use of the drug that is either:
• Approved by the Food and Drug Administration. (That is, the Food and Drug
Administration has approved the drug for the diagnosis or condition for which it is being
prescribed.)
• -- or -- Supported by certain reference books. (These reference books are the American
Hospital Formulary Service Drug Information; the DRUGDEX Information System; and
the USPDI or its successor; and, for cancer, the National Comprehensive Cancer Network
and Clinical Pharmacology or their successors.)
The Drug List includes both brand name and generic drugs
A generic drug is a prescription drug that has the same active ingredients as the brand name drug.
Generally, it works just as well as the brand name drug and usually costs less. There are generic
drug substitutes available for many brand name drugs.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
What is not on the Drug List?
The plan does not cover all prescription drugs.
• In some cases, the law does not allow any Medicare plan to cover certain types of drugs
(for more about this, see Section 7.1 in this chapter).
• In other cases, we have decided not to include a particular drug on our Drug List.
Section 3.2 There are 5 "cost-sharing tiers" for drugs on the Drug List
Every drug on the plan's Drug List is in one of 5 cost - sharing tiers. In general, the higher the
cost - sharing tier, the higher your cost for the drug:
• Tier 1 drugs are preferred generic drugs and are the lowest cost - sharing tier.
• Tier 2 drugs are higher cost generic drugs.
• Tier 3 drugs are preferred brand drugs and includes some generic drugs.
• Tier 4 drugs are non - preferred brand drugs and non- preferred generic drugs, and are the
highest cost - sharing tier.
• Tier 5 drugs are specialty drugs.
To fmd out which cost - sharing tier your drug is in, look it up in the plan's Drug List.
The amount you pay for drugs in each cost - sharing tier is shown in Chapter 4 (What you pay for
your Part D prescription drugs).
Note: If your Group offers coverage of Non -Part D drugs this will be outlined in the
Supplemental Formulary from your Employer Group. These drugs are excluded from the
above cost - sharing tiers and also from any out -of- pocket costs.
Section 3.3 How can you find out if a specific drug is on the Drug List?
You have 3 ways to fmd out:
1. Check the most recent Drug List we sent you in the mail. (Please note: The Drug
List we send includes information for the covered drugs.that are most commonly
used by our members. However, we cover additional drugs that are not included
in the printed Drug List. If one of your drugs is not listed in the Drug List, you
should visit our website or contact Member Services to find out if we cover it.)
2. Visit the plan's website (www.envisionrxplus.com). The Drug List on the website
is always the most current.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
3. Call Member Services to find out if a particular drug is on the plan's Drug List or
to ask for a copy of the list. (Phone numbers for Member Services are printed on
the back cover of this booklet.)
SECTION 4 There are restrictions on coverage for some drugs
Section 4.1 Why do some drugs have restrictions?
For certain prescription drugs, special rules restrict how and when the plan covers them. A team
of doctors and pharmacists developed these rules to help our members use drugs in the most
effective ways. These special rules also help control overall drug costs, which keeps your drug
coverage more affordable.
In general, our rules encourage you to get a drug that works for your medical condition and is
safe and effective. Whenever a safe, lower -cost drug will work just as well medically as a higher -
cost drug, the plan's rules are designed to encourage you and your provider to use that lower -cost
option. We also need to comply with Medicare's rules and regulations for drug coverage and
cost - sharing.
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If you want us to waive the restriction for
you, you will need to use the coverage decision process and ask us to make an exception. We
may or may not agree to waive the restriction for you. (See Chapter 7, Section 5.2 for
information about asking for exceptions.)
Please note that sometimes a drug may appear more than once in our drug list. This is because
different restrictions or cost - sharing may apply based on factors such as the strength, amount, or
form of the drug prescribed by your health care provider (for instance, 10 mg versus 100 mg; one
per day versus two per day; tablet versus liquid).
Section 4.2 What kinds of restrictions?
Our plan uses different types of restrictions to help our members use drugs in the most effective
ways. The sections below tell you more about the types of restrictions we use for certain drugs.
Restricting brand name drugs when a generic version is available
Generally, a "generic" drug works the same as a brand name drug and usually costs less. In most
cases, when a generic version of a brand name drug is available, our network pharmacies
will provide you the generic version. We usually will not cover the brand name drug when a
generic version is available. However, if your provider has told us the medical reason that neither
the generic drug nor other covered drugs that treat the same condition will work for you, then we
will cover the brand name drug. (Your share of the cost may be greater for the brand name drug
than for the generic drug.)
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
Getting plan approval in advance
For certain drugs, you or your provider need to get approval from the plan before we will agree to
cover the drug for you. This is called "prior authorization." Sometimes the requirement for
getting approval in advance helps guide appropriate use of certain drugs. If you do not get this
approval, your drug might not be covered by the plan.
Trying a different drug first
This requirement encourages you to try less costly but just as effective drugs before the plan
covers another drug. For example, if Drug A and Drug B treat the same medical condition, the
plan may require you to try Drug A first. If Drug A does not work for you, the plan will then
cover Drug B. This requirement to try a different drug first is called "step therapy."
Quantity limits
For certain drugs, we limit the amount of the drug that you can have by limiting how much of a
drug you can get each time you fill your prescription. For example, if it is normally considered
safe to take only one pill per day for a certain drug, we may limit coverage for your prescription
to no more than one pill per day.
Section 4.3 Do any of these restrictions apply to your drugs?
The plan's Drug List includes information about the restrictions described above. To find out if
any of these restrictions apply to a drug you take or want to take, check the Drug List. For the
most up -to -date information, call Member Services (phone numbers are printed on the back
cover of this booklet) or check our website (www.envisionrxplus.com).
If there is a restriction for your drug, it usually means that you or your provider will have
to take extra steps in order for us to cover the drug. If there is a restriction on the drug you
want to take, you should contact Member Services to learn what you or your provider would
need to do to get coverage for the drug. If you want us to waive the restriction for you, you will
need to use the coverage decision process and ask us to make an exception. We may or may not
agree to waive the restriction for you. (See Chapter 7, Section 5.2 for information about asking
for exceptions.)
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
SECTION 5 What if one of your drugs is not covered in the way
you'd like it to be covered?
Section 5.1 There are things you can do if your drug is not covered in the
way you'd like it to be covered
We hope that your drug coverage will work well for you. But it's possible that there could be a
prescription drug you are currently taking, or one that you and your provider think you should be
taking that is not on our formulary or is on our formulary with restrictions. For example:
• The drug might not be covered at all. Or maybe a generic version of the drug is covered
but the brand name version you want to take is not covered.
• The drug is covered, but there are extra rules or restrictions on coverage for that drug. As
explained in Section 4, some of the drugs covered by the plan have extra rules to restrict
their use. For example, you might be required to try a different drug first, to see if it will
work, before the drug you want to take will be covered for you. Or there might be limits
on what amount of the drug (number of pills, etc.) is covered during a particular time
period. In some cases, you may want us to waive the restriction for you.
• The drug is covered, but it is in a cost - sharing tier that makes your cost - sharing more
expensive than you think it should be. The plan puts each covered drug into one of 5
different cost - sharing tiers. How much you pay for your prescription depends in part on
which cost - sharing tier your drug is in.
There are things you can do if your drug is not covered in the way that you'd like it to be
covered. Your options depend on what type of problem you have:
• If your drug is not on the Drug List or if your drug is restricted, go to Section 5.2 to learn
what you can do.
• If your drug is in a cost - sharing tier that makes your cost more expensive than you think
it should be, go to Section 5.3 to learn what you can do.
Section 5.2 What can you do if your drug is not on the Drug List or if the
drug is restricted in some way?
If your drug is not on the Drug List or is restricted, here are things you can do:
• You may be able to get a temporary supply of the drug (only members in certain
situations can get a temporary supply). This will give you and your provider time to
change to another drug or to file a request to have the drug covered.
• You can change to another drug.
• You can request an exception and ask the plan to cover the drug or remove restrictions
from the drug.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
• Note: Drugs excluded from Medicare Part D coverage or Non -Part D drugs may be
offered as a supplemental benefit by your employer group, but they are neither covered
nor guaranteed under the Medicare program.
You may be able to get a temporary supply
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your
drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to
talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
1. The change to your drug coverage must be one of the following types of changes:
• The drug you have been taking is no longer on the plan's Drug List.
• -- or -- The drug you have been taking is now restricted in some way (Section 4 in this
chapter tells about restrictions).
2. You must be in one of the situations described below:
• For those members who are new or who were in the plan Last year and aren't in a
long -term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of your
membership in the plan if you were new and during the first 90 days of the calendar
year if you were in the plan last year. This temporary supply will be for a maximum of
30 days. If your prescription is written for fewer days, we will allow multiple fills to
provide up to a maximum of 30 days of medication. The prescription must be filled at a
network pharmacy.
• For those members who are new or who were in the plan last year and reside in a
long -term care (LTC) facility:
We will cover a temporary supply of your drug during the first 90 days of your
membership in the plan if you are new and during the first 90 days of the calendar
year if you were in the plan last year. The total supply will be for a maximum of 98-
days depending on the dispensing increment. If your prescription is written for fewer
days, we will allow multiple fills to provide up to a maximum of a 98 -day supply of
medication. (Please note that the long -term care pharmacy may provide the drug in
smaller amounts at a time to prevent waste.)
• For those members who have been in the plan for more than 90 days and reside in a
long -term care (LTC) facility and need a supply right away:
We will cover one 31 -day supply of a particular drug, or less if your prescription is
written for fewer days. This is in addition to the above long -term care transition supply.
• For members who are outside their transition period, and experience a change in
the level of care when changing from one treatment setting to another (example:
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
long -term care facility to hospital, hospital to long -term care facility, hospital to
home, home to long -term care facility, hospice to long -term care facility, hospice to
home):
•
We will allow an early refill for a 30 -day supply of medication in the retail setting and up
to a 31 -day supply in the long -term care setting for formulary medications and an
emergency transition fill for non - formulary medications (including those medications that
are on formulary but require prior authorization, step therapy, or are subject to quantity
limit restrictions).
This does not apply for short-term leaves of absences (i.e. holidays or vacations)
from LTC or hospital facilities.
If you are outside of your 90 -day transition period, we will still provide an emergency 30-
day supply in the retail setting or up to a 31 -day supply in the long -term care setting of
Part D covered non - formulary medications (including Part D covered drugs that are on
our formulary that would otherwise require prior authorization, step therapy, or quantity
limit restrictions), on a case by case basis, while an exception is being processed.
To ask for a temporary supply, call Member Services (phone numbers are printed on the back
cover of this booklet).
During the time when you are getting a temporary supply of a drug, you should talk with your
provider to decide what to do when your temporary supply runs out. You can either switch to a
different drug covered by the plan or ask the plan to make an exception for you and cover your
current drug. The sections below tell you more about these options.
You can change to another drug
Start by talking with your provider. Perhaps there is a different drug covered by the plan that
might work just as well for you. You can call Member Services to ask for a list of covered drugs
that treat the same medical condition. This list can help your provider fmd a covered drug that
might work for you. (Phone numbers for Member Services are printed on the back cover of this
booklet.)
You can ask for an exception
You and your provider can ask the plan to make an exception for you and cover the drug in the
way you would like it to be covered. If your provider says that you have medical reasons that
justify asking us for an exception, your provider can help you request an exception to the rule.
For example, you can ask the plan to cover a drug even though it is not on the plan's Drug List.
Or you can ask the plan to make an exception and cover the drug without restrictions. If your
employer group offers any Non -Part D supplemental benefit, there are no exceptions allowed for
any Non -Part D drugs that are offered through your employer group's supplemental benefit.
If you are a current member and a'drug you are taking will be removed from the formulary or
restricted in some way for next year, we will allow you to request a formulary exception in
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
advance for next year. We will tell you about any change in the coverage for your drug for next
year. You can ask for an exception before next year, and we will give you an answer within 72
hours after we receive your request (or your prescriber's supporting statement). If we approve
your request, we will authorize the coverage before the change takes effect.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to make sure your request
is handled promptly and fairly.
Section 5.3 What can you do if your drug is in a cost - sharing tier you think
is too high?
If your drug is in a cost - sharing tier you think is too high, here are things you can do:
You can change to another drug
If your drug is in a cost - sharing tier you think is too high, start by talking with your provider.
Perhaps there is a different drug in a lower cost - sharing tier that might work just as well for you.
You can call Member Services to ask for a list of covered drugs that treat the same medical
condition. This list can help your provider find a covered drug that might work for you. (Phone
numbers for Member Services are printed on the back cover of this booklet.)
You can ask for an exception
For drugs in the Non - Preferred Drug Tier (Tier 4), Preferred Brand (Tier 3) and Generic Tier
(Tier 2), you and your provider can ask the plan to make an exception in the cost - sharing tier for
the drug so that you pay less for it. If your provider says that you have medical reasons that
justify asking us for an exception, your provider can help you request an exception to the rule.
If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what to do. It
explains the procedures and deadlines that have been set by Medicare to make sure your request
is handled promptly and fairly.
Drugs of our Specialty Tier (Tier 5) are not eligible for this type of exception. We do not lower
the cost - sharing amount for drugs in this tier.
SECTION 6 What if your coverage changes for one of your
drugs?
Section 6.1 The Drug List can change during the year
Most of the changes in drug coverage happen at the beginning of each year (January 1).
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
However, during the year, the plan might make changes to the Drug List. For example, the plan
might:
• Add or remove drugs from the Drug List. New drugs become available, including new
generic drugs. Perhaps the government has given approval to a new use for an existing
drug. Sometimes, a drug gets recalled and we decide not to cover it. Or we might remove
a drug from the list because it has been found to be ineffective.
• Move a drug to a higher or lower cost - sharing tier.
• Add or remove a restriction on coverage for a drug (for more information about
restrictions to coverage, see Section 4 in this chapter).
• Replace a brand name drug with a generic drug.
In almost all cases, we must get approval from Medicare for changes we make to the plan's Drug
List.
Section 6.2 What happens if coverage changes for a drug you are taking?
How will you find out if your drug's coverage has been changed? •
If there is a change to coverage for a drug you are taking, the plan will send you a notice to tell
you. Normally, we will let you know at least 60 days ahead of time.
Once in a while, a drug is suddenly recalled because it's been found to be unsafe or for other
reasons. If this happens, the plan will immediately remove the drug from the Drug List. We will
let you know of this change right away. Your provider will also know about this change, and can
work with you to fmd another drug for your condition.
Do changes to your drug coverage affect you right away?
If any of the following types of changes affect a drug you are taking, the change will not affect
you until January 1 of the next year if you stay in the plan:.
• If we move your drug into a higher cost - sharing tier.
• If we put a new restriction on your use of the drug.
• If we remove your drug from the Drug List, but not because of a sudden recall or because
a new generic drug has replaced it.
If any of these changes happens for a drug you are taking, then the change won't affect your use
or what you pay as your share of the cost until January 1 of the next year. Until that date, you
probably won't see any increase in your payments or any added restriction to your use of the
drug. However, on January 1 of the next year, the changes will affect you.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
In some cases, you will be affected by the coverage change before January 1:
• If a brand name drug you are taking is replaced by a new generic drug, the plan must
give you at least 60 days' notice or give you a 60 -day refill of your brand name drug at a
network pharmacy.
o During this 60 -day period, you should be working with your provider to switch to
the generic or to a different drug that we cover.
o Or you and your provider can ask the plan to make an exception and continue to
cover the brand name drug for you. For information on how to ask for an
exception, see Chapter 7 (What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)).
• Again, if a drug is suddenly recalled because it's been found to be unsafe or for other
reasons, the plan will immediately remove the drug from the Drug List. We will let you
know of this change right away.
o Your provider will also know about this change, and can work with you to fmd
another drug for your condition.
SECTION 7 What types of drugs are not covered by the plan?
Section 7.1 Types of drugs we do not cover
This section tells you what kinds of prescription drugs are "excluded." but they may be covered
by your employer under your plan, EnvisionRxPlus Employer Group Retiree PDP.
If you get drugs that are excluded, you must pay for them yourself. We won't pay for the drugs
that are listed in this section. The only exception: If the requested drug is found upon appeal to
be a drug that is not excluded under Part D and we should have paid for or covered it because of
your specific situation. (For information about appealing a decision we have made to not cover a
drug, go to Chapter 7, Section 5.5 in this booklet.)
Here are three general rules about drugs that Medicare drug plans will not cover under Part D:
• Our plan's Part D drug coverage cannot cover a drug that would be covered under
Medicare Part A or Part B.
• Our plan cannot cover a drug purchased outside the United States and its territories.
• Our plan usually cannot cover off -label use. "Off -label use" is any use of the drug other
than those indicated on a drug's label as approved by the Food and Drug Administration.
o Generally, coverage for "off -label use" is allowed only when the use is supported
by certain reference books. These reference books are the American Hospital
Formulary Service Drug Information, the DRUGDEX Information System, for
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
cancer, the National Comprehensive Cancer Network and Clinical Pharmacology,
or their successors. If the use is not supported by any of these reference books,
then our plan cannot cover its "off -label use."
Also, by law, these categories of drugs are not covered by Medicare drug plans:
• Non - prescription drugs (also called over - the - counter drugs)
• Drugs when used to promote fertility
• Drugs when used for the relief of cough or cold symptoms
• Drugs when used for cosmetic purposes or to promote hair growth
• Prescription vitamins and mineral products, except prenatal vitamins and fluoride
preparations
• Drugs when used for the treatment of sexual or erectile dysfunction, such as Viagra,
Cialis, Levitra, and Caverject
• Drugs when used for treatment of anorexia, weight loss, or weight gain
• Outpatient drugs for which the manufacturer seeks to require that associated tests or
monitoring services be purchased exclusively from the manufacturer as a condition of
sale
If you receive "Extra Help" paying for your drugs, your state Medicaid program may cover
some prescription drugs not normally covered in a Medicare drug plan. Please contact your state
Medicaid program to determine what drug coverage may be available to you. (You can find
phone numbers and contact information for Medicaid in Chapter 2, Section 6.)
•
SECTION 8 Show your plan membership card when you fill a
prescription
Section 8.1 Show your membership card
To fill your prescription, show your plan membership card at the network pharmacy you choose.
When you show your plan membership card, the network pharmacy will automatically bill the
plan for our share of your covered prescription drug cost. You will need to pay the pharmacy
your share of the cost when you pick up your prescription.
Section 8.2 What if you don't have your membership card with you?
If you don't have your plan membership card with you when you fill your prescription, ask the
pharmacy to call the plan to get the necessary information.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
If the pharmacy is not able to get the necessary information, you may have to pay the full cost
of the prescription when you pick it up. (You can then ask us to reimburse you for our share.
See Chapter 5, Section 2.1 for information about how to ask the plan for reimbursement.)
SECTION 9 Part D drug coverage in special situations
Section 9.1 What if you're in a hospital or a skilled nursing facility for a
stay that is covered by Original Medicare?
If you are admitted to a hospital for a stay covered by Original Medicare, Medicare Part A will
generally cover the cost of your prescription drugs during your stay. Once you leave the hospital,
our plan will cover your drugs as long as the drugs meet all of our rules for coverage. See the
previous parts of this chapter that tell about the rules for getting drug coverage.
If you are admitted to a skilled nursing facility for a stay covered by Original Medicare,
Medicare Part A will generally cover your prescription drugs during all or part of your stay. If
you are still in the skilled nursing facility, and Part A is no longer covering your drugs, our plan
will cover your drugs as long as the drugs meet all of our rules for coverage. See the previous
parts of this chapter that tell about the rules for getting drug coverage.
Please Note: When you enter, live in, or leave a skilled nursing facility, you are entitled to a
Special Enrollment Period. During this time period, you can switch plans or change your
coverage. (Chapter 8, Ending your membership in the plan, tells when you can leave our plan
and join a different Medicare plan.)
Section 9.2 What if you're a resident in a long -term care (LTC) facility?
Usually, a long -term care facility (LTC) (such as a nursing home) has its own pharmacy, or a
pharmacy that supplies drugs for all of its residents. If you are a resident of a long -term care
facility, you may get your prescription drugs through the facility's pharmacy as long as it is part
of our network.
Check your Pharmacy Directory to find out if your long -term care facility's pharmacy is part of
our network. If it isn't, or if you need more information, please contact Member Services (phone
numbers are printed on the back cover of this booklet).
What if you're a resident in a long -term care (LTC) facility and become a new
member of the plan?
If you need a drug that is not on our Drug List or is restricted in some way, the plan will cover a
temporary supply of your drug during the first 90 days of your membership. The total supply
will be for a maximum of 98 days, or less if your prescription is written for fewer days. (Please
note that the long -term care pharmacy may provide the drug in smaller amounts at a time to
prevent waste.) If you have been a member of the plan for more than 90 days and need a drug
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
that is not on our Drug List or if the plan has any restriction on the drug's coverage, we will
cover one 31 -day supply, or less if your prescription is written for fewer days.
During the time when you are getting a temporary supply of a drug, you should talk with your
provider to decide what to do when your temporary supply runs out. Perhaps there is a different
drug covered by the plan that might work just as well for you. Or you and your provider can ask
the plan to make an exception for you and cover the drug in the way you would like it to be
covered. If you and your provider want to ask for an exception, Chapter 7, Section 5.4 tells what
to do.
Section 9.3 What if you are taking drugs covered by Original Medicare?
Your enrollment in EnvisionRxPlus Employer Group Retiree PDP doesn't affect your
coverage for drugs covered under Medicare Part A or Part B. If you meet Medicare's coverage
requirements, your drug will still be covered under Medicare Part A or Part B, even though you
are enrolled in this plan. In addition, if your drug would be covered by Medicare Part A or Part
B, our plan can't cover it, even if you choose not to enroll in Part A or Part B.
Some drugs may be covered under Medicare Part B in some situations and through
EnvisionRxPlus Employer Group Retiree PDP in other situations. But drugs are never
covered by both Part B and our plan at the same time. In general, your pharmacist or provider
will determine whether to bill Medicare Part B or EnvisionRxPlus Employer Group Retiree
PDP for the drug.
Section 9.4 What if you have a Medigap (Medicare Supplement Insurance)
policy with prescription drug coverage?
If you currently have a Medigap policy that includes coverage for prescription drugs, you must
contact your Medigap issuer and tell them you have enrolled in our plan. If you decide to keep
your current Medigap policy, your Medigap issuer will remove the prescription drug coverage
portion of your Medigap policy and lower your premium.
Each year your Medigap insurance company should send you a notice that tells if your
prescription drug coverage is "creditable," and the choices you have for drug coverage. (If the
coverage from the Medigap policy is "creditable," it means that it is expected to pay, on
average, at least as much as Medicare's standard prescription drug coverage.) The notice will
also explain how much your premium would be lowered if you remove the prescription drug
coverage portion of your Medigap policy. If you didn't get this notice, or if you can't find it,
contact your Medigap insurance company and ask for another copy.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
Section 9.5 What if you're also getting drug coverage from an employer or
retiree group plan?
Do you currently have other prescription drug coverage through your (or your spouse's)
employer or retiree group? If so, please contact that group's benefits administrator. He or
she can help you determine how your current prescription drug coverage will work with our
plan.
In general, if you are currently employed, the prescription drug coverage you get from us will be
secondary to your employer or retiree group coverage. That means your group coverage would
pay first.
Special note about `creditable coverage':
Each year your employer or retiree group should send you a notice that tells if your prescription
drug coverage for the next calendar year is "creditable" and the choices you have for drug
coverage.
If the coverage from the group plan is "creditable," it means that the plan has drug coverage that
is expected to pay, on average, at least as much as Medicare's standard prescription drug
coverage.
Keep these notices about creditable coverage, because you may need them later. If you enroll
in a Medicare plan that includes Part D drug coverage, you may need these notices to show that
you have maintained creditable coverage. If you didn't get .a notice about creditable coverage
from your employer or retiree group plan, you can get a copy from the employer or retiree
group's benefits administrator or the employer or union.
Section 9.6 What if you are in Medicare- certified Hospice?
Drugs are never covered by both hospice and our plan at the same time. If you are enrolled in
Medicare hospice and require an anti - nausea, laxative, pain medication, or antianxiety drug that
is not covered by your hospice because it is unrelated to your terminal illness and related
conditions, our plan must receive notification from either the prescriber or your hospice provider
that the drug is unrelated before our plan can cover the drug. To prevent delays in receiving any
unrelated drugs that should be covered by our plan, you can ask your hospice provider or
prescriber to make sure we have the notification that the drug is unrelated before you ask a
•
pharmacy to fill your prescription.
In the event you either revoke your hospice election or are discharged from hospice, our plan
should cover all your drugs. To prevent any delays at a pharmacy when your Medicare hospice
benefit ends, you should bring documentation to the pharmacy to verify your revocation or
discharge. See the previous parts of this section that tell about the rules for getting drug coverage
under Part D. Chapter 4 (What you pay for your Part D prescription drugs) gives more
information about drug coverage and what you pay.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
SECTION 10 Programs on drug safety and managing medications
Section 10.1 Programs to help members use drugs safely
We conduct drug use reviews for our members to help make sure that they are getting safe and
appropriate care. These reviews are especially important for members who have more than one
provider who prescribes their drugs.
We do a review each time you fill a prescription. We also review our records on a regular basis.
During these reviews, we look for potential problems such as:
• Possible medication errors
• Drugs that may not be necessary because you are taking another drug to treat the same
medical condition
• Drugs that may not be safe or appropriate because of your age or gender
• Certain combinations of drugs that could harm you if taken at the same time
• Prescriptions written for drugs that have ingredients you are allergic to
• Possible errors in the amount (dosage) of a drug you are taking
If we see a possible problem in your use of medications, we will work with your provider to
correct the problem.
Section 10.2 Medication Therapy Management (MTM) to help members
manage their medications
We have a program that can help our members with complex health needs. For example, some
members have several medical conditions, take different drugs at the same time, and have high
drug costs.
This program is voluntary and free to members. A team of pharmacists and doctors developed
the program for us. This program can help make sure that our members get the most benefit from
the drugs they take. Our program is called a Medication Therapy Management (MTM) program.
Some members who take medications for different medical conditions may be able to get
services through an MTM program. A pharmacist or other health professional will give you a
comprehensive review of all your medications. You can talk about how best to take your
medications, your costs, and any problems or questions you have about your prescription and
over - the - counter medications. You'll get a written summary of this discussion. The summary
has a medication action plan that recommends what you can do to make the best use of your
medications, with space for you to take notes or write down any follow -up questions. You'll also
get a personal medication list that will include all the medications you're taking and why you
take them.
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Chapter 3. Using the plan's coverage for your Part D prescription drugs
It's a good idea to have your medication review before your yearly "Wellness" visit, so you can
talk to your doctor about your action plan and medication list. Bring your action plan and
medication list with you to your visit or anytime you talk with your doctors, pharmacists, and
other health care providers. Also, keep your medication list with you (for example, with your ID)
in case you go to the hospital or emergency room.
If we have a program that fits your needs, we will automatically enroll you in the program and
send you information. If you decide not to participate, please notify us and we will withdraw you
from the program. If you have any questions about these programs, please contact Member
Services (phone numbers are printed on the back cover of this booklet).
CHAPTER 4
What you pay for your Part D
prescription drugs
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Chapter 4. What you pay for your Part D prescription drugs
Chapter 4. What you pay for your Part D prescription drugs
SECTION 1 Introduction 60
Section 1.1 Use this chapter together with other materials that explain your drug
coverage 60
Section 1.2 Types of out -of- pocket costs you may pay for covered drugs 61
•
SECTION 2 What you pay for a drug depends on which "drug payment
stage" you are in when you get the drug 62
Section 2.1 What are the drug payment stages for EnvisionRxPlus Employer Group
Retiree PDP members? 62
SECTION 3 We send you reports that explain payments for your drugs
and which payment stage you are in 62
Section 3.1 We send you a monthly report called the "Part D Explanation of
Benefits" (the "Part D EOB ") 62
Section 3.2 Help us keep our information about your drug payments up to date 63
SECTION 4 During the Deductible Stage, you pay the full cost of your
drugs (this stage may not apply to you if your employer
group plan does not have a deductible) 64
Section 4.1 You stay in the Deductible Stage (if applicable) until you have paid the
deductible amount for your drugs (this amount may differ or not apply,
based on if your employer group plan has a deductible or not) 64
SECTION 5 During the Initial Coverage Stage, the plan pays its share of
your drug costs and you pay your share 64
Section 5.1 What you pay for a drug depends on the drug and where you fill your
prescription 65
Section 5.2 Your costs for a one -month supply of a drug 65
• Section 5.3 If your doctor prescribes less than a full month's supply, you may not
have to pay the cost of the entire month's supply 66
Section 5.4 Your costs for a long -term 90 -day supply of a drug 66
Section 5.5 You stay in the Initial Coverage Stage until your total drug costs for the
year reach $3,750 67
SECTION 6 During the Coverage Gap Stage, you receive a discount on
brand name drugs and pay no more than 44% of the costs
for generic drugs 67
Section 6.1 You stay in the Coverage Gap Stage until your out -of- pocket costs reach
$5,000 67
Section 6.2 How Medicare calculates your out -of- pocket costs for prescription drugs 68 .
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Chapter 4. What you pay for your Part D prescription drugs
SECTION 7 During the Catastrophic Coverage Stage, the plan pays
most of the cost for your drugs 70
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will stay in this
stage for the rest of the year 70
SECTION 8 Additional benefits information 70
Section 8.1 Our plan offers additional benefits 70
SECTION 9 What you pay for vaccinations covered by Part D depends
on how and where you get them 70
Section 9.1 Our plan may have separate coverage for the Part D vaccine medication
itself and for the cost of giving you the vaccine 71
Section 9.2 You may want to call us at Member Services before you get a vaccination 72
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Chapter 4. What you pay for your Part D prescription drugs
Did you know there are programs to help people pay for their drugs?
There are programs to help people with limited resources pay for their drugs. These
include "Extra Help" and State Pharmaceutical Assistance Programs. For more
information, see Chapter 2, Section 7.
Are you currently getting help to pay for your drugs?
If you are in a program that helps pay for your drugs, some information in this Evidence
of Coverage about the costs for Part D prescription drugs may not apply to you. We
have included a separate insert, called the "Evidence of Coverage Rider for People Who
Get Extra Help Paying for Prescription Drugs" (also known as the "Low Income Subsidy
Rider" or the "LIS Rider "), which tells you about your drug coverage. If you don't have
this insert, please call Member Services and ask for the "LIS Rider." (Phone numbers for
Member Services are printed on the back cover of this booklet.)
SECTION 1 Introduction
Section 1.1 Use this . chapter together with other materials that explain
your drug coverage
This chapter focuses on what you pay for your Part D prescription drugs. To keep things simple,
we use "drug" in this chapter to mean a Part D prescription drug. As explained in Chapter 3, not
all drugs are Part D drugs — some drugs are covered under Medicare Part A or Part B and other
drugs are excluded from Medicare coverage by law.
To understand the payment information we give you in this chapter, you need to know the basics
of what drugs are covered, where to fill your prescriptions, and what rules to follow when you
get your covered drugs. Here are materials that explain these basics:
• The plan's List of Covered Drugs (Formulary). To keep things simple, we call this the
"Drug List."
o This Drug List tells which drugs are covered for you.
o It also tells which of the 5 "cost- sharing tiers" the drug is in and whether there are
any restrictions on your coverage for the drug.
o If you need a copy of the Drug List, call Member Services (phone numbers are
printed on the back cover of this booklet). You can also find the Drug List on our
website at www.envisionrxplus.com. The Drug List on the website is always the
most current.
• Chapter 3 of this booklet. Chapter 3 gives the details about your prescription drug
coverage, including rules you need to follow when you get your covered drugs. Chapter 3
also tells which types of prescription drugs are not covered by our plan.
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Chapter 4. What you pay for your Part D prescription drugs
• The plan's Pharmacy Directory. In most situations you must use a network pharmacy to
get your covered drugs (see Chapter 3 for the details). The Pharmacy Directory has a list
of pharmacies in the plan's network. It also tells you which pharmacies in our network
can give you a long -term supply of a drug (such as filling a prescription for a three -
month's supply).
Section 1.2 Types of out -of- pocket costs you may pay for covered drugs
To understand the payment information we give you in this chapter, you need to know about the
types of out -of- pocket costs you may pay for your covered services. The amount that you pay for
a drug is called "cost- sharing," and there are three ways you may be asked to pay.
• The "deductible" is the amount you must pay for drugs before our plan begins to pay its
share.
• "Copayment" means that you pay a fixed amount each time you fill a prescription.
• "Coinsurance" means that you pay a percent of the total cost of the drug each time you
fill a prescription.
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Chapter 4. What you pay for your Part D prescription drugs
SECTION 2 What you pay for a drug depends on which "drug
payment stage" you are in when you get the drug
Section 2.1 What are the drug payment stages for EnvisionRxPlus
Employer Group Retiree PDP members?
As shown in the table below,there are "drug payment stages"for your prescription drug
coverage under EnvisionRxPlus Employer Group Retiree PDP. How much you pay for a drug
depends on which of these stages you are in at the time you get a prescription filled or refilled.
1
Stage 1 Stage 2 Stage 3 Stage 4
Yearly Deductible Initial Coverage Coverage Gap Catastrophic Coverage
Stage Stage Stage Stage
This stage may not apply During this stage,the plan This stage may not apply During this stage,the
to you. Refer to your pays its share of the cost of to you. Refer to your Plan plan will pay most of
Plan Benefit Design your drugs and you pay Benefit Design Sheet to the cost of your drugs
Sheet to see if your your share of the cost. see if your for the rest of the
EnvisionRxPlus You stay in this stage until EnvisionRxPlus calendar year(through
Employer Group your year-to-date"total Employer Group Retiree December 31,2018).
Retiree PDP has a PDP has a coverage gap.
drug costs"(your payments (Details are in Section
deductible. plus any Part D plan's During this stage,you pay 7 of this chapter.)
If you have a deductible, payments)total$3,750. 35%of the price for brand
you begin in this (Details are in Section 5 of name drugs(plus a portion
payment stage when you this chapter.) of the dispensing fee)and
fill your first 44%of the price for
prescription of the year. generic drugs.
During this stage,you You stay in this stage until
pay the full cost of your your year-to-date"out-of-
drugs. pocket costs"(your
You stay in this stage payments)reach a total of
until you have paid your $5,000.This amount and
deductible amount. rules for counting costs
toward this amount have
(Details are in Section 4 been set by Medicare.
of this chapter.)
(Details are in Section 6 of
this chapter.)
SECTION 3 We send you reports that explain payments for your
drugs and which payment stage you are in
Section 3.1 We send you a monthly report called the "Part D Explanation
of Benefits" (the "Part D EOB")
Our plan keeps track of the costs of your prescription drugs and the payments you have made
when you get your prescriptions filled or refilled at the pharmacy. This way, we can tell you
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Chapter 4. What you pay for your Part D prescription drugs
when you have moved from one drug payment stage to the next. In particular, there are two types
of costs we keep track of:
• We keep track of how much you have paid. This is called your "out -of- pocket" cost.
• We keep track of your "total drug costs." This is the amount you pay out -of- pocket or
others pay on your behalf plus the amount paid by the plan.
Our plan will prepare a written report called the Part D Explanation of Benefits (it is sometimes
called the "EOB ") when you have had one or more prescriptions filled through the plan during
the previous month. It includes:
• Information for that month. This report gives the payment details about the
prescriptions you have filled during the previous month. It shows the total drugs costs,
what the plan paid, and what you and others on your behalf paid.
• Totals for the year since January 1. This is called "year -to- date" information. It shows
you the total drug costs and total payments for your drugs since the year began.
Note: Non -Part D drugs provided as a supplemental benefit by your employer group DO
NOT count towards your out -of- pocket costs and will not be reflected on your EOB.
Section 3.2 Help us keep our information about your drug payments up to
date
To keep track of your drug costs and the payments you make for drugs, we use records we get
from pharmacies. Here is how you can help us keep your information correct and up to date:
• Show your membership card when you get a prescription filled. To make sure we
know about the prescriptions you are filling and what you are paying, show your plan
membership card every time you get a prescription filled.
• Make sure we have the information we need. There are times you may pay for
prescription drugs when we will not automatically get the information we need to
keep track of your out -of- pocket costs. To help us keep track of your out -of- pocket costs,
you may give us copies of receipts for drugs that you have purchased: (If you are billed
for a covered drug, you can ask our plan to pay our share of the cost. For instructions on
how to do this, go to Chapter 5, Section 2 of this booklet.) Here are some types of
situations when you may want to give us copies of your drug receipts to be sure we have
a complete record of what you have spent for your drugs:
o When you purchase a covered drug at a network pharmacy at a special price or
using a discount card that is not part of our plan's benefit.
o When you made a copayment for drugs that are provided under a drug
manufacturer patient assistance program.
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Chapter 4. What you pay for your Part D prescription drugs
o Any time you have purchased covered drugs at out -of- network pharmacies or
other times you have paid the full price for a covered drug under special
circumstances.
• Send us information about the payments others have made for you. Payments made
by certain other individuals and organizations also count toward your out -of- pocket costs
and help qualify you for catastrophic coverage. For example, payments made by a State
Pharmaceutical Assistance Program, an AIDS drug assistance program (ADAP), the
Indian Health Service, and most charities count toward your out -of- pocket costs. You
should keep a record of these payments and send them to us so we can track your costs.
• Check the written report we send you. When you receive a Part D Explanation of
Benefits (an EOB) in the mail, please look it over to be sure the information is complete
and correct. If you think something is missing from the report, or you have any questions,
please call us at Member Services (phone numbers are printed on the back cover of this
booklet). You can also get your Explanation of Benefits on our website at
www.envisionrxplus.com. To access this information online, go to
www.envisionrxplus.com and click "sign in" in the top right comer (if you have not yet
registered, you will need to click "register now" and follow the registration steps to
proceed). Be sure to keep these reports. They are an important record of your drug
expenses.
SECTION 4 During the Deductible Stage, you pay the full cost of
your drugs
Section 4.1 You stay in the Deductible Stage until you have paid the
deductible amount (if applicable) for your drugs
This section may not apply to you because of your plan's participation in
EnvisionRxPlus Employer Group Retiree PDP. Refer to your Plan Benefit Design Sheet
for more information.
The Deductible Stage is the first payment stage for your drug coverage. This stage begins when
you fill your first prescription in the year. When you are in this payment stage, you must pay the
full cost of your drugs until you reach the plan's deductible amount, if applicable.
• Your "full cost" is usually lower than the normal full price of the drug, since our plan has
negotiated lower costs for most drugs.
• The "deductible" is the amount you must pay for your Part D prescription drugs before
the plan begins to pay its share.
Once you have paid your deductible (if applicable) for your drugs, you leave the Deductible
Stage and move on to the next drug payment stage, which is the Initial Coverage Stage.
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Chapter 4. What you pay for your Part D prescription drugs
SECTION 5 During the Initial Coverage Stage, the plan pays its
share of your drug costs and you pay your share
Section 5.1 What you pay for a drug depends on the drug and where you
fill your prescription
During the Initial Coverage Stage, the plan pays its share of the cost of your covered prescription
drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost
will vary depending on the drug and where you fill your prescription.
The plan has 5 Cost - Sharing Tiers
Every drug on the plan's Drug List is in one of 5 cost - sharing tiers. In general, the higher the
cost - sharing tier number, the higher your cost for the drug:
• Tier 1 drugs are preferred generic drugs and are the lowest cost - sharing tier.
• Tier 2 drugs are higher cost generic drugs.
• Tier 3 drugs are preferred brand drugs and includes some generic drugs.
• Tier 4 drugs are non - preferred brand drugs and non - preferred generic drugs, and are the
highest cost - sharing tier.
• Tier 5 drugs are specialty drugs.
To find out which cost - sharing tier your drug is in, look it up in the plan's Drug List.
Your pharmacy choices
How much you pay for a drug depends on whether you get the drug from:
• A retail pharmacy that is in our plan's network
• A pharmacy that is not in the plan's network
• The plan's mail -order pharmacy
For more information about these pharmacy choices and filling your prescriptions, see Chapter 3
in this booklet and the plan's Pharmacy Directory.
Section 5.2 Your costs for a one - month supply of a drug
During the Initial Coverage Stage, your share of the cost of a covered drug will be either a
copayment or coinsurance.
• " Copayment" means that you pay a fixed amount each time you fill a prescription.
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Chapter 4. What you pay for your Part D prescription drugs
• "Coinsurance" means that you pay a percent of the total cost of the drug each time you
fill a prescription.
Refer to your Plan Benefit Design Sheet for cost - sharing information on a one -month
supply of a drug.
Section 5.3 If your doctor prescribes Tess than a full month's supply, you
may not have to pay the cost of the entire month's supply
Typically, the amount you pay for a prescription drug covers a full month's supply of a covered
drug. However, your doctor can prescribe less than a month's supply of drugs. There may be
times when you want to ask your doctor about prescribing less than a month's supply of a drug
(for example, when you are trying a medication for the first time that is known to have serious
side effects). If your doctor prescribes less than a full month's supply, you will not have to pay
for the full month's supply for certain drugs.
The amount you pay when you get less than a full month's supply will depend on whether you
are responsible for paying coinsurance (a percentage of the total cost) or a copayment (a flat
dollar amount).
• If you are responsible for coinsurance, you pay a percentage of the total cost of the drug.
You pay the same percentage regardless of whether the prescription is for a full month's
supply or for fewer days. However, because the entire drug cost will be lower if you get
less than a full month's supply, the amount you pay will be less.
• If you are responsible for a copayment for the drug, your copay will be based on the
number of days of the drug that you receive. We will calculate the amount you pay per
day for your drug (the "daily cost- sharing rate ") and multiply it by the number of days of
the drug you receive.
o Here's an example: Let's say the copay for your drug for a full month's supply (a
30 -day supply) is $30. This means that the amount you pay per day for your drug
is $1. If you receive a 7 days' supply of the drug, your payment will be $1 per day
multiplied by 7 days, for a total payment of $7.
Daily cost - sharing allows you to make sure a drug works for you before you have to pay for an
entire month's supply. You can also ask your doctor to prescribe, and your pharmacist to
dispense, less than a full month's supply of a drug or drugs, if this will help you better plan refill
dates for different prescriptions so that you can take fewer trips to the pharmacy. The amount
you pay will depend upon the days' supply you receive.
Section 5.4 Your costs for a long - term 90 -day supply of a drug
Refer to your Plan Benefit Design Sheet for cost - sharing information on a 90 -day
supply of a drug.
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Chapter 4. What you pay for your Part D prescription drugs
Section 5.5 You stay in the Initial Coverage Stage until your total drug
costs for the year reach $3,750
You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have
filled and refilled reaches the $3,750 limit for the Initial Coverage Stage.
Your total drug cost is based on adding together what you have paid and what any Part D plan
has paid:
• What coq have paid for all the covered drugs you have gotten since you started with
your first drug purchase of the year. (See Section 6.2 for more information about how
Medicare calculates your out -of- pocket costs.) This includes:
o If applicable to your employer group plan, the amount you paid when you were in
the Deductible Stage.
o The total you paid as your share of the cost for your drugs during the Initial
Coverage Stage.
• What the plan has paid as its share of the cost for your drugs during the Initial
Coverage Stage. (If you were enrolled in a different Part D plan at any time during 2018,
the amount that plan paid during the Initial Coverage Stage also counts toward your total
drug costs.)
The Explanation of Benefits (EOB) that we send to you will help you keep track of how much
you and the plan, as well as any third parties, have spent on your behalf during the year. Many
people do not reach the $3,750 limit in a year.
We will let you know if you reach this $3,750 amount. If you do reach this amount, you will
leave the Initial Coverage Stage and move on to the Coverage Gap Stage.
SECTION 6 During the Coverage Gap Stage, you receive a
discount on brand name drugs and pay no more than
44% of the costs for generic drugs
Section 6.1 You stay in the Coverage Gap Stage until your out -of- pocket
costs reach $5,000
Your Employer Group Plan may provide additional coverage during the Coverage Gap
Stage. Refer to the Plan Benefit Design Sheet.
When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program
provides manufacturer discounts on brand name drugs. You pay 35% of the negotiated price and
a portion of the dispensing fee for brand name drugs. Both the amount you pay and the amount
discounted by the manufacturer count toward your out -of- pocket costs as if you had paid them
and move you through the coverage gap.
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Chapter 4. What you pay for your Part D prescription drugs
You also receive some coverage for generic drugs. You pay no more than 44% of the cost for
generic drugs and the plan pays the rest. For generic drugs, the amount paid by the plan (56 %)
does not count toward your out -of- pocket costs. Only the amount you pay counts and moves you
through the coverage gap.
You continue paying the discounted price for brand name drugs and no more than 44% of the
costs of generic drugs until your yearly out -of- pocket payments reach a maximum amount that
Medicare has set. In 2018, that amount is $5,000.
Medicare has rules about what counts and what does not count as your out -of- pocket costs.
When you reach an out -of- pocket limit of $5,000, you leave the Coverage Gap Stage and move
on to the Catastrophic Coverage Stage.
Section 6.2 How Medicare calculates your out -of- pocket costs for
prescription drugs
Here are Medicare's rules that we must follow when we keep track of your out -of- pocket costs
for your drugs.
These payments are included in your out -of- pocket costs
When you add up your out -of- pocket costs, you can include the payments listed below (as
long as they are for Part D covered drugs and you followed the rules for drug coverage that
are explained in Chapter 3 of this booklet):
• The amount you pay for drugs when you are in any of the following drug payment
stages:
o The Deductible Stage (if applicable)
o The Initial Coverage Stage
o The Coverage Gap Stage
• Any payments you made during this calendar year as a member of a different
Medicare prescription drug plan before you joined our plan.
It matters who pays:
• If you make these payments yourself, they are included in your out -of- pocket
costs.
• These payments are also included if they are made on your behalf by certain other
individuals or organizations. This includes payments for your drugs made by a
friend or relative, by most charities, by AIDS drug assistance programs, by a State
Pharmaceutical Assistance Program that is qualified by Medicare, or by the Indian
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Chapter 4. What you pay for your Part D prescription drugs
Health Service. Payments made by Medicare's "Extra Help" Program are also
included.
• Some of the payments made by the Medicare Coverage Gap Discount Program are
included. The amount the manufacturer pays for your brand name drugs is
included. But the amount the plan pays for your generic drugs is not included.
Moving on to the Catastrophic Coverage Stage:
When you (or those paying on your behalf) have spent a total of $5,000 in out -of- pocket
costs within the calendar year, you will move from the Coverage Gap Stage to the
Catastrophic Coverage Stage.
These payments are not included in your out -of- pocket costs
When you add up your out -of- pocket costs, you are not allowed to include any of these
types of payments for prescription drugs:
• The amount you pay for your monthly premium (if applicable to your group plan).
• Drugs you buy outside the United States and its territories.
• Drugs that are not covered by our plan.
• Drugs you get at an out -of- network pharmacy that do not meet the plan's requirements
for out -of- network coverage.
• Non -Part D drugs, including prescription drugs covered by Part A or Part B and other
drugs excluded from coverage by Medicare.
• Payments you make toward prescription drugs not normally covered in a Medicare
Prescription Drug Plan.
• Payments made by the plan for your brand or generic drugs while in the Coverage Gap.
• Payments for your drugs that are made by group health plans including employer health
plans.
• Payments for your drugs that are made by certain insurance plans and government -
funded health programs such as TRICARE and Veterans Affairs.
• Payments for your drugs made by a third -party with a legal obligation to pay for
prescription costs (for example, Workers' Compensation).
Reminder: If any other organization such as the ones listed above pays part or all of your
out -of- pocket costs for drugs, you are required to tell our plan. Call Member Services to let
us know (phone numbers are printed on the back cover of this booklet).
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Chapter 4. What you pay for your Part D prescription drugs
How can you keep track of your out -of- pocket total?
• We will help you. The Part D Explanation of Benefits (Part D EOB) report we send to
you includes the current amount of your out -of- pocket costs (Section 3 in this chapter
tells about this report). When you reach a total of $5,000 in out -of- pocket costs for the
year, this report will tell you that you have left the Coverage Gap Stage and have moved
on to the Catastrophic Coverage Stage.
• Make sure we have the information we need. Section 3.2 tells what you can do to
help make sure that our records of what you have spent are complete and up to date.
SECTION 7 During the Catastrophic Coverage Stage, the plan
pays most of the cost for your drugs
Section 7.1 Once you are in the Catastrophic Coverage Stage, you will
stay in this stage for the rest of the year
You qualify for the Catastrophic Coverage Stage when your out -of- pocket costs have reached the
$5,000 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will
stay in this payment stage until the end of the calendar year.
During this stage, the plan will pay most of the cost for your drugs.
• Your share of the cost for a covered drug will be either coinsurance or a copayment,
whichever is the larger amount:
o — either — Coinsurance of 5% of the cost of the drug
o —or — $[Insert 2018 catastrophic cost - sharing amount for generics /preferred
multisource drugs] for a generic drug or a drug that is treated like a generic and
$[insert 2018 catastrophic cost - sharing amount for all other drugs] for all other
drugs.
• Our plan pays the rest of the cost.
SECTION 8 Additional benefits information
Section 8.1 Our plan offers additional benefits
No additional benefits are offered under this plan.
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Chapter 4. What you pay for your Part D prescription drugs
SECTION 9 What you pay for vaccinations covered by Part D
depends on how and where you get them
Section 9.1 Our plan may have separate coverage for the Part D vaccine
medication itself and for the cost of giving you the vaccine
Our plan provides coverage of a number of Part D vaccines. There are two parts to our coverage
of vaccinations:
• The first part of coverage is the cost of the vaccine medication itself. The vaccine is a
prescription medication.
• The second part of coverage is for the cost of giving you the vaccine. (This is sometimes
called the "administration" of the vaccine.)
What do you pay for a Part D vaccination?
What you pay for a Part D vaccination depends on three things:
1. The type of vaccine (what you are being vaccinated for).
o Some vaccines are considered Part D drugs. You can find these vaccines listed in
the plan's List of Covered Drugs (Formulary).
o Other vaccines are considered medical benefits. They are covered under Original
Medicare.
2. Where you get the vaccine medication.
3. Who gives you the vaccine.
What you pay at the time you get the Part D vaccination can vary depending on the
circumstances. For example:
• Sometimes when you get your vaccine, you will have to pay the entire cost for both the
vaccine medication and for getting the vaccine. You can ask our plan to pay you back for
our share of the cost.
• Other times, when you get the vaccine medication or the vaccine, you will pay only your
share of the cost.
To show how this works, here are three common ways you might get a Part D vaccine.
Remember you are responsible for all of the costs associated with vaccines (including their
administration) during the Deductible (if applicable) and Coverage Gap Stage of your benefit.
Situation 1: You buy the Part D vaccine at the pharmacy and you get your vaccine at the
network pharmacy. (Whether you have this choice depends on where you live.
Some states do not allow pharmacies to administer a vaccination.)
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Chapter 4. What you pay for your Part D prescription drugs
• You will have to pay the pharmacy the amount of your coinsurance or
copayment for the vaccine and the cost of giving you the vaccine.
• Our plan will pay the remainder of the costs.
Situation 2: You get the Part D vaccination at your doctor's office.
• When you get the vaccination, you will pay for the entire cost of the
vaccine and its administration.
• You can then ask our plan to pay our share of the cost by using the
procedures that are described in Chapter 5 of this booklet (Asking us to
pay our share of the costs for covered drugs).
• You will be reimbursed the amount you paid less your normal
coinsurance or copayment for the vaccine (including administration)
less any difference between the amount the doctor charges and what
we normally pay. (If you get "Extra Help," we will reimburse you for
this difference.)
Situation 3: You buy the Part D vaccine at your pharmacy, and then take it to your
doctor's office where they give you the vaccine.
• You will have to pay the pharmacy the amount of your coinsurance or
copayment for the vaccine itself.
• When your doctor gives you the vaccine, you will pay the entire cost
for this service. You can then ask our plan to pay our share of the cost
by using the procedures described in Chapter 5 of this booklet.
• You will be reimbursed the amount charged by the doctor for
administering the vaccine less any difference between the amount the
doctor charges and what we normally pay. (If you get "Extra Help,"
we will reimburse you for this difference.)
•
Section 9.2 You may want to call us at Member Services before you get a
vaccination
The rules for coverage of vaccinations are complicated. We are here to help. We recommend that
you call us first at Member Services whenever you are planning to get a vaccination. (Phone
numbers for Member Services are printed on the back cover of this booklet.)
• We can tell you about how your vaccination is covered by our plan and explain your
share of the cost.
• We can tell you how to keep your own cost down by using providers and pharmacies in
our network.
• If you are not able to use a network provider and pharmacy, we can tell you what you
need to do to get payment from us for our share of the cost.
CHAPTER 5
Asking us to pay our share of the
costs for covered drugs
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Chapter 5. Asking us to pay our share of the costs for covered drugs
Chapter 5. Asking us to pay our share of the costs for covered drugs
SECTION 1 Situations in which you should ask us to pay our share of
the cost of your covered drugs 75
Section 1.1 If you pay our plan's share of the cost of your covered drugs, you can ask
us for payment 75
SECTION 2 How to ask us to pay you back 76
Section 2.1 How and where to send us your request for payment 76
SECTION 3 We will consider your request for payment and say yes or
no 77
Section 3.1 We check to see whether we should cover the drug and how much we
owe 77
Section 3.2 If we tell you that we will not pay for all or part of the drug, you can
make an appeal 77
SECTION 4 Other situations in which you should save your receipts
and send copies to us 78
Section 4.1 In some cases, you should send copies of your receipts to us to help us
track your out -of- pocket drug costs 78
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Chapter 5. Asking us to pay our share of the costs for covered drugs
SECTION 1 Situations in which you should ask us to pay our
share of the cost of your covered drugs
Section 1.1 If you pay our plan's share of the cost of your covered drugs,
you can ask us for payment
Sometimes when you get a prescription drug, you may need to pay the full cost right away. Other
times, you may fmd that you have paid more than you expected under the coverage rules of the
plan. In either case, you can ask our plan to pay you back (paying you back is often called
"reimbursing" you).
Here are examples of situations in which you may need to ask our plan to pay you back. All of
these examples are types of coverage decisions (for more information about coverage decisions,
go to Chapter 7 of this booklet).
1. When you use an out -of- network pharmacy to get a prescription filled
If you go to an out -of- network pharmacy and try to use your membership card to fill a
prescription, the pharmacy may not be able to submit the claim directly to us. When that
happens, you will have to pay the full cost of your prescription. (We cover prescriptions
filled at out -of- network pharmacies only in a few special situations. Please go to Chapter 3,
Section 2.5 to learn more.)
Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost.
2. When you pay the full cost for a prescription because you don't have
your plan membership card with you
If you do not have your plan membership card with you, you can ask the pharmacy to call the
plan or look up your enrollment information. However, if the pharmacy cannot get the
enrollment information they need right away, you may need to pay the full cost of the
prescription yourself.
Save your receipt and send a copy to us when you ask us to pay you back for our share of the
cost.
3. When you pay the full cost for a prescription in other situations
You may pay the full cost of the prescription because you find that the drug is not covered
for some reason.
• For example, the drug may not be on the plan's List of Covered Drugs (Formulary); or
it could have a requirement or restriction that you didn't know about or don't think
should apply to you. If you decide to get the drug immediately, you may need to pay
the full cost for it.
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Chapter 5. Asking us to pay our share of the costs for covered drugs
• Save your receipt and send a copy to us when you ask us to pay you back. In some
situations, we may need to get more information from your doctor in order to pay you
back for our share of the cost.
4. If you are retroactively enrolled in our plan
Sometimes a person's enrollment in the plan is retroactive. (Retroactive means that the first
day of their enrollment has already passed. The enrollment date may even have occurred last
year.)
If you were retroactively enrolled in our plan and you paid out -of- pocket for any of your
drugs after your enrollment date, you can ask us to pay you back for our share of the costs.
You will need to submit paperwork for us to handle the reimbursement.
Please call Member Services for additional information about how to ask us to pay you back
and deadlines for making your request. (Phone numbers for Member Services are printed on
the back cover of this booklet.)
To ensure that the claims are applied to your annual out -of- pocket expenses appropriately, please
submit your request for reimbursement with your receipts (the receipt(s) that is normally is
attached to the bag and shows the National Drug Code) no later than 3 months from the date the
prescription was processed by the pharmacy. Requests received outside of this timeframe (but
must be within the last 3 years) will be handled on a case -by -case basis per Medicare guidance
but will require management approval prior to processing. In most cases, your reimbursement
will be based on the network pharmacy rate not the cash price you paid at the pharmacy. If you
fill a prescription at an out -of- network pharmacy, you may be responsible for the difference in
cost between what you paid and the network pharmacy rate.
All of the examples above are types of coverage decisions. This means that if we deny your
request for payment, you can appeal our decision. Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)) has information about
how to make an appeal.
SECTION 2 How to ask us to pay you back
Section 2.1 How and where to send us your request for payment
Send us your request for payment, along with your receipt documenting the payment you have
made. It's a good idea to make a copy of your receipts for your records.
To make sure you are giving us all the information we need to make a decision, you can fill out
our claim form to make your request for payment.
• You don't have to use the form, but it will help us process the information faster.
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Chapter 5. Asking us to pay our share of the costs for covered drugs
• Either download a copy of the form from our website (www.envisionrxplus.com) or call
Member Services and ask for the form. (Phone numbers for Member Services are printed
on the back cover of this booklet.)
Mail your request for payment together with any receipts to us at this address:
EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Attn: Direct Member Reimbursement
You must submit your claim to us within 90 days of the date you received the service, item, or
drug.
Contact Member Services if you have any questions (phone numbers are printed on the back
cover of this booklet). If you don't know what you should have paid, we can help. You can also
call if you want to give us more information about a request for payment you have already sent
to us.
SECTION 3 We will consider your request for payment and say
yes or no
Section 3.1 We check to see whether we should cover the drug and how
much we owe
When we receive your request for payment, we will let you know if we need any additional
information from you. Otherwise, we will consider your request and make a coverage decision.
• If we decide that the drug is covered and you followed all the rules for getting the drug,
we will pay for our share of the cost. We will mail your reimbursement of our share of
the cost to you. (Chapter 3 explains the rules you need to follow for getting your Part D
prescription drugs covered.) We will send payment within 30 days after your request was
received.
• If we decide that the drug is not covered, or you did not follow all the rules, we will not
pay for our share of the cost. Instead, we will send you a letter that explains the reasons
why we are not sending the payment you have requested and your rights to appeal that
decision.
Section 3.2 If we tell you that we will not pay for all or part of the drug, you
can make an appeal
If you think we have made a mistake in turning down your request for payment or you don't
agree with the amount we are paying, you can make an appeal. If you make an appeal, it means
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Chapter 5. Asking us to pay our share of the costs for covered drugs
you are asking us to change the decision we made when we turned down your request for
payment.
For the details on how to make this appeal, go to Chapter 7 of this booklet (What to do if you
have a problem or complaint (coverage decisions, appeals, complaints)). The appeals process is
a formal process with detailed procedures and important deadlines. If making an appeal is new to
you, you will find it helpful to start by reading Section 4 of Chapter 7. Section 4 is an
introductory section that explains the process for coverage decisions and appeals and gives
definitions of terms such as "appeal." Then after you have read Section 4, you can go to Section
5.5 in Chapter 7 for a step -by -step explanation of how to file an appeal.
SECTION 4 Other situations in which you should save your
receipts and send copies to us
Section 4.1 In some cases, you should send copies of your receipts to us
to help us track your out -of- pocket drug costs
There are some situations when you should let us know about payments you have made for your
drugs. In these cases, you are not asking us for payment. Instead, you are telling us about your
payments so that we can calculate your out -of- pocket costs correctly. This may help you to
qualify for the Catastrophic Coverage Stage more quickly.
Here are two situations when you should send us copies of receipts to let us know about
payments you have made for your drugs:
1. When you buy the drug for a price that is lower than our price
Sometimes when you are in the Deductible Stage (if applicable) and Coverage Gap Stage you
can buy your drug at a network pharmacy for a price that is lower than our price.
• For example, a pharmacy might offer a special price on the drug. Or you may have a
discount card that is outside our benefit that offers a lower price.
• Unless special conditions apply, you must use a network pharmacy in these situations
and your drug must be on our Drug List.
• Save your receipt and send a copy to us so that we can have your out -of- pocket
expenses count toward qualifying you for the Catastrophic Coverage Stage.
• Please note: If you are in the Deductible Stage (if applicable) and Coverage Gap
Stage, we may not pay for any share of these drug costs. But sending a copy of the
receipt allows us to calculate your out -of- pocket costs correctly and may help you
qualify for the Catastrophic Coverage Stage more quickly.
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Chapter 5. Asking us to pay our share of the costs for covered drugs
2. When you get a drug through a patient assistance program offered by a
drug manufacturer
Some members are enrolled in a patient assistance program offered by a drug manufacturer
that is outside the plan benefits. If you get any drugs through a program offered by a drug
manufacturer, you may pay a copayment to the patient assistance program.
• Save your receipt and send a copy to us so that we can have your out -of- pocket
expenses count toward qualifying you for the Catastrophic Coverage Stage.
• Please note: Because you are getting your drug through the patient assistance
program and not through the plan's benefits, we will not pay for any share of these
drug costs. But sending a copy of the receipt allows us to calculate your out -of- pocket
costs correctly and may help you qualify for the Catastrophic Coverage Stage more
quickly.
Since you are not asking for payment in the two cases described above, these situations are not
considered coverage decisions. Therefore, you cannot make an appeal if you disagree with our
decision.
•
CHAPTER 6
Your rights and responsibilities
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Chapter 6. Your rights and responsibilities
Chapter 6. Your rights and responsibilities
SECTION 1 Our plan must honor your rights as a member of the plan 82
Section 1.1 We must provide information in a way that works for you (in Spanish and
large print) 82
Section 1.2 We must treat you with fairness and respect at all times 82
Section 1.3 We must ensure that you get timely access to your covered drugs 83
Section 1.4 We must protect the privacy of your personal health information 83
Section 1.5 We must give you information about the plan, its network of pharmacies,
and your covered drugs _ 84
Section 1.6 We must support your right to make decisions about your care 85
Section 1.7 You have the right to make complaints and to ask us to reconsider
decisions we have made 86
Section 1.8 What can you do if you believe you are being treated unfairly or your
rights are not being respected? 87
Section 1.9 How to get more information about your rights 87
SECTION 2 You have some responsibilities as a member of the plan 88
Section 2.1 What are your responsibilities? 88
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Chapter 6. Your rights and responsibilities
SECTION 1 Our plan must honor your rights as a member of the
plan
Section 1.1 We must provide information in a way that works for you (in
Spanish and large print)
To get information from us in a way that works for you, please call Member Services (phone
numbers are printed on the back cover of this booklet).
Our plan has people and free interpreter services available to answer questions from disabled
and non - English speaking members. We can also give you information in large print or
Spanish at no cost if you need it. We are required to give you information about the plan's
benefits in a format that is accessible and appropriate for you. To get information from us in a
way that works for you, please call Member Services and ask for a supervisor (phone numbers
are printed on the back cover of this booklet).
If you have any trouble getting information from our plan in a format that is accessible and
appropriate for you, please call to file a grievance with us at 1- 844 - 293 -4760. You may also file
a complaint with Medicare by calling 1- 800 - MEDICARE (1- 800 - 633 - 4227), or directly with the
Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this
mailing, or you may contact our Member Services for additional information.
Seccion 1.1 Debemos proveer informacion de una manera que funcione
para usted (en espanol, en tetra grande)
Para obtener informacion de nosotros de una manera que funcione para usted, por favor llame a
Servicios para Miembros (los numeros estan en la contraportada de este folleto).
Nuestro plan cuenta con personas y servicios de interprete disponibles para contestar preguntas
de miembros con discapacidades o que no hablan ingles. Tambien podemos darle informacion en
Braille, en letra grande o en espanol sin costo alguno si lo necesita. Tenemos que brindarle
informacion sobre los beneficios del plan en un formato que sea accesible y apropiado para
usted. Para obtener informacion de nosotros de una manera que funcione para usted, llame a
Servicios para Miembros y solicite un supervisor (los numeros de telefono estan impresos en la
contraportada de este folleto).
Si tiene algun problema para obtener informacion de nuestro plan en un formato que sea
accesible y apropiado para usted, llame para presentar una queja con nosotros al 1- 844 -293-
4760. Tambien puede presentar una queja ante Medicare llamando al 1- 800 - MEDICARE (1 -800-
633- 4227), o directamente a la Oficina de Derechos Civiles. La informacion de contacto esta
incluida en esta Evidencia de Cobertura o con este envio, o puede comunicarse con nuestros
Servicios para Miembros para obtener informacion adicional.
•
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Chapter 6. Your rights and responsibilities
Section 1.2 We must treat you with fairness and respect at all times
Our plan must obey laws that protect you from discrimination or unfair treatment. We do not
discriminate based on a person's race, ethnicity, national origin, religion, gender, age, mental or
physical disability, health status, claims experience, medical history, genetic information,
evidence of insurability, or geographic location within the service area.
If you want more information or have concerns about discrimination or unfair treatment, please
call the Department of Health and Human Services' Office for Civil Rights at 1- 800 - 368 -1019
(TTY 1- 800 -537 -7697) or your local Office for Civil Rights.
If you have a disability and need help with access to care, please call us at Member Services
(phone numbers are printed on the back cover of this booklet). If you have a complaint, such as a
problem with wheelchair access, Member Services can help.
Section 1.3 We must ensure that you get timely access to your covered
drugs
As a member of our plan, you have the right to get your prescriptions filled or refilled at any of
our network pharmacies without long delays. If you think that you are not getting your Part D
drugs within a reasonable amount of time, Chapter 7, Section 7 of this booklet tells what you can
do. (If we have denied coverage for your prescription drugs and you don't agree with our
decision, Chapter 7, Section 4 tells what you can do.)
Section 1.4 We must protect the privacy of your personal health
information
Federal and state laws protect the privacy of your medical records and personal health
information. We protect your personal health information as required by these laws.
• Your "personal health information" includes the personal information you gave us when
you enrolled in this plan as well as your medical records and other medical and health
information.
• The laws that protect your privacy give you rights related to getting information and
controlling how your health information is used. We give you a written notice, called a
"Notice of Privacy Practice," that tells about these rights and explains how we protect the
privacy of your health information.
How do we protect the privacy of your health information?
• We make sure that unauthorized people don't see or change your records.
• In most situations, if we give your health information to anyone who isn't providing your
care or paying for your care, we are required to get written permission from you first.
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Chapter 6. Your rights and responsibilities
Written permission can be given by you or by someone you have given legal power to
make decisions for you.
• There are certain exceptions that do not require us to get your written permission first.
These exceptions are allowed or required by law.
o For example, we are required to release health information to government
agencies that are checking on quality of care.
o Because you are a member of our plan through Medicare, we are required to give
Medicare your health information including information about your Part D
prescription drugs. If Medicare releases your information for research or other
uses, this will be done according to Federal statutes and regulations.
You can see the information in your records and know how it has been shared
with others
You have the right to look at your medical records held at the plan, and to get a copy of your
records. We are allowed to charge you a fee for making copies. You also have the right to ask us
to make additions or corrections to your medical records. If you ask us to do this, we will work
with your healthcare provider to decide whether the changes should be made.
You have the right to know how your health information has been shared with others for any
purposes that are not routine.
If you have questions or concerns about the privacy of your personal health information, please
call Member Services (phone numbers are printed on the back cover of this booklet).
In order to release information we require a written request from the member or their Power of
Attorney or Legal Representative.
Section 1.5 We must give you information about the plan, its network of
pharmacies, and your covered drugs
As a member of EnvisionRxPlus Employer Group Retiree PDP, you have the right to get
several kinds of information from us. (As explained above in Section 1.1, you have the right to
get information from us in a way that works for you. This includes getting the information in
languages other than English and in large print.)
If you want any of the following kinds of information, please call Member Services (phone
numbers are printed on the back cover of this booklet):
• Information about our plan. This includes, for example, information about the plan's
fmancial condition. It also includes information about the number of appeals made by
members and the plan's performance ratings, including how it has been rated by plan
members and how it compares to other Medicare prescription drug plans.
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Chapter 6. Your rights and responsibilities
• Information about our network pharmacies.
o For example, you have the right to get information from us about the pharmacies
in our network.
o For a list of the pharmacies in the plan's network, see the pharmacy directory.
o For more detailed information about our pharmacies, you can call Member
Services (phone numbers are printed on the back cover of this booklet) or visit our
website at www.envisionrxplus.com.
• Information about your coverage and the rules you must follow when using your
coverage.
o To get the details on your Part D prescription drug coverage, see Chapters 3 and 4
of this booklet plus the plan's List of Covered Drugs (Formulary). These chapters,
together with the List of Covered Drugs (Formulary), tell you what drugs are
covered and explain the rules you must follow and the restrictions to your
coverage for certain drugs.
o If you have questions about the rules or restrictions, please call Member Services
(phone numbers are printed on the back cover of this booklet).
• Information about why something is not covered and what you can do about it.
o If a Part D drug is not covered for you, or if your coverage is restricted in some
way, you can ask us for a written explanation. You have the right to this
explanation even if you received the drug from an out -of- network pharmacy.
o If you are not happy or if you disagree with a decision we make about what Part
D drug is covered for you, you have the right to ask us to change the decision.
You can ask us to change the decision by making an appeal. For details on what
to do if something is not covered for you in the way you think it should be
covered, see Chapter 7 of this booklet. It gives you the details about how to make
an appeal if you want us to change our decision. (Chapter 7 also tells about how
to make a complaint about quality of care, waiting times, and other concerns.)
o If you want to ask our plan to pay our share of the cost for a Part D prescription
drug, see Chapter 5 of this booklet.
Section 1.6 We must support your right to make decisions about your care
You have the right to give instructions about what is to be done if you are not
able to make medical decisions for yourself
Sometimes people become unable to make health care decisions for themselves due to accidents
or serious illness. You have the right to say what you want to happen if you are in this situation.
This means that, if you want to, you can:
• Fill out a written form to give someone the legal authority to make medical decisions
for you if you ever become unable to make decisions for yourself.
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Chapter•6. Your rights and responsibilities
• Give your doctors written instructions about how you want them to handle your
medical care if you become unable to make decisions for yourself.
The legal documents that you can use to give your directions in advance in these situations are
called "advance directives." There are different types of advance directives and different names
for them. Documents called "living will" and "power of attorney for health care" are examples
of advance directives.
If you want to use an "advance directive" to give your instructions, here is what to do:
• Get the form. If you want to have an advance directive, you can get a form from your
lawyer, from a social worker, or from some office supply stores. You can sometimes get
advance directive forms from organizations that give people information about Medicare.
• Fill it out and sign it. Regardless of where you get this form, keep in mind that it is a
legal document. You should consider having a lawyer help you prepare it.
• Give copies to appropriate people. You should give a copy of the form to your doctor
and to the person you name on the form as the one to make decisions for you if you can't.
You may want to give copies to close friends or family members as well. Be sure to keep
a copy at home.
If you know ahead of time that you are going to be hospitalized, and you have signed an advance
directive, take a copy with you to the hospital.
• If you are admitted to the hospital, they will ask you whether you have signed an advance
directive form and whether you have it with you.
• If you have not signed an advance directive form, the hospital has forms available and
will ask if you want to sign one.
Remember, it is your choice whether you want to fill out an advance directive (including
whether you want to sign one if you are in the hospital). According to law, no one can deny you
care or discriminate against you based on whether or not you have signed an advance directive.
What if your instructions are not followed?
If you have signed an advance directive, and you believe that a doctor or hospital did not follow
the instructions in it, you may file a complaint with the appropriate state - specific agency as listed
in Appendix E.
Section 1.7 You have the right to make complaints and to ask us` to
reconsider decisions we have made
If you have any problems or concerns about your covered services or care, Chapter 7 of this
booklet tells what you can do. It gives the details about how to deal with all types of problems
and complaints. What you need to do to follow up on a problem or concern depends on the
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Chapter 6. Your rights and responsibilities
situation. You might need t� ask our plan to make a coverage decision for you, make an appeal
to us to change a coverage decision, or make a complaint. Whatever you do — ask for a coverage
decision, make an appeal, or make a complaint — we are required to treat you fairly.
You have the right to get a summary of information about the appeals and complaints that other
members have filed against our plan in the past. To get this information, please call Member
Services (phone numbers are printed on the back cover of this booklet).
Section 1.8 What can you do if you believe you are being treated unfairly
or your rights are not being respected?
If it is about discrimination, call the Office for Civil Rights
If you believe you have been treated unfairly or your rights have not been respected due to your
race, disability, religion, sex, health, ethnicity, creed (beliefs), age, or national origin, you should
call the Department of Health and Human Services' Office for Civil Rights at 1- 800 - 368 -1019
or TTY 1- 800 -537 -7697, or call your local Office for Civil Rights.
Is it about something else?
If you believe you have been treated unfairly or your rights have not been respected, and it's not
about discrimination, you can get help dealing with the problem you are having:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.
• Or, you can call Medicare at 1 -800- MEDICARE (1- 800 - 633 - 4227), 24 hours a day, 7
days a week. TTY users should call 1- 877 - 486 -2048.
Section 1.9 How to get more information about your rights
There are several places where you can get more information about your rights:
• You can call Member Services (phone numbers are printed on the back cover of this
booklet).
• You can call the State Health Insurance Assistance Program. For details about this
organization and how to contact it, go to Chapter 2, Section 3.
• You can contact Medicare.
0 You can visit the Medicare website to read or download the publication "Your
Medicare Rights & Protections." (The publication is available at:
• https: / /www.medicare.gov /Pubs /pdf/11534.pdf.)
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Chapter 6. Your rights and responsibilities
o Or, you can call 1- 800 - MEDICARE (1- 800 - 633 - 4227), 24 hours a day, 7 days a
week. TTY users should call 1- 877 - 486 -2048.
SECTION 2 You have some responsibilities as a member of the
plan
Section 2.1 What are your responsibilities?
Things you need to do as a member of the plan are listed below. If you have any questions,
please call Member Services (phone numbers are printed on the back cover of this booklet).
We're here to help.
• Get familiar with your covered drugs and the rules you must follow to get these
covered drugs. Use this Evidence of Coverage booklet to learn what is covered for you
and the rules you need to follow to get your covered drugs.
o Chapters 3 and 4 give the details about your coverage for Part D prescription
drugs.
• If you have any other prescription drug coverage in addition to our plan, you are
required to tell us. Please call Member Services to let us know (phone numbers are
printed on the back cover of this booklet).
o We are required to follow rules set by Medicare to make sure that you are using
all of your coverage in combination when you get your covered drugs from our
plan. This is called "coordination of benefits" because it involves coordinating
the drug benefits you get from our plan with any other drug benefits available to
you. We'11 help you coordinate your benefits. (For more information about
coordination of benefits, go to Chapter 1, Section 10.)
• Tell your doctor and pharmacist that you are enrolled in our plan. Show your plan
membership card whenever you get your Part D prescription drugs.
• Help your doctors and other providers help you by giving them information, asking
questions, and following through on your care.
o To help your doctors and other health providers give you the best care, learn as
much as you are able to about your health problems and give them the
information they need about you and your health. Follow the treatment plans and
instructions that you and your doctors agree upon.
o Make sure your doctors know all of the drugs you are taking, including over -the-
. counter drugs, vitamins, and supplements.
o If you have any questions, be sure to ask. Your doctors and other health care
providers are supposed to explain things in a way you can understand. If you ask a
question and you don't understand the answer you are given, ask again.
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Chapter 6. Your rights and responsibilities
• Pay what you owe. As a plan member, you are responsible for these payments:
o You must pay your plan premiums to continue being a member of our plan.
o For most of your drugs covered by the plan, you must pay your share of the cost
when you get the drug. This will be a copayment (a fixed amount) or coinsurance
(a percentage of the total cost) Chapter 4 tells what you must pay for your Part D
prescription drugs.
o If you get any drugs that are not covered by our plan or by other insurance you
may have, you must pay the full cost.
• If you disagree with our decision to deny coverage for a drug, you can
make an appeal. Please see Chapter 7 of this booklet for information about
how to make an appeal.
o If you are required to pay a late enrollment penalty, you must pay the penalty to
remain a member of the plan.
o If you are required to pay the extra amount for Part D because of your yearly
income, you must pay the extra amount directly to the government to remain a
member of the plan.
• Tell us if you move. If you are going to move, it's important to tell us right away. Call
Member Services (phone numbers are printed on the back cover of this booklet).
o If you move outside of our plan service area, you cannot remain a member of
our plan. (Chapter 1 tells about our service area.) We can help you figure out
whether you are moving outside our service area. If you are leaving our service
area, you will have a Special Enrollment Period when you can join any Medicare
plan available in your new area. We can let you know if we have a plan in your
new area.
o If you move within our service area, we still need to know so we can keep your
membership record up to date and know how to contact you.
o If you move, it is also important to tell Social Security (or the Railroad
Retirement Board). You can find phone numbers and contact information for
these organizations in Chapter 2.
• Call Member Services for help if you have questions or concerns. We also welcome
any suggestions you may have for improving our plan.
o Phone numbers and calling hours for Member Services are printed on the back
cover of this booklet.
o For more information on how to reach us, including our mailing address, please
see Chapter 2.
CHAPTER 7
What to do if you have a problem or
complaint (coverage decisions,
appeals, complaints)
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Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
Chapter 7. What to do if You have a problem or complaint
(coverage decisions, appeals, complaints)
BACKGROUND 93
SECTION 1 Introduction 93
Section 1.1 What to do if you have a problem or concern 93
Section 1.2 What about the legal terms? 93
SECTION 2 You can get help from government organizations that are
not connected with us 94
Section 2.1 Where to get more information and personalized assistance 94
SECTION 3 To deal with your problem, which process should you use? 94
Section 3.1 Should you use the process for coverage decisions and appeals? Or
should you use the process for making complaints? 94
COVERAGE DECISIONS AND APPEALS 95
SECTION 4 A guide to the basics of coverage decisions and appeals 95
Section 4.1 Asking for coverage decisions and making appeals: the big picture 95
Section 4.2 How to get help when you are asking for a coverage decision or making
an appeal 96
SECTION 5 Your Part D prescription drugs: How to ask for a coverage
decision or make an appeal 97
Section 5.1 This section tells you what to do if you have problems getting a Part D
drug or you want us to pay you back for a Part D drug 97
Section 5.2 What is an exception? 99
Section 5.3 Important things to know about asking for exceptions 100
Section 5.4 Step -by -step: How to ask for a coverage decision, including an exception 101
Section 5.5 Step -by -step: How to make a Level 1 Appeal (how to ask for a review of
a coverage decision made by our plan) 104
Section 5.6 Step -by -step: How to make a Level 2 Appeal 107
SECTION 6 Taking your appeal to Level 3 and beyond 109
Section 6.1 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals 109
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Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
MAKING COMPLAINTS 110
SECTION 7 How to make a complaint about quality of care, waiting
times, customer service, or other concerns 110
Section 7.1 What kinds of problems are handled by the complaint process? 110
Section 7.2 The formal name for "making a complaint" is "filing a grievance" 112
Section 7.3 Step -by -step: Making a complaint 113
Section 7.4 You can also make complaints about quality of care to the Quality
Improvement Organization 114
Section 7.5 You can also tell Medicare about your complaint 114
•
•
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Chapter 7. What to do if you have a problem or complaint
(coverage decisions, appeals, complaints)
BACKG OUNDn .
SECTION 1 Introduction
Section 1.1 What to do if you have a problem or concern
This chapter explains two types of processes for handling problems and concerns:
• For some types of problems, you need to use the process for coverage decisions and
appeals.
• For other types of problems, you need to use the process for making complaints.
Both of these processes have been approved by Medicare. To ensure fairness and prompt
handling of your problems, each process has a set of rules,procedures, and deadlines that must
be followed by us and by you.
Which one do you use?That depends on the type of problem you are having. The guide in
Section 3 will help you identify the right process to use.
Section 1.2 What about the legal terms?
There are technical legal terms for some of the rules,procedures, and types of deadlines
explained in this chapter. Many of these terms are unfamiliar to most people and can be hard to
understand.
To keep things simple, this chapter explains the legal rules and procedures using simpler words
in place of certain legal terms. For example, this chapter generally says "making a complaint"
rather than"filing a grievance," "coverage decision" rather than"coverage determination,"and
"Independent Review Organization" instead of"Independent Review Entity." It also uses
abbreviations as little as possible.
However, it can be helpful—and sometimes quite important—for you to know the correct legal
terms for the situation you are in. Knowing which terms to use will help you communicate more
clearly and accurately when you are dealing with your problem and get the right help or
information for your situation. To help you know which terms to use, we include legal terms
when we give the details for handling specific types of situations.
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•
SECTION 2 You can get help from government organizations that
are not connected with us
Section 2.1 Where to get more information and personalized assistance
Sometimes it can be confusing to start or follow through the process for dealing with a problem.
This can be especially true if you do not feel well or have limited energy. Other times, you may
not have the knowledge you need to take the next step.
Get help from an independent government organization
We are always available to help you. But in some situations you may also want help or
guidance from someone who is not connected us. You can always contact your State Health
Insurance Assistance Program (SHIP). This government program has trained counselors in
every state. The program is not connected with us or with any insurance company or health
plan. The counselors at this program can help you understand which process you should use to
handle a problem you are having. They can also answer your questions, give you more
information, and offer guidance on what to do.
The services of SHIP counselors are free. You will fmd SHIP phone numbers in Appendix A
of this booklet.
You can also get help and information from Medicare
For more information and help in handling a problem, you can also contact Medicare. Here are
two ways to get information directly from Medicare:
• You can call 1- 800 - MEDICARE (1- 800 - 633 - 4227), 24 hours a day, 7 days a week. TTY
users should call 1- 877 - 486 -2048.
• You can visit the Medicare website (https: / /www.medicare.gov).
SECTION 3 To deal with your problem, which process should you
use?
Section 3.1 Should you use the process for coverage decisions and
appeals? Or should you use the process for making
complaints?
If you have a problem or concern, you only need to read the parts of this chapter that apply to
your situation. The guide that follows will help.
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To figure out which part of this chapter will help with your specific problem or concern,
START HERE
Is your problem or concern about your benefits or coverage?
(This includes problems about whether particular medical care or prescription drugs are
covered or not, the way in which they are covered, and problems related to payment for
medical care or prescription drugs.)
Yes. My problem is about benefits or coverage.
Go on to the next section of this chapter, Section 4, "A guide to the basics of
coverage decisions and appeals."
No.My problem is not about benefits or coverage.
Skip ahead to Section 7 at the end of this chapter: "How to make a complaint
about quality of care,waiting times, customer service or other concerns."
COVERAGE DECISIONS AND APPEALS
SECTION 4 A guide to the basics of coverage decisions and
appeals
Section 4.1 Asking for coverage decisions and making appeals: the big
picture
The process for coverage decisions and appeals deals with problems related to your benefits
and coverage for prescription drugs, including problems related to payment. This is the process
you use for issues such as whether a drug is covered or not and the way in which the drug is
covered.
Asking for coverage decisions
A coverage decision is a decision we make about your benefits and coverage or about the amount
we will pay for your prescription drugs.
We are making a coverage decision for you whenever we decide what is covered for you and
how much we pay. In some cases,we might decide a drug is not covered or is no longer covered
by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
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Making an appeal
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the
decision. An appeal is a formal way of asking us to review and change a coverage decision we
have made.
When you appeal a decision for the first time, this is called a Level 1 Appeal. In this appeal, we
review the coverage decision we made to check to see if we were following all of the rules
properly. Your appeal is handled by different reviewers than those who made the original
unfavorable decision. When we have completed the review we give you our decision. Under
certain circumstances, which we discuss later, you can request an expedited or "fast coverage
decision" or fast appeal of a coverage decision.
If we say no to all or part of your Level 1 Appeal, you can ask for a Level 2 Appeal. The Level 2
Appeal is conducted by an independent organization that is not connected to us. If you are not
satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional
levels of appeal.
Section 4.2 How to get help when you are asking for a coverage decision
or making an appeal
Would you like some help? Here are resources you may wish to use if you decide to ask for any
kind of coverage decision or appeal a decision:
• You can call us at Member Services (phone numbers are printed on the back cover of
this booklet).
• To get free help from an independent organization that is not connected with our plan,
contact your State Health Insurance Assistance Program (see Section 2 of this chapter).
• Your doctor or other prescriber can make a request for you. For Part D prescription
drugs, your doctor or other prescriber can request a coverage decision or a Level 1 or
• Level 2 Appeal on your behalf. To request any appeal after Level 2, your doctor or other
prescriber must be appointed as your representative.
• You can ask someone to act on your behalf. If you want to, you can name another
person to act for you as your "representative" to ask for a coverage decision or make an
appeal.
o There may be someone who is already legally authorized to act as your
representative under State law.
o If you want a friend, relative, your doctor or other prescriber, or other person to be
your representative, call Member Services (phone numbers are printed on the
back cover of this booklet) and ask for the "Appointment of Representative"
form. (The form is also available on Medicare's website at
https : / /www.cros.hhs.gov /crosforms /downloads /cros1696.pdf or on our website at
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www.envisionrxplus.com.) The form gives that person permission to act on your
behalf. It must be signed by you and by the person who you would like to act on
your behalf. You must give us a copy of the signed form.
• You also have the right to hire a Lawyer to act for you. You may contact your own
lawyer, or get the name of a lawyer from your local bar association or other referral
service. There are also groups that will give you free legal services if you qualify.
However, you are not required to hire a lawyer to ask for any kind of coverage
decision or appeal a decision.
SECTION 5 Your Part D prescription drugs: How to ask for a
coverage decision or make an appeal
Have you read Section 4 of this chapter (A guide to "the basics" of
coverage decisions and appeals)? If not, you may want to read it before
you start this section.
Section 5.1 This section tells you what to do if you have problems getting
a Part D drug or you want us to pay you back for a Part D drug
Your benefits as a member of our plan include coverage for many prescription drugs. Please
refer to our plan's List of Covered Drugs (Formulary). To be covered, the drug must be used for
a medically accepted indication. (A "medically accepted indication" is a use of the drug that is
either approved by the Food and Drug Administration or supported by certain reference books.
See Chapter 3, Section 3 for more information about a medically accepted indication.)
• This section is about your Part D drugs only. To keep things simple, we generally say
"drug" in the rest of this section, instead of repeating "covered outpatient prescription
drug" or "Part D drug" every time.
• For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary),
rules and restrictions on coverage, and cost information, see Chapter 3 (Using our plan's
coverage for your Part D prescription drugs) and Chapter 4 (What you pay for your Part
D prescription drugs).
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Part D coverage decisions and appeals
As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your
benefits and coverage or about the amount we will pay for your drugs.
Legal Terms
An initial coverage decision about your
Part D drugs is called a "coverage
determination."
Here are examples of coverage decisions you ask us to make about your Part D drugs:
• You ask us to make an exception, including:
o Asking us to cover a Part D drug that is not on the plan's List of Covered Drugs
(Formulary)
o Asking us to waive a restriction on the plan's coverage for a drug (such as limits
on the amount of the drug you can get)
o Asking to pay a lower cost - sharing amount for a covered drug on a higher cost -
sharing tier
• You ask us whether a drug is covered for you and whether you satisfy any applicable
coverage rules. (For example, when your drug is on the plan's List of Covered Drugs
(Formulary) but we require you to get approval from us before we will cover it for you.)
o Please note: If your pharmacy tells you that your prescription cannot be filled as
written, you will get a written notice explaining how to contact us to ask for a
coverage decision.
• You ask us to pay for a prescription drug you already bought. This is a request for a
coverage decision about payment.
If you disagree with a coverage decision we have made, you can appeal our decision.
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This section tells you both how to ask for coverage decisions and how to request an appeal. Use
the chart below to help you determine which part has information for your situation:
Which of these situations are you in?
If yob are in this situation; This is what you can do
Do you need a drug that isn't on our Drug You can ask us to make an exception. (This is a
List or need us to waive a rule or restriction type of coverage decision.)
on a drug we cover? Start with Section 5.2 of this chapter
Do you want us to cover a drug on our You can ask us for a coverage decision.
Drug List and you believe you meet any Skip ahead to Section 5.4 of this chapter.
plan rules or restrictions (such as getting
approval in advance) for the drug you need?
Do you want to ask us to pay you back for a You can ask us to pay you back. (This is a type
drug you have already received and paid of coverage decision.)
for? Skip ahead to Section 5.4 of this chapter.
Have we already told you that we will not You can make an appeal. (This means you are
cover or pay for a drug in the way that you asking us to reconsider.)
want it to be covered or paid for? Skip ahead to Section 5.5 of this chapter.
Section 5.2 What is an exception?
If a drug is not covered in the way you would like it to be covered, you can ask us to make an
"exception."An exception is a type of coverage decision. Similar to other types of coverage
decisions, if we turn down your request for an exception, you can appeal our decision.
When you ask for an exception, your doctor or other prescriber will need to explain the medical
reasons why you need the exception approved. We will then consider your request. Here are
three examples of exceptions that you or your doctor or other prescriber can ask us to make:
1. Covering a Part D drug for you that is not on our List of Covered Drugs (Formulary).
(We call it the"Drug List"for short.)
Legal Terms
Asking for coverage of a drug that is not on
the Drug List is sometimes called asking
for a"formulary exception."
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• If we agree to make an exception and cover a drug that is not on the Drug List, you will
need to pay the cost - sharing amount that applies to drugs in Tier 4. You cannot ask for an
exception to the copayment or coinsurance amount we require you to pay for the drug.
2. Removing a restriction on our coverage for a covered drug. There are extra rules or
restrictions that apply to certain drugs on our List of Covered Drugs (Formulary) (for more
information, go to Chapter 3).
Legal Terms
Asking for removal of a restriction on
coverage for a drug is sometimes called
asking for a "formulary exception."
• The extra rules and restrictions on coverage for certain drugs include:
o Being required to use the generic version of a drug instead of the brand name
drug.
o Getting plan approval in advance before we will agree to cover the drug for you.
(This is sometimes called "prior authorization. ")
o Being required to try a different drug first before we will agree to cover the drug
you are asking for. (This is sometimes called "step therapy. ")
o Quantity limits. For some drugs, there are restrictions on the amount of the drug
you can have.
• If we agree to make an exception and waive a restriction for you, you can ask for an
exception to the copayment or coinsurance amount we require you to pay for the drug.
3. Changing coverage of a drug to a lower cost - sharing tier. Every drug on our Drug List is
in one of 5 cost - sharing tiers. In general, the lower the cost - sharing tier number, the less you
will pay as your share of the cost of the drug.
Legal Terms
Asking to pay a lower price for a covered
non - preferred drug is sometimes called
asking for a "tiering exception."
• You cannot ask us to change the cost - sharing tier for any drug in Specialty Drug Tier
(Tier 5).
Section 5.3 Important things to know about asking for exceptions
Your doctor must tell us the medical reasons
Your doctor or other prescriber must give us a statement that explains the medical reasons for
requesting an exception. For a faster decision, include this medical information from your doctor
or other prescriber when you ask for the exception.
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Typically, our Drug List includes more than one drug for treating a particular condition. These
different possibilities are called "alternative" drugs. If an alternative drug would be just as
effective as the drug you are requesting and would not cause more side effects or other health
problems, we will generally not approve your request for an exception. If you ask us for a tiering
exception, we will generally not approve your request for an exception unless all the alternative
drugs in the lower cost - sharing tier(s) won't work as well for you.
We can say yes or no to your request
• If we approve your request for an exception, our approval usually is valid until the end of
the plan year. This is true as long as your doctor continues to prescribe the drug for you
and that drug continues to be safe and effective for treating your condition.
• If we say no to your request for an exception, you can ask for a review of our decision by
making an appeal. Section 5.5 tells you how to make an appeal if we say no.
The next section tells you how to ask for a coverage decision, including an exception.
Section 5.4 Step -by -step: How to ask for a coverage decision, including an
exception
Step 1: You ask us to make a coverage decision about the drug(s) or payment
you need. If your health requires a quick response, you must ask us to make a
"fast coverage decision." You cannot ask for a fast coverage decision if you are
asking us to pay you back for a drug you already bought.
What to do
• Request the type of coverage decision you want. Start by calling, writing, or faxing us
to make your request. You, your representative, or your doctor (or other prescriber) can
do this. You can also access the coverage decision process through our website. For the
details, go to Chapter 2, Section 1 and look for the section called How to contact us when
you are asking for a coverage decision about your Part D prescription drugs, or when
you are making an appeal or complaint about your Part D prescription drugs. Or if you
are asking us to pay you back for a drug, go to the section called Where to send a request
that asks us to pay for our share of the cost for a drug you have received.
• You or your doctor or someone else who is acting on your behalf can ask for a
coverage decision. Section 4 of this chapter tells how you can give written permission to
someone else to act as your representative. You can also have a lawyer act on your
behalf.
• If you want to ask us to pay you back for a drug, start by reading Chapter 5 of this
booklet: Asking us to pay our share of the costs for covered drugs. Chapter 5 describes
the situations in which you may need to ask for reimbursement. It also tells how to send
us the paperwork that asks us to pay you back for our share of the cost of a drug you have
paid for.
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• If you are requesting an exception, provide the "supporting statement." Your doctor
or other prescriber must give us the medical reasons for the drug exception you are
requesting. (We call this the "supporting statement. ") Your doctor or other prescriber can
fax or mail the statement to us. Or your doctor or other prescriber can tell us on the phone
and follow up by faxing or mailing a written statement if necessary. See Sections 5.2 and
5.3 for more information about exception requests.
• We must accept any written request, including a request submitted on the CMS Model
Coverage Determination Request Form, which is available on our website.
If your health requires it, ask us to give you a `fast coverage decision"
Legal Terms
A "fast coverage decision" is called an
"expedited coverage determination."
• When we give you our decision, we will use the "standard" deadlines unless we have
agreed to use the "fast" deadlines. A standard coverage decision means we will give you
an answer within 72 hours after we receive your doctor's statement. A fast coverage
decision means we will answer within 24 hours after we receive your doctor's statement.
• To get a fast coverage decision, you must meet two requirements:
o You can get a fast coverage decision only if you are asking for a drug you have
not yet received. (You cannot get a fast coverage decision if you are asking us to
pay you back for a drug you have already bought.)
o You can get a fast coverage decision only if using the standard deadlines could
cause serious harm to your health or hurt your ability to function.
• If your doctor or other prescriber tells us that your health requires a "fast coverage
decision," we will automatically agree to give you a fast coverage decision.
• If you ask for a fast coverage decision on your own (without your doctor's or other
prescriber's support), we will decide whether your health requires that we give you a fast
coverage decision.
o If we decide that your medical condition does not meet the requirements for a fast
coverage decision, we will send you a letter that says so (and we will use the
standard deadlines instead).
o This letter will tell you that if your doctor or other prescriber asks for the fast
coverage decision, we will automatically give a fast coverage decision.
o The letter will also tell how you can file a complaint about our decision to give
you a standard coverage decision instead of the fast coverage decision you
requested. It tells how to file a "fast" complaint, which means you would get our
answer to your complaint within 24 hours of receiving the complaint. (The
process for making a complaint is different from the process for coverage
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decisions and appeals. For more information about the process for making
complaints, see Section 7 of this chapter.)
Step 2: We consider your request and we give you our answer.
Deadlines for a `fast" coverage decision
• If we are using the fast deadlines, we must give you our answer within 24 hours.
o Generally, this means within 24 hours after we receive your request. If you are
requesting an exception, we will give you our answer within 24 hours after we
receive your doctor's statement supporting your request. We will give you our
answer sooner if your health requires us to.
o If we do not meet this deadline, we are required to send your request on to Level 2
of the appeals process, where it will be reviewed by an independent outside
organization. Later in this section, we talk about this review organization and
explain what happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 24 hours after we receive your request or
doctor's statement supporting your request.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no. We will also tell you how to appeal.
Deadlines for a "standard" coverage decision about a drug you have not yet received
• If we are using the standard deadlines, we must give you our answer within 72 hours.
o Generally, this means within 72 hours after we receive your request. If you are
requesting an exception, we will give you our answer within 72 hours after we
receive your doctor's statement supporting your request. We will give you our
answer sooner if your health requires us to.
o If we do not meet this deadline, we are required to send your request on to Level 2
of the appeals process, where it will be reviewed by an independent organization.
Later in this section, we talk about this review organization and explain what
happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested —
o If we approve your request for coverage, we must provide the coverage we have
agreed to provide within 72 hours after we receive your request or doctor's
statement supporting your request.
•. If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no. We will also tell you how to appeal.
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Deadlines for a "standard" coverage decision about payment for a drug you have already
bought
• We must give you our answer within 14 calendar days after we receive your request.
o If we do not meet this deadline, we are required to send your request on to Level 2
of the appeals process, where it will be reviewed by an independent organization.
Later in this section, we talk about this review organization and explain what
happens at Appeal Level 2.
• If our answer is yes to part or all of what you requested, we are also required to make
payment to you within 14 calendar days after we receive your request
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no. We will also tell you how to appeal.
Step 3: If we say no to your coverage request, you decide if you want to make an
appeal.
• If we say no, you have the right to request an appeal. Requesting an appeal means asking
us to reconsider — and possibly change — the decision we made.
Section 5.5 Step -by -step: How to make a Level 1 Appeal
(how to ask for a review of a coverage decision made by our plan)
Legal Terms
An appeal to the plan about a Part D drug
coverage decision is called a plan
"redetermination.
Step 1: You contact us and make your Level 1 Appeal. If your health requires a
quick response, you must ask for a "fast appeal."
What to do
• To start your appeal, you (or your representative or your doctor or other
prescriber) must contact us.
o For details on how to reach us by phone, fax, or mail, or on our website, for any
purpose related to your appeal, go to Chapter 2, Section 1, and look for the section
called How to contact us when you are making an appeal about your Part D
prescription drugs, or when you are making an appeal or complaint about your
Part D prescription drugs.
• If you are asking for a standard appeal, make your appeal by submitting a written
request. You may also ask for an appeal by calling us at the phone number shown in
Chapter 2, Section 1 (How to contact us when you are making an appeal about your Part
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D prescription drugs, or when you are making an appeal or complaint about your Part D
prescription drugs).
• If you are asking for a fast appeal, you may make your appeal in writing or you may
call us at the phone number shown in Chapter 2, Section 1 (How to contact us when
you are making an appeal about your Part D prescription drugs, or when you are making
an appeal or complaint about your Part D prescription drugs).
• We must accept any written request, including a request submitted on the CMS Model
Coverage Determination Request Form, which is available on our website.
• We also accept requests through our website at www.envisionrxplus.com. Go to our
Coverage Determination policy section and click on On -line Coverage Determination to
submit your request on our website.
• You must make your appeal request within 60 calendar days from the date on the
written notice we sent to tell you our answer to your request for a coverage decision. If
you miss this deadline and have a good reason for missing it, we may give you more time
to make your appeal. Examples of good cause for missing the deadline may include if
you had a serious illness that prevented you from contacting us or if we provided you
with incorrect or incomplete information about the deadline for requesting an appeal.
• You can ask for a copy of the information in your appeal and add more
information.
o You have the right to ask us for a copy of the information regarding your appeal.
We are allowed to charge a fee for copying and sending this information to you.
o If you wish, you and your doctor or other prescriber may give us additional
information to support your appeal.
If your health requires it, ask for a `fast appeal"
Legal Terms
A "fast appeal" is also called an
" expedited redetermination."
• If you are appealing a decision we made about a drug you have not yet received, you and
your doctor or other prescriber will need to decide if you need a "fast appeal."
• The requirements for getting a "fast appeal" are the same as those for getting a "fast
coverage decision" in Section 5.4 of this chapter.
Step 2: We consider your appeal and we give you our answer.
• When we are reviewing your appeal, we take another careful look at all of the
information about your coverage request. We check to see if we were following all the
rules when we said no to your request. We may contact you or your doctor or other
prescriber to get more information.
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Deadlines for a `fast" appeal
• If we are using the fast deadlines, we must give you our answer within 72 hours after
we receive your appeal. We will give you our answer sooner if your health requires it.
o If we do not give you an answer within 72 hours, we are required to send your
request on to Level 2 of the appeals process, where it will be reviewed by an
Independent Review Organization. (Later in this section, we talk about this
review organization and explain what happens at Level 2 of the appeals process.)
• If our answer is yes to part or all of what you requested, we must provide the
coverage we have agreed to provide within 72 hours after we receive your appeal.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.
Deadlines for a "standard" appeal
• If we are using the standard deadlines, we must give you our answer within 7 calendar
days after we receive your appeal. We will give you our decision sooner if you have not
received the drug yet and your health condition requires us to do so. If you believe your
health requires it, you should ask for "fast" appeal.
o If we do not give you a decision within 7 calendar days, we are required to send
your request on to Level 2 of the appeals process, where it will be reviewed by an
Independent Review Organization. Later in this section, we tell about this review
organization and explain what happens at Level 2 of the appeals process.
• If our answer is yes to part or all of what you requested —
o If we approve a request for coverage, we must provide the coverage we have
agreed to provide as quickly as your health requires, but no later than 7 calendar
days after we receive your appeal.
o If we approve a request to pay you back for a drug you already bought, we are
required to send payment to you within 30 calendar days after we receive your
appeal request.
• If our answer is no to part or all of what you requested, we will send you a written
statement that explains why we said no and how to appeal our decision.
Step 3: If we say no to your appeal, you decide if you want to continue with the
appeals process and make another appeal.
• If we say no to your appeal, you then choose whether to accept this decision or continue
by making another appeal.
• If you decide to make another appeal, it means your appeal is going on to Level 2 of the
appeals process (see below).
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Section 5.6 Step -by -step: How to make a Level 2 Appeal
If we say no to your appeal, you then choose whether to accept this decision or continue by
making another appeal. If you decide to go on to a Level 2 Appeal, the Independent Review
Organization reviews the decision we made when we said no to your first appeal. This
organization decides whether the decision we made should be changed.
Legal Terms
The formal name for the "Independent
Review Organization" is the "Independent
Review Entity." It is sometimes called the
".,"
Step 1: To make a Level 2 Appeal, you (or your representative or your doctor or
other prescriber) must c ontact the Independent Review Organization and ask for
a review of your case.
• If we say no to your Level 1 Appeal, the written notice we send you will include
instructions on how to make a Level 2 Appeal with the Independent Review
Organization. These instructions will tell who can make this Level 2 Appeal, what
deadlines you must follow, and how to reach the review organization.
• When you make an appeal to the Independent Review Organization, we will send the
information we have about your appeal to this organization. This information is called
your "case file." You have the right to ask us for a copy of your case file. We are
allowed to charge you a fee for copying and sending this information to you.
• You have a right to give the Independent Review Organization additional information to
support your appeal.
Step 2: The Independent Review Organization does a review of your appeal and
gives you an answer.
• The Independent Review Organization is an independent organization that is hired
by Medicare. This organization is not connected with us and it is not a government
agency. This organization is a company chosen by Medicare to review our decisions
about your Part D benefits with us.
• Reviewers at the Independent Review Organization will take a careful look at all of the
information related to your appeal. The organization will tell you its decision in writing
and explain the reasons for it.
Deadlines for `fast appeal" at Level 2
• If your health requires it, ask the Independent Review Organization for a "fast appeal."
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• If the review organization agrees to give you a "fast appeal," the review organization
must give you an answer to your Level 2 Appeal within 72 hours after it receives your
appeal request.
• If the Independent Review Organization says yes to part or all of what you
requested, we must provide the drug coverage that was approved by the review
organization within 24 hours after we receive the decision from the review organization.
Deadlines for "standard appeal" at Level 2
• If you have a standard appeal at Level 2, the review organization must give you an
answer to your Level 2 Appeal within 7 calendar days after it receives your appeal.
• If the Independent Review Organization says yes to part or all of what you
requested
• If the Independent Review Organization approves a request for coverage, we must
provide the drug coverage that was approved by the review organization within 72
hours after we receive the . decision from the review organization.
• If the Independent Review Organization approves a request to pay you back for a drug
you already bought, we are required to send payment to you within 30 calendar days
after we receive the decision from the review organization.
What if the review organization says no to your appeal?
If this organization says no to your appeal, it means the organization agrees with our decision not
to approve your request. (This is called "upholding the decision." It is also called "turning down
your appeal. ")
If the Independent Review Organization "upholds the decision" you have the right to. a Level 3
Appeal. However, to make another appeal at Level 3, the dollar value of the drug coverage you
are requesting must meet a minimum amount. If the dollar value of the drug coverage you are
requesting is too low, you cannot make another appeal and the decision at Level 2 is final. The
notice you get from the Independent Review Organization will tell you the dollar value that must
be in dispute to continue with the appeals process.
Step 3: If the dollar value of the coverage you are requesting meets the
requirement, you choose whether you want to take your appeal further.
• There are three additional levels in the appeals process after Level 2 (for a total of five
levels of appeal).
• If your Level 2 Appeal is turned down and you meet the requirements to continue with
the appeals process, you must decide whether you want to go on to Level 3 and make a
third appeal. If you decide to make a third appeal, the details on how to do this are in the
written notice you got after your second appeal.
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• The Level 3 Appeal is handled by an administrative law judge. Section 6 in this chapter
tells more about Levels 3,4, and 5 of the appeals process.
SECTION 6 Taking your appeal to Level 3 and beyond
Section 6.1 Levels of Appeal 3, 4, and 5 for Part D Drug Appeals
This section may be appropriate for you if you have made a Level 1 Appeal and a Level 2
Appeal, and both of your appeals have been turned down.
If the value of the drug you have appealed meets a certain dollar amount, you may be able to go
on to additional levels of appeal. If the dollar amount is less, you cannot appeal any further. The
written response you receive to your Level 2 Appeal will explain who to contact and what to do
to ask for a Level 3 Appeal.
For most situations that involve appeals, the last three levels of appeal work in much the same
way. Here is who handles the review of your appeal at each of these levels.
Level 3 Appeal A judge who works for the Federal government will review your appeal
and give you an answer. This judge is called an "Administrative Law Judge."
• If the answer is yes,the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Administrative Law Judge within 72 hours (24 hours for expedited appeals) or
make payment no later than 30 calendar days after we receive the decision.
• If the Administrative Law Judge says no to your appeal, the appeals process may or
may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you can continue to the next level of the
review process. If the administrative law judge says no to your appeal, the notice
you get will tell you what to do next if you choose to continue with your appeal.
Level 4 Appeal The Appeals Council will review your appeal and give you an answer. The
Appeals Council works for the Federal government.
• If the answer is yes,the appeals process is over. What you asked for in the appeal has
been approved. We must authorize or provide the drug coverage that was approved by
the Appeals Council within 72 hours (24 hours for expedited appeals) or make
payment no later than 30 calendar days after we receive the decision.
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• If the answer is no, the appeals process may or may not be over.
o If you decide to accept this decision that turns down your appeal, the appeals
process is over.
o If you do not want to accept the decision, you might be able to continue to the
next level of the review process. If the Appeals Council says no to your appeal or
denies your request to review the appeal, the notice you get will tell you whether
the rules allow you to go on to a Level 5 Appeal. If the rules allow you to go on,
the written notice will also tell you who to contact and what to do next if you
choose to continue with your appeal.
Level 5 Appeal A judge at the Federal District Court will review your appeal.
• This is the last step of the appeals process.
SECTION 7 How to make a complaint about quality of care,
waiting times, customer service, or other concerns
• If your problem is about decisions related to benefits, coverage, or
payment, then this section is not for you. Instead, you need to use the
process for coverage decisions and appeals. Go to Section 4 of this
chapter.
Section 7.1 What kinds of problems are handled by the complaint
process?
This section explains how to use the process for making complaints. The complaint process is
used for certain types of problems only. This includes problems related to quality of care, waiting
times, and the customer service you receive. Here are examples of the kinds of problems handled
by the complaint process.
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If you have any of these kinds of problems, you can "make a complaint"
Complaint Example � �
Quality of your • Are you unhappy with the quality of the care you have received?
medical care
Respecting your • Do you believe that someone did not respect your right to privacy
privacy or shared information about you that you feel should be
confidential?
Disrespect,poor • Has someone been rude or disrespectful to you?
customer service, • Are you unhappy with how our Member Services has treated you?
or other negative • Do you feel you are being encouraged to leave the plan?
behaviors
Waiting times • Have you been kept waiting too long by pharmacists? Or by our
Member Services or other staff at the plan?
o Examples include waiting too long on the phone or when
getting a prescription.
Cleanliness • Are you unhappy with the cleanliness or condition of a pharmacy?
Information you • Do you believe we have not given you a notice that we are required
get from us to give?
• Do you think written information we have given you is hard to
understand?
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Complaint Example
Timeliness The process of asking for a coverage decision and making appeals is
(These types of explained in sections 4-6 of this chapter. If you are asking for a
complaints are all decision or making an appeal, you use that process,not the complaint
related to the process.
timeliness of our However, if you have already asked us for a coverage decision or made
actions related to an appeal, and you think that we are not responding quickly enough,
coverage decisions you can also make a complaint about our slowness. Here are examples:
and appeals)
• If you have asked us to give you a"fast coverage decision"or a
"fast appeal," and we have said we will not, you can make a
complaint.
• If you believe we are not meeting the deadlines for giving you a
coverage decision or an answer to an appeal you have made, you
can make a complaint.
• When a coverage decision we made is reviewed and we are told
that we must cover or reimburse you for certain drugs,there are
deadlines that apply. If you think we are not meeting these
deadlines, you can make a complaint.
• When we do not give you a decision on time, we are required to
forward your case to the Independent Review Organization. If we
do not do that within the required deadline, you can make a
complaint.
Section 7.2 The formal name for "making a complaint" is "filing a
grievance"
Legal Terms
• What this section calls a "complaint"
is also called a"grievance."
• Another term for"making a
complaint" is "filing a grievance."
Another way to say"using the process for
complaints" is "using the process for
filing a grievance."
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Section 7.3 Step -by -step: Making a complaint
Step 1: Contact us promptly — either by phone or in writing.
• Usually, calling Member Services is the first step. If there is anything else you need to
do, Member Services will let you know. 1 -844- 293 -4760, TTY/TDD 711, 24 hours a day,
7 days a week.
• If you do not wish to call (or you called and were not satisfied), you can put your
complaint in writing and send it to us. If you put your complaint in writing, we will
respond to your complaint in writing.
• Grievances can be filed orally by calling 1 -844- 293 -4760 (TTY/TDD users should call
711) or in writing to EnvisionRxPlus, 2181 E. Aurora Rd., Suite 201, Twinsburg, OH
44087, Attn: Grievances. We are available 24 hours a day, 7 days a week. The grievance
must be filed no later than 60 days after the incident that caused your grievance. Once
EnvisionRxPlus receives your grievance, it will be resolved as quickly as possible, but
no later than 30 days. The 30 day timeframe may be extended up to 14 days if you
request the extension or if EnvisionRxPlus requires additional information and the delay
is in your best interest. You can file an expedited grievance if your grievance is due to
EnvisionRxPlus's refusal to grant your request for an expedited coverage determination
or expedited redetermination. When filing this type of grievance, state that it is an
expedited grievance and it will be responded to within 24 hours
• Whether you call or write, you should contact Member Services right away. The
complaint must be made within 60 calendar days after you had the problem you want to
complain about.
• If you are making a complaint because we denied your request for a "fast coverage
decision" or a "fast appeal," we will automatically give you a "fast" complaint. If
you have a "fast" complaint, it means we will give you an answer within 24 hours.
Legal Terms
What this section calls a "fast complaint"
•
is also called an "expedited grievance."
Step 2: We look into your complaint and give you our answer.
• If possible, we will answer you right away. If you call us with a complaint, we maybe
able to give you an answer on the same phone call. If your health condition requires us to
answer quickly, we will do that.
• Most complaints are answered in 30 calendar days. If we need more information and
the delay is in your best interest or if you ask for more time, we can take up to 14 more
calendar days (44 calendar day's total) to answer your complaint. If we decide to take
extra days, we will tell you in writing.
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• If we do not agree with some or all of your complaint or don't take responsibility for the
problem you are complaining about, we will let you know. Our response will include our
reasons for this answer. We must respond whether we agree with the complaint or not.
Section 7.4 You can also make complaints about quality of care to the
Quality Improvement Organization
You can make your complaint about the quality of care you received to us by using the step -by-
step process outlined above.
When your complaint is about quality of care, you also have two extra options:
• You can make your complaint to the Quality Improvement Organization. If you
prefer, you can make your complaint about the quality of care you received directly to
this organization (without making the complaint to us).
o The Quality Improvement Organization is a group of practicing doctors and other
health care experts paid by the Federal government to check and improve the care
given to Medicare patients.
o To find the name, address, and phone number of the Quality Improvement
Organization for your state, look in Chapter 2, Section 4, of this booklet. If you
make a complaint to this organization, we will work with them to resolve your
complaint.
• Or you can make your complaint to both at the same time. If you wish, you can make
your complaint about quality of care to us and also to the Quality Improvement
Organization.
Section 7.5 You can also tell Medicare about your complaint
You can submit a complaint about EnvisionRxPlus Employer Group Retiree PDP directly to
Medicare. To submit a complaint to Medicare, go to
https: / /www. medicare. gov /MedicareComplaintForm /home.aspx. Medicare takes your complaints
seriously and will use this information to help improve the quality of the Medicare program.
If you have any other feedback or concerns, or if you feel the plan is not addressing your issue,
please call 1- 800 - MEDICARE (1- 800 - 633 - 4227). TTY/TDD users can call 1- 877 - 486 -2048.
CHAPTER 8
Ending your membership in the plan
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Chapter 8. Ending your membership in the plan
Chapter 8. Endinq your membership in the plan
SECTION 1 Introduction 117
Section 1.1 This chapter focuses on ending your membership in our plan 117
SECTION 2 When can you end your membership in our plan? 117
Section 2.1 Usually, you can end your membership during the Annual Enrollment
Period 117
Section 2.2 In certain situations, you can end your membership during a Special
Enrollment Period 118
Section 2.3 Where can you get more information about when you can end your
membership? 120
SECTION 3 How do you end your membership in our plan? 120
Section 3.1 Usually, you end your membership by enrolling in another plan 120
SECTION 4 Until your membership ends, you must keep getting your
drugs through our plan 122
Section 4.1 Until your membership ends, you are still a member of our plan 122
SECTION 5 EnvisionRx Plus Employer Group Retiree PDP must end
your membership in the plan in certain situations 122
Section 5.1 When must we end your membership in the plan? 122 -
Section 5.2 We cannot ask you to leave our plan for any reason related to your health 123
Section 5.3 You have the right to make a complaint if we end your membership in
our plan 124
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Chapter 8. Ending your membership in the plan
SECTION 1 Introduction
Section 1.1 This chapter focuses on ending your membership in our plan
Ending your membership in EnvisionRxPlus Employer Group Retiree PDP may be voluntary
(your own choice) or involuntary (not your own choice):
• You might leave our plan because you have decided that you want to leave.
o There are only certain times during the year, or certain situations, when you may
voluntarily end your membership in the plan. Section 2 tells you when you can
end your membership in the plan.
o The process for voluntarily ending your membership varies depending on what
type of new coverage you are choosing. Section 3 tells you how to end your
membership in each situation.
• There are also limited situations where you do not choose to leave, but we are required to
end your membership. Section 5 tells you about situations when we must end your
membership.
If you are leaving our plan, you must continue to get your Part D prescription drugs through our
plan until your membership ends.
SECTION 2 When can you end your membership in our plan?
You may end your membership in our plan only during certain times of the year, known as
enrollment periods. All members have the opportunity to leave the plan during the Annual
Enrollment Period. In certain situations, you may also be eligible to leave the plan at other times
of the year.
Section 2.1 Usually, you can end your membership during the Annual
Enrollment Period
You can end your membership during the Annual Enrollment Period (also known as the
"Annual Coordinated Election Period "). This is the time when you should review your health
and drug coverage and make a decision about your coverage for the upcoming year.
• When is the Annual Enrollment Period? This happens from October 15 to
December 7.
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• What type of plan can you switch to during the Annual Enrollment Period? You can
choose to keep your current coverage or make changes to your coverage for the
upcoming year. If you decide to change to a new plan, you can choose any of the
following types of plans:
o Another Medicare prescription drug plan.
o Original Medicare without a separate Medicare prescription drug plan.
• • If you receive "Extra Help" from Medicare to pay for your
prescription drugs: If you do not enroll in a separate Medicare
prescription drug plan, Medicare may enroll you in a drug plan, unless you
have opted out of automatic enrollment.
o — or — A Medicare health plan. A Medicare health plan is a plan offered by a
private company that contracts with Medicare to provide all of the Medicare Part
A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also
include Part D prescription drug coverage.
• If you enroll in most Medicare health plans, you will be disenrolled from
EnvisionRxPlus Employer Group Retiree PDP when your new plan's
coverage begins. However, if you choose a Private Fee - for - Service plan
without Part D drug coverage, a Medicare Medical Savings Account plan,
or a Medicare Cost Plan, you can enroll in that plan and keep
EnvisionRxPlus Employer Group Retiree PDP for your drug coverage.
If you do not want to keep our plan, you can choose to enroll in another
Medicare prescription drug plan or drop Medicare prescription drug
coverage.
Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage, you may need to pay a late enrollment penalty if
you join a Medicare drug plan later. ( "Creditable" coverage means the coverage is
expected to pay, on average, at least as much as Medicare's standard prescription drug
coverage.) See Chapter 1, Section 5 for more information about the late enrollment
penalty.
• When will your membership end? Your membership will end when your new plan's
coverage begins on January 1.
Section 2.2 In certain situations, you can end your membership during a
Special Enrollment Period
In certain situations, members of EnvisionRxPlus Employer Group Retiree PDP may be
eligible to end their membership at other times of the year. This is known as a Special
Enrollment Period.
• Who is eligible for a Special Enrollment Period? If any of the following situations
apply to you, you are eligible to end your membership during a Special Enrollment
Period. These are just examples, for the full list you can contact the plan, call Medicare,
or visit the Medicare website (https: / /www.medicare.gov):
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o If you have moved out of your plan's service area.
o If you have Medicaid.
o If you are eligible for "Extra Help" with paying for your Medicare prescriptions.
o If we violate our contract with you.
o If you are getting care in an institution, such as a nursing home or long -term care
(LTC) hospital.
o If you enroll in the Program of All- inclusive Care for the Elderly (PACE). PACE
is not available in all states. If you would like to know if PACE is available in
your state, please contact Member Services (phone numbers are printed on the
back cover of this booklet).
• When are Special Enrollment Periods? The enrollment periods vary depending on your
situation.
• What can you do? To fmd out if you are eligible for a Special Enrollment Period, please
call Medicare at 1- 800 - MEDICARE (1- 800 - 633- 4227), 24 hours a day, 7 days a week.
TTY users call 1- 877 - 486 -2048. If you are eligible to end your membership because of a
special situation, you can choose to change both your Medicare health coverage and
prescription drug coverage. This means you can choose any of the following types of
plans:
o Another Medicare prescription drug plan.
o Original Medicare without a separate Medicare prescription drug plan.
• If you receive "Extra Help" from Medicare to pay for your
prescription drugs: If you switch to Original Medicare and do not enroll
in a separate Medicare prescription drug plan, Medicare may enroll you in
a drug plan, unless you have opted out of automatic enrollment.
o — or — A Medicare health plan. A Medicare health plan is a plan offered by a
private company that contracts with Medicare to provide all of the Medicare Part
A (Hospital) and Part B (Medical) benefits. Some Medicare health plans also
include Part D prescription drug coverage.
• If you enroll in most Medicare health plans, you will automatically be
disenrolled from EnvisionRxPlus Employer Group Retiree PDP when
your new plan's coverage begins. However, if you choose a Private Fee -
for- Service plan without Part D drug coverage, a Medicare Medical
Savings Account plan, or a Medicare Cost Plan, you can enroll in that plan
and keep EnvisionRxPlus Employer Group Retiree PDP for your drug
coverage. If you do not want to keep our plan, you can choose to enroll in
another Medicare prescription drug plan or to drop Medicare prescription
drug coverage.
Note: If you disenroll from Medicare prescription drug coverage and go without
creditable prescription drug coverage for a continuous period of 63 days or more, you
may need to pay a Part D late enrollment penalty if you join a Medicare drug plan later.
( "Creditable" coverage means the coverage is expected to pay, on average, at least as
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Chapter 8. Ending your membership in the plan
much as Medicare's standard prescription drug coverage.) See Chapter 1, Section 5 for
more information about the late enrollment penalty.
• When will your membership end? Your membership will usually end on the first day of
the month after we receive your request to change your plan.
Section 2.3 Where can you get more information about when you can end
your membership?
If you have any questions or would like more information on when you can end your
membership:
• You can call your Group Benefit Administrator or Human Resources.
• You can fmd the information in the Medicare & You 2018 Handbook.
o Everyone with Medicare receives a copy of Medicare & You each fall. Those new
to Medicare receive it within a month after first signing up.
o You can also download a copy from the Medicare website
(https: / /www.medicare.gov). Or, you can order a printed copy by calling
•
Medicare at the number below.
• You can contact Medicare at 1- 800 - MEDICARE (1- 800 - 633 - 4227), 24 hours a day,
7 days a week. TTY users should call 1- 877 - 486 -2048.
SECTION 3 How do you end your membership in our plan?
Section 3.1 Usually, you end your membership by enrolling in another
plan
Usually, to end your membership in our plan, you simply enroll in another Medicare plan during
one of the enrollment periods (see Section 2 in this chapter for information about the enrollment
periods). However, there are two situations in which you will need to end your membership in a
different way:
• If you want to switch from our plan to Original Medicare without a Medicare prescription
drug plan, you must ask to be disenrolled from our plan.
• If you join a Private Fee - for - Service plan without prescription drug coverage, a Medicare
Medical Savings Account Plan, or a Medicare Cost Plan, enrollment in the new plan will
not end your membership in our plan. In this case, you can enroll in that plan and keep
EnvisionRxPlus Employer Group Retiree PDP for your drug coverage. If you do not
want to keep our plan, you can choose to enroll in another Medicare prescription drug
plan or ask to be disenrolled from our plan.
•
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If you are in one of these two situations and want to leave our plan, there are two ways you can
ask to be disenrolled:
• You can make a request in writing to your Group Benefit Administrator or Human
Resources. Contact Member Services if you need more information on how to do this
(phone numbers are printed on the back cover of this booklet).
• --or--You can contact Medicare at 1-800-MEDICARE (1-800-633-4227), 24 hours a day,
7 days a week. TTY users should call 1-877-486-2048.
Note: If you disenroll from Medicare prescription drug coverage and go without creditable
prescription drug coverage, you may need to pay a Part D late enrollment penalty if you join a
Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on
average, at least as much as Medicare's standard prescription drug coverage.) See Chapter 1,
Section 5 for more information about the late enrollment penalty.
The table below explains how you should end your membership in our plan.
If you would like to switch from
our plan to: This is what you should do:
• Another Medicare prescription • Enroll in the new Medicare prescription drug plan
drug plan. between October 15 and December 7.
You will automatically be disenrolled from
EnvisionRxPlus Employer Group Retiree PDP
when your new plan's coverage begins.
• A Medicare health plan. • Enroll in the Medicare health plan. With most Medicare
health plans,you will automatically be disenrolled from
EnvisionRxPlus Employer Group Retiree PDP
when your new plan's coverage begins.
If you want to leave our plan,you must either enroll in
another Medicare prescription drug plan or ask to be
disenrolled. To ask to be disenrolled, you must send a
written request to your Group Benefit
Administrator or Human Resources or contact
Medicare at 1-800-MEDICARE(1-800-633-4227),24
hours a day, 7 days a week(TTY users should call 1-
877-486-2048).
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Chapter 8. Ending your membership in the plan
7106,
P If you would like to switch from
our plan to: This is what you should do:
• Original Medicare without a • Send a written request to your Group Benefit
separate Medicare prescription Administrator or Human Resources to disenroll.
drug plan. Contact Member Services if you need more information
Note: If you disenroll from a on how to do this(phone numbers are printed on the
Medicare prescription drug plan back cover of this booklet).
and go without creditable • You can also contact Medicare at 1-800-MEDICARE
prescription drug coverage,you (1-800-633-4227),24 hours a day, 7 days a week, and
may need to pay a late enrollment ask to be disenrolled. TTY users should call 1-877-486-
penalty if you join a Medicare drug 2048.
plan later. See Chapter 1, Section 5
for more information about the late
enrollment penalty.
SECTION 4 Until your membership ends, you must keep getting
your drugs through our plan
Section 4.1 Until your membership ends, you are still a member of our
plan
If you leave EnvisionRxPlus Employer Group Retiree PDP, it may take time before your
membership ends and your new Medicare coverage goes into effect. (See Section 2 for
information on when your new coverage begins.) During this time, you must continue to get your
prescription drugs through our plan.
• You should continue to use our network pharmacies to get your prescriptions filled
until your membership in our plan ends. Usually, your prescription drugs are only
covered if they are filled at a network pharmacy including through our mail-order
pharmacy services.
SECTION 5 EnvisionRxPlus Employer Group Retiree PDP must
end your membership in the plan in certain situations
Section 5.1 When must we end your membership in the plan?
EnvisionRxPlus Employer Group Retiree PDP must end your membership in the plan if
any of the following happen:
• If you no longer have Medicare Part A or Part B (or both).
• If you move out of our service area.
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• If you are away from our service area for more than 12 months.
o If you move or take a long trip, you need to call Member Services to find out if
the place you are moving or traveling to is in our plan's area. (Phone numbers for
Member Services are printed on the back cover of this booklet.)
• If you become incarcerated (go to prison).
• If you are not a United States citizen or lawfully present in the United States.
• If you lie about or withhold information about other insurance you have that provides
prescription drug coverage.
• If you intentionally give us incorrect information when you are enrolling in our plan and
that information affects your eligibility for our plan. (We cannot make you leave our plan
for this reason unless we get permission from Medicare first.)
• If you continuously behave in a way that is disruptive and makes it difficult for us to
provide care for you and other members of our plan. (We cannot make you leave our plan
for this reason unless we get permission from Medicare first.)
• If you let someone else use your membership card to get prescription drugs. (We cannot
make you leave our plan for this reason unless we get permission from Medicare first.)
o If we end your membership because of this reason, Medicare may have your case
investigated by the Inspector General.
• If you do not pay the plan premiums for 60 consecutive days.
o We must notify you in writing that you have 60 consecutive days (2 calendar
months) to pay the plan premium before we end your membership.
• If you are required to pay the extra Part D amount because of your income and you do not
pay it, Medicare will disenroll you from our plan and you will lose prescription drug
coverage.
Where can you get more information?
If you have questions or would like more information on when we can end your. membership:
• You can call Member Services for more information (phone numbers are printed on the
back cover of this booklet).
Section 5.2 We cannot ask you to leave our plan for any reason related to
your health
EnvisionRxPlus Employer Group Retiree PDP is not allowed to ask you to leave our plan for
any reason related to your health.
•
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Chapter 8. Ending your membership in the plan
What should you do if this happens?
If you feel that you are being asked to leave our plan because of a health - related reason, you
should call Medicare at 1- 800 - MEDICARE (1- 800 - 633 - 4227). TTY users should call 1 -877-
486 -2048. You may call 24 hours a day, 7 days a week.
Section 5.3 You have the right to make a complaint if we end your
membership in our plan
If we end your membership in our plan, we must tell you our reasons in writing for ending your
membership. We must also explain how you file a grievance or can make a complaint about our
decision to end your membership. You can also look in Chapter 7, Section 7 for information
about how to make a complaint.
CHAPTERS
Legal notices
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Chapter 9. Legal notices
SECTION 1 Notice about governing law 127
SECTION 2 Notice about non- discrimination 127
SECTION 3 Notice about Medicare Secondary Payer subrogation rights 128
SECTION 4 Notice about third -party liability 128
SECTION 5 Notice of Privacy Practice 129
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Chapter 9. Legal notices
SECTION 1 Notice about governing law
Many laws apply to this Evidence of Coverage and some additional provisions may apply
because they are required by law. This may affect your rights and responsibilities even if the
laws are not included or explained in this document. The principal law that applies to this
document is Title XVIII of the Social Security Act and the regulations created under the Social
Security Act by the Centers for Medicare & Medicaid Services, or CMS. In addition, other
Federal laws may apply and, under certain circumstances, the laws of the state you live in.
SECTION 2 Notice about non - discrimination
We don't discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age,
mental or physical disability, health status, claims experience, medical history, genetic
information, evidence of instability, or geographic location. All organizations that provide
Medicare prescription drug plans, like our plan, must obey Federal laws against discrimination,
including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age
Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable
Care Act, all other laws that apply to organizations that get Federal funding, and any other laws
and rules that apply for any other reason.
EnvisionRxPlus:
• Provides free aids and services to people with disabilities to communicate effectively
with us, such as:
o Written information in other formats (large print and accessible electronic formats)
• Provides free language services to people whose primary language is not English, such
as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact Member Services.
If you believe that EnvisionRxPlus has failed to provide these services or discriminated in
another way on the basis of race, color, national origin, age, disability, or sex, you can file a
grievance with: EnvisionRxPlus, mailing address: 2181 E. Aurora Rd, Ste. 201, Twinsburg, OH,
44087, Member Services: 1- 844 - 293 -4760, TTY: 711, fax: 1- 866 - 250 -5178. If you need help
filing a grievance, Member Services is available to help you. You can also file a civil rights
complaint with the U.S. Department of Health and Human Services, Office for Civil Rights
electronically through the Office for Civil Rights Complaint Portal, available at
https://ocrportahhs.gov/oceportal/lobbyjsf, or by mail or phone at: U.S. Department of Health
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and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington,
DC 20201, 1- 800 - 368 -1019, 800 -537 -7697 (TDD).
Complaint forms are available at http: / /www.hhs.gov /ocr /office /file /index.html.
SECTION 3 Notice about Medicare Secondary Payer subrogation
rights
We have the right and responsibility to collect for covered Medicare prescription drugs for which
Medicare is not the primary payer. According to CMS regulations at 42 CFR sections 422.108
and 423.462, EnvisionRxPlus Employer Group Retiree PDP, as a Medicare prescription drug
plan sponsor, will exercise the same rights of recovery that the Secretary exercises under CMS
regulations in subparts B through D of part 411 of 42 CFR and the rules established in this
section supersede any State laws.
SECTION 4 Notice about third -party liability
Right of Subrogation
You explicitly acknowledge EnvisionRxPlus's Right of Subrogation. When EnvisionRxPlus
provides prescription drug benefits for injuries or illnesses for which another party is or may be
responsible, EnvisionRxPlus shall be subrogated to your rights of recovery against any party to
the extent of the full cost of all benefits provided by EnvisionRxPlus and may proceed against
any party with or without your consent. This means that if prescription drug benefits are
provided to you by EnvisionRxPlus for injuries or illness for which another party is or may be
responsible, then EnvisionRxPlus reserves the right to obtain reimbursement from such other
party for the full cost of all prescription drug benefits provided by EnvisionRxPlus on your
behalf that are associated with the injury or illness.
Right of Reimbursement
You explicitly acknowledge EnvisionRxPlus's Right of Reimbursement. This means that if
prescription drug benefits are provided to you by EnvisionRxPlus for injuries or illness for
which another party is or may be responsible and you and/or your representative has recovered
any amounts from another party or any party making payments on the party's behalf, then
EnvisionRxPlus is hereby granted an assignment of the proceeds of any settlement, judgment or
other payment received by you to the extent of the full cost of all benefits provided by
EnvisionRxPlus. This Right of Reimbursement is cumulative with and not exclusive of
EnvisionRxPlus's Right of Subrogation, and EnvisionRxPlus may choose to exercise either or
both rights of recovery.
Cooperation with EnvisionRxPlus
You and your legal representatives agree to fully cooperate with EnvisionRxPlus in its efforts to
recover the cost of all benefits provided by EnvisionRxPlus that is the responsibility of another
party. It is your duty to notify EnvisionRxPlus within thirty (30) days of the date you provide
notice to any party, including an insurance company or an attorney, of your intention to pursue or
investigate a claim to recover damages or obtain compensation for your injury or illness. You
and your agents or representatives agree to provide EnvisionRxPlus all information requested by
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Chapter 9. Legal notices
EnvisionRxPlus. You agree to do nothing to prejudice EnvisionRxPlus's Right of
Reimbursement or Subrogation or its ability to enforce the terms of this section.
SECTION 5 Notice of Privacy Practice
This Notice of Privacy Practices applies to Envision Insurance Company's Medicare Part D
Prescription Drug Plans ("EnvisionRxPlus"). EnvisionRxPlus is a PDP with a Medicare
contract. Enrollment in EnvisionRxPlus depends on contract renewal.
Para recibir esta notificacion en espafiol por favor llamar al numeeo gratuito de Servicios a
Miembros a 1- 844 - 293 -4760 (Los usuarios de TTY/TDD deben llamar al 711). El horario es 24
horas del dia, 7 dias a la semana.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW IT CAREFULLY.
This notice describes how we may use and disclose information about you in administering your
benefits, and it explains your legal rights regarding the information. When we use the term
personal health information, we mean information that identifies you as an individual, such as your
name, date of birth, or Social Security number and relates to your medical history, the health care
you receive, or payment for health care services.
How EnvisionRxPlus Uses and Discloses Personal Information.
In order to provide you with insurance coverage, we need personal information about you, and we
obtain that information from many different sources, including Medicare. In administering your
pharmacy benefits, we may use and disclose your personal information in various ways, including:
Treatment. We may use and disclose your personal health information to doctors, dentists,
pharmacies, hospitals and health care providers in furtherance of your care. For example, we may
disclose information to the pharmacies where you receive covered medications.
Payment. We may use and disclose your personal health information to manage your pharmacy
benefits, such as collecting premiums and calculating cost - sharing amounts. For example, we may
use your health information to pay the pharmacies that fill your prescriptions.
Operations. We may use and disclose your personal health information to assess and improve
quality, license and accredit companies, measure service performance and assess outcomes,
determine formulary compliance, provide care management, and respond to complaints and
appeals. For example, we may use the information to provide medication therapy management
programs for members with specific medical conditions, such as diabetes. We may use and
disclose information for the administration of reinsurance, underwriting and rating, detection and
investigation of fraud, waste, and abuse, administration of pharmaceutical services and payments,
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and other general administrative activities. We may use your information, with the exception of
genetic information, for underwriting purposes.
To Others Involved in Your Health Care. We may disclose your personal health information to
a relative, a close friend, or any other person involved in your care, provided the information is
directly relevant to that person's involvement with your health care or payment for that care. For
example, if a family member or a caregiver calls us with prior knowledge of a claim, we may
confirm whether or not the claim has been received and paid. You have the right to stop or limit
this kind of disclosure by calling Member Services toll -free at 1- 844 - 293 -4760 (TTY/TDD users
should call 711). Hours are 24 hours a day, 7 days a week.
Business Associates. We enter into contracts with third parties known as business associates.
These business associates provide services to us or perform functions on our behalf, e.g.,
accountants, consultants and attorneys. We may disclose your health information to our business
associates once they have agreed in writing to safeguard your health information. Business
associates are also required by law to secure and protect the privacy of your health information.
Special Circumstances. We may use or disclose your personal health information without your
authorization in the following circumstances: for any purpose when required by law; for public
health activities; to certain government authorities if we reasonably believe you are a victim of
abuse, neglect or domestic violence; for health oversight activities; to avert a serious threat to your
health and safety or the health and safety of the public or another person; for investigations or civil
proceedings; if required by a court or administrative tribunal or in response to a subpoena,
discovery request or other lawful process under certain circumstances; to law enforcement in
limited circumstances; to coroners, medical examiners, and funeral directors or to organizations
that handle organ and tissue donation or transplantation consistent with law; for certain specially -
approved research projects; for specialized government functions (such as military, national
security or intelligence activities or to correctional institutions); for disaster relief efforts; or to
workers' compensation agencies if necessary to make a benefit determination.
Uses and Disclosures Requiring Your Written Authorization.
In all situations other than those described above, we will ask for your written authorization before
using or disclosing your personal health information. For example, we will seek your authorization
for (i) most uses or disclosures of psychotherapy notes (ii) uses or disclosures of your personal
health information for marketing purposes (iii) disclosures of your personal health information that
constitute the sale of your health information. If you have given us an authorization, you may
revoke it at any time, if we have not already acted on it.
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Your Legal Rights.
Federal regulations concerning the privacy and security of personal health information give you
the right to make certain requests regarding your personal health information. By law, you have
the right to:
• See and get a copy of your personal health information held by EnvisionRxPlus. If we
maintain an electronic health record containing your personal health information, you have
the right to ask to get the information in an electronic format. If we are not able to provide
your personal health information in the electronic format you request, we will provide it in a
mutually agreed upon electronic format. You may ask us to send a copy of your information
to other individuals or entities that you designate. We may deny your request to inspect and
copy in certain limited circumstances. If you are denied access to your information, you may
request that the denial be reviewed.
• Request an amendment of your information. If you feel that the personal health
information we maintain about you is incomplete or incorrect, you may request that we
amend it. You must include a reason that supports your request. If we deny your request for
an amendment, we will provide you with a written explanation of why we denied it.
• Get a list of those who received your personal health information from EnvisionRxPlus.
Except for certain disclosures, you have a right to receive a list of the disclosures we have
made of your personal health information in the six years prior to the date of your request.
The list will not include disclosures of your personal health information to you or your
personal representative or for treatment, payment or operations reasons.
• Ask EnvisionRxPlus to communicate with you in a different manner or at a different
place (for example, you may ask us to send materials to a P.O. Box instead of your home
address).
• Ask EnvisionRxPlus to restrict or limit how we use or disclose your personal health
information. You have the right to request restrictions on our use or disclosure of your
information. We are not required to agree to the restrictions, except in the case where the
disclosure is to a health plan for purposes of carrying out payment or health care operations,
is not otherwise required by law, and the information pertains solely to a health care item or
service for which you, or a person on your behalf, has paid in full.
• Receive a notice of a breach of certain health information. We are required to notify you
of any breach that involves your unsecure personal health information.
• Get a separate paper copy of this notice. You can ask for a paper copy of this notice at any
time, even if you have agreed to receive the notice electronically.
You may make any of the requests described above, or may request a paper copy of this notice,
by calling Member Services toll-free at 1 -844- 293 -4760 (TTY/TDD users should call 711).
Hours are 24 hours a day, 7 days a week.
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How to File a Complaint.
You also have the right to file a complaint if you think your privacy rights have been violated.
To do so, please send your inquiry to the following address: EnvisionRxPlus, 2181 E. Aurora
Rd., Suite 201, Twinsburg, OH 44087, Attn: Privacy Officer. You also may write to the U.S.
Department of Health and Human Services, Office for Civil Rights, 200 Independence Ave.
S.W., Room 509F HHH Bldg., Washington DC 20201 (OCRComplaint @hhs.gov). You will not
be retaliated against for filing a complaint and your benefits under the Plan will not be adversely
affected by doing so.
Legal Obligations of EnvisionRxPlus.
Federal privacy regulations require us to keep your personal health information private, to give
you notice of our legal duties and privacy practices, and to follow the terms of the notice currently
in effect. Please note that we do not destroy your personal health information when you terminate
your coverage with us. It may be necessary to use and disclose this information for the purposes
described above even after your coverage terminates, although policies and procedures will remain
in place to protect against inappropriate use or disclosure.
State Privacy Laws. Some state privacy laws may give you greater protection than those
described in this notice. Depending on the state in which you live, there may be additional laws
regarding the use and disclosure of health information such as that related to genetics,
HIV /AIDS, mental health, sexually transmitted diseases, and substance abuse. For more
information, please contact the EnvisionRxPlus Privacy Officer:
EnvisionRx Plus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
Attn: Privacy Officer
This Notice is Subject to Change.
This notice is being provided to you herein and is also posted on our website. We may change the
terms of this notice and our privacy policies at any time. If we do change the terms of this notice,
the revised notice will be available upon request and posted to our website. The new terms will be
effective for all of the information that we already have about you, as well as any information that
we may receive or hold in the future.
If you have questions regarding this notice, please contact Member Services toll -free at 1 -844-
293 -4760 (TTY /TDD users should call 711). Hours are 24 hours a day, 7 days a week. Please
include your name, phone number, and fax number.
The original version of this notice went into effect on September 10, 2009. The effective date of
this notice is August 2, 2017.
CHAPTER 10
Definitions of important words
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Chapter 10. Definitions of important words
Chapter 10. Definitions of important words
Another Party - Any individual or entity, other than EnvisionRxPlus, that is liable or legally
responsible to pay expenses, compensation or damages in connection with a beneficiary's
injuries or illnesses. Another Party shall include the party or parties who caused the injuries or
illness (first or third parties); the insurer, guarantor or other indemnifier of the party or parties
who caused the injuries or illness; a beneficiary's own insurer, such as uninsured, underinsured,
pharmacy payments, no- fault, homeowner's, renter's, or any other liability insurer; a workers'
compensation insurer; a pharmacy malpractice or similar fund; and any other person,
corporation, or entity that is liable or legally responsible for payment in connection with the
injuries or illness.
Advance Directive — A legal document that controls critical decisions about your health care.
You also have the right to give instructions for health care providers to follow if you become
unable to direct your own care, an Advance Directive can be used in these circumstances.
Appeal — An appeal is something you do if you disagree with our decision to deny a request for
coverage of prescription drugs or payment for drugs you already received. For example, you may
ask for an appeal if we don't pay for a drug you think you should be able to receive. Chapter 7
explains appeals, including the process involved in making an appeal.
Annual Enrollment Period — A set time each fall when members can change their health or
drug plans or switch to Original Medicare. The Annual Enrollment Period is from October 15
until December 7.
Brand Name Drug — A prescription drug that is manufactured and sold by the pharmaceutical
company that originally researched and developed the drug. Brand name drugs have the same
active - ingredient formula as the generic version of the drug. However, generic drugs are
manufactured and sold by other drug manufacturers and are generally not available until after the
patent on the brand name drug has expired.
Catastrophic Coverage Stage — The stage in the Part D Drug Benefit where you pay a low
copayment or coinsurance for your drugs after you or other qualified parties on your behalf have
spent $5,000 in covered drugs during the covered year.
Centers for Medicare & Medicaid Services (CMS) — The Federal agency that administers
Medicare. Chapter 2 explains how to contact CMS.
Coinsurance — An amount you may be required to pay as your share of the cost for prescription
drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20 %).
Complaint — The formal name for "making a complaint" is "filing a grievance." The complaint
process is used for certain types of problems only. This includes problems related to quality of
care, waiting times, and the customer service you receive. See also "Grievance," in this list of
definitions.
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Chapter 10. Definitions of important words
Copayment (or "copay ") — An amount you may be required to pay as your share of the cost for
a prescription drug. A copayment is a set amount, rather than a percentage. For example, you
might pay $10 or $20 for a prescription drug.
Cost - sharing — Cost - sharing refers to amounts that a- member has to pay when drugs are
received. (This is in addition to the plan's monthly premium, if applicable.) Cost - sharing
includes any combination of the following three types of payments: (1) any deductible amount a
plan may impose before drugs are covered; (2) any fixed "copayment" amount that a plan
requires when a specific drug is received; or (3) any "coinsurance" amount, a percentage of the
total amount paid for a drug, that a plan requires when a specific drug is received. A "daily cost -
sharing rate" may apply when your doctor prescribes less than a full month's supply of certain
drugs for you and you are required to pay a copayment.
Cost - Sharing Tier — Every drug on the list of covered drugs is in one of 5 cost - sharing tiers. In
general, the higher the cost - sharing tier, the higher your cost for the drug.
Coverage Determination — A decision about whether a drug prescribed for you is covered by
the plan and the amount, if any, you are required to pay for the prescription. In general, if you
bring your prescription to a pharmacy and the pharmacy tells you the prescription isn't covered
under your plan, that isn't a coverage determination. You need to call or write to your plan to ask
for a formal decision about the coverage. Coverage determinations are called "coverage
decisions" in this booklet. Chapter 7 explains how to ask us for a coverage decision.
Covered Drugs — The term we use to mean all of the prescription drugs covered by our plan.
Creditable Prescription Drug Coverage — Prescription drug coverage (for example, from an
employer or union) that is expected to pay, on average, at least as much as Medicare's standard
prescription drug coverage. People who have this kind of coverage when they become eligible
for Medicare can generally keep that coverage without paying a penalty, if they decide to enroll
in Medicare prescription drug coverage later.
Daily cost - sharing rate — A "daily cost - sharing rate" may apply when your doctor prescribes
less than a full month's supply of certain drugs for you and you are required to pay a copayment.
A daily cost - sharing rate is the copayment divided by the number of days in a month's supply.
Here is an example: If your copayment for a one -month supply of a drug is $30, and a one-
month's supply in your plan is 30 days, then your "daily cost - sharing rate" is $1 per day. This
means you pay $1 for each day's supply when you fill your prescription.
Deductible — The amount you must pay for prescriptions before our plan begins to pay.
Disenroll or Disenrollment — The process of ending your membership in our plan.
Disenrollment may be voluntary (your own choice) or involuntary (not your own choice).
Dispensing Fee — A fee charged each time a covered drug is dispensed to pay for the cost of
filling a prescription. The dispensing fee covers costs such as the pharmacist's time to prepare
and package the prescription.
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Chapter 10. Definitions of important words
Emergency — A medical emergency is when you, or any other prudent layperson with an
average knowledge of health and medicine, believe that you have medical symptoms that require
immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb.
The medical symptoms may be an illness, injury, severe pain, or a medical condition that is
quickly getting worse.
Evidence of Coverage (EOC) and Disclosure Information — This document, along with your
enrollment form and any other attachments, riders, or other optional coverage selected, which
explains your coverage, what we must do, your rights, and what you have to do as a member of
our plan.
Exception — A type of coverage determination that, if approved, allows you to get a drug that is
not on your plan sponsor's formulary (a formulary exception), or get a non - preferred drug at a
lower cost - sharing level (a tiering exception). You may also request an exception if your plan
sponsor requires you to .try another drug before receiving the drug you are requesting, or the plan
limits the quantity or dosage of the drug you are requesting (a formulary exception).
Extra Help — A Medicare program to help people with limited income and resources pay
Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance.
Generic Drug — A prescription drug that is approved by the Food and Drug Administration
(FDA) as having the same active ingredient(s) as the brand name drug. Generally, a "generic"
drug works the same as a brand name drug and usually costs less.
Grievance — A type of complaint you make about us or one of our network pharmacies,
including a complaint concerning the quality of your care. This type of complaint does not
involve coverage or payment disputes.
Income Related Monthly Adjustment Amount (IRMAA) — If your income is above a certain
limit, you will pay an income - related monthly adjustment amount in addition to your plan
premium. For example, individuals with income greater than $85,000 and married couples with
income greater than $170,000 must pay a higher Medicare Part B (medical insurance) and
Medicare prescription drug coverage premium amount. This additional amount is called the
income- related monthly adjustment amount. Less than 5% of people with Medicare are affected,
so most people will not pay a higher premium.
Initial Coverage Limit — The maximum limit of coverage under the Initial Coverage Stage.
Initial Coverage Stage — This is the stage before your total drug costs including amounts you
have paid and what your plan has paid on your behalf for the year have reached $3,750
Initial Enrollment Period — When you are first eligible for Medicare, the period of time when
you can sign up for Medicare Part A and Part B. For example, if you're eligible for Medicare
when you turn 65, your Initial Enrollment Period is the 7 -month period that begins 3 months
before the month you turn 65, includes the month you turn 65, and ends 3 months after the month
you turn 65.
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Chapter 10. Definitions of important words
List of Covered Drugs (Formulary or "Drug List ") — A list of prescription drugs covered by
the plan. The drugs on this list are selected by the plan with the help of doctors and pharmacists.
The list includes both brand name and generic drugs.
Low Income Subsidy (LIS) — See "Extra Help."
Medicaid (or Medical Assistance) — A joint Federal and state program that helps with medical
costs for some people with low incomes and limited resources. Medicaid programs vary from
state to state, but most health care costs are covered if you qualify for both Medicare and
Medicaid. See Chapter 2, Section 6 for information about how to contact Medicaid in your state.
Medically Accepted Indication — A use of a drug that is either approved by the Food and Drug
Administration or supported by certain reference books. See Chapter 3, Section 3 for more
information about a medically accepted indication.
Medicare — The Federal health insurance program for people 65 years of age or older, some
people under age 65 with certain disabilities, and people with End -Stage Renal Disease
(generally those with permanent kidney failure who need dialysis or a kidney transplant). People
with Medicare can get their Medicare health coverage through Original Medicare, a Medicare
Cost Plan, a PACE plan, or a Medicare Advantage Plan.
Medicare Advantage (MA) Plan — Sometimes called Medicare Part C. A plan offered by a
private company that contracts with Medicare to provide you with all your Medicare Part A and
Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee - for - Service
(PFFS) plan, or a Medicare Medical Savings Account (MSA) plan. If you are enrolled in a
Medicare Advantage Plan, Medicare services are covered through the plan, and are not paid for
under Original Medicare. In most cases, Medicare Advantage Plans also offer Medicare Part D
(prescription drug coverage). These plans are called Medicare Advantage Plans with
Prescription Drug Coverage. Everyone who has Medicare Part A and Part B is eligible to join
any Medicare health plan that is offered in their area, except people with End -Stage Renal
Disease (unless certain exceptions apply).
Medicare Cost Plan — A Medicare Cost Plan is a plan operated by a Health Maintenance
Organization (HMO) or Competitive Medical Plan (CMP) in accordance with a cost - reimbursed
contract under section 1876(h) of the Act.
Medicare Coverage Gap Discount Program — A program that provides discounts on most
covered Part D brand name drugs to Part D members who have reached the Coverage Gap Stage
and who are not already receiving "Extra Help." Discounts are based on agreements between the
Federal government and certain drug manufacturers. For this reason, most, but not all, brand
name drugs are discounted.
Medicare - Covered Services — Services covered by Medicare Part A and Part B.
Medicare Health Plan — A Medicare health plan is offered by a private company that contracts
with Medicare to provide Part A and Part B benefits to people with Medicare who enroll in the
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Chapter 10. Definitions of important words
plan. This term includes all Medicare Advantage Plans, Medicare Cost Plans,
Demonstration/Pilot Programs, and Programs of All- inclusive Care for the Elderly (PACE).
Medicare Prescription Drug Coverage (Medicare Part D) — Insurance to help pay for
outpatient prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare
Part AorPart B.
"Medigap" (Medicare Supplement Insurance) Policy — Medicare supplement insurance sold
by private insurance companies to fill "gaps" in Original Medicare. Medigap policies only work
with Original Medicare. (A Medicare Advantage Plan is not a Medigap policy.)
Member (Member of our Plan, or "Plan Member ") — A person with Medicare who is eligible
to get covered services, who has enrolled in our plan and whose enrollment has . been confirmed
by the Centers for Medicare & Medicaid Services (CMS).
Member Services — A department within our plan responsible for answering your questions
about your membership, benefits, grievances, and appeals. See Chapter 2 for information about
how to contact Member Services.
Network Pharmacy — A network pharmacy is a pharmacy where members of our plan can get
their prescription drug benefits. We call them "network pharmacies" because they contract with
our plan. In most cases, your prescriptions are covered only if they are filled at one of our
network pharmacies.
Original Medicare ( "Traditional Medicare" or "Fee- for - service" Medicare) — Original Medicare
is offered by the government, and not a private health plan like Medicare Advantage Plans and
prescription drug plans. Under Original Medicare, Medicare services are covered by paying
doctors, hospitals, and other health care providers payment amounts established by Congress.
You can see any doctor, hospital, or other health care provider that accepts Medicare. You must
pay the deductible. Medicare pays its share of the Medicare - approved amount, and you pay your
share. Original Medicare has two parts: Part A (Hospital Insurance) and Part B (Medical
Insurance) and is available everywhere in the United States.
Out-of-Network Pharmacy — A pharmacy that doesn't have a contract with our plan to
coordinate or provide covered drugs to members of our plan. As explained in this Evidence of
Coverage, most drugs you get from out -of- network pharmacies are not covered by our plan
unless certain conditions apply.
Out -of- Pocket Costs — See the definition for "cost- sharing" above. A member's cost - sharing
requirement to pay for a portion of drugs received is also referred to as the member's "out -of-
pocket" cost requirement.
PACE plan — A PACE (Program of All - Inclusive Care for the Elderly) plan combines medical,
social, and long -term care (LTC) services for frail people to help people stay independent and
living in their community (instead of moving to a nursing home) as long as possible, while
getting the high- quality care they need. People enrolled in PACE plans receive both their
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 139
Chapter 10. Definitions of important words
Medicare and Medicaid benefits through the plan. PACE is not available in all states. If you
would like to know if PACE is available in your state, please contact Member Services (phone
numbers are printed on the back cover of this booklet).
Part C — see "Medicare Advantage (MA) Plan."
Part D — The voluntary Medicare Prescription Drug Benefit Program. (For ease of reference, we
will refer to the prescription drug benefit program as Part D.)
Part D Drugs — Drugs that can be covered under Part D. We may or may not offer all Part D
drugs. (See your formulary for a specific list of covered drugs.) Certain categories of drugs were
specifically excluded by Congress from being covered as Part D drugs.
Part D Late Enrollment Penalty — An amount added to your monthly premium for Medicare
drug coverage if you go without creditable coverage (coverage that is expected to pay, on
average, at least as much as standard Medicare prescription drug coverage) for a continuous
period of 63 days or more. You pay this higher amount as long as you have a Medicare drug
plan. There are some exceptions. For example, if you receive "Extra Help" from Medicare to pay
your prescription drug plan costs, the late enrollment penalty rules do not apply to you. If you
receive "Extra Help," you do not pay a late enrollment penalty.
Premium — The periodic payment to Medicare, an insurance company, or a health care plan for
health or prescription drug coverage.
Prior Authorization — Approval in advance to get certain drugs that may or may not be on our
formulary. Some drugs are covered only if your doctor or other network provider gets "prior
authorization" from us. Covered drugs that need prior authorization are marked in the formulary.
Quality Improvement Organization (QIO) — A group of practicing doctors and other health
care experts paid by the Federal government to check and improve the care given to Medicare
patients. See Chapter 2, Section 4 for information about how to contact the QIO for your state.
Quantity Limits — A management tool that is designed to limit the use of selected drugs for
quality, safety, or utilization reasons. Limits may be on the amount of the drug that we cover per
prescription or for a defined period of time.
Recovery - Any and all money, fund, property, compensation, as well as all rights thereto, or
damages paid or available to the beneficiary's by Another Party through insurance payments,
settlement proceeds, first or third party payments or settlement proceeds, judgments,
reimbursements or otherwise (no matter how those monies may be characterized, designated, or
allocated) to compensate for any losses caused by, or in connection with, the injuries or illness.
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 140
Chapter 10. Definitions of important words
Reimbursement / Reimburse - Repayment to EnvisionRxPlus for pharmacy or other benefits
paid or payable toward care and treatment of the illness or injury and for any other expenses
incurred by EnvisionRxPlus in connection with benefits paid or payable.
Service Area — A geographic area where a prescription drug plan accepts members if it limits
membership based on where people live. The plan may disenroll you if you permanently move
out of the plan's service area.
Special Enrollment Period — A set time when members can change their health or drug plans or
return to Original Medicare. Situations in which you may be eligible for a Special Enrollment
Period include: if you move outside the service area, if you are getting "Extra Help" with your
prescription drug costs, if you move into a nursing home, or if we violate our contract with you.
Step Therapy — A utilization tool that requires you to first try another drug to treat your medical
condition before we will cover the drug your physician may have initially prescribed.
Supplemental Security Income (SSI) — A monthly benefit paid by Social Security to people
with limited income and resources who are disabled, blind, or age 65 and older. SSI benefits are
not the same as Social Security benefits.
Subrogation / Subrogate - EnvisionRxPlus's right to pursue the beneficiary's claims against
Another Party for pharmacy or other charges paid by EnvisionRxPlus.
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 141
Appendices
Appendix A - State Health Insurance Assistance Programs
Alabama Alaska Arizona Arkansas
Alabama Dept. of Senior Medicare Information Arizona State Health Senior Health Insurance
Services Office Insurance Assistance Information Program (SHIIP)
201 Monroe St., Ste. 350 400 Gambell St. Program (SHIP) 1200 W 3rd St.
Montgomery, AL 36104 Anchorage, AK 99501 1789 W. Jefferson St. Little Rock, AR 72201.
Phone: (800) 243 -5463 Phone: (800) 478 -6065 #950a Phone: (800) 224 -6330
TTY: (800) 243 -5463 TTY: (800) 770 -8973 Phoenix, AZ 85007 TTY: (501) 683 -4468
Phone: (800) 432 -4040
TTY: 711
California Colorado Connecticut Delaware
Health Insurance Counseling Senior Health Insurance CHOICES ELDERinfo
and Advocacy Program Assistance Program 55 Farmington Ave., 10th 841 Silverlake Blvd.
(HICAP) (SHIP) Floor Dover, DE 19904
1300 National Dr., Ste. 200 .1560 Broadway Hartford, CT 05 Phone: (800) 336 -9500
Sacramento, CA 95834 Ste. 850 Phone: (800) 994 -9422
Phone: (800) 434 -0222 Denver, CO 80202 TTY: (800) 842 -4524
TDD: (800) 735 -2929 Phone: (888) 696 -7213
TTY: (303) 894 -7880
Florida Georgia Guam Hawaii
Serving Health Insurance GeorgiaCares Guam Medicare Sage PLUS
Needs of Elders (SHINE) 2 Peachtree St., NW 33r Assistance Program 250 South Hotel St.
4040 Esplanade Way Floor (Guam MAP) Ste. 406
Ste. 270 Atlanta, GA 30303 130 University Dr., Ste. 8 Honolulu, HI 96813
Tallahassee, FL 32399 Phone: (866) 552 -4464 University Castle Mall, Phone: (888) 875 -9229
Phone: (800) 963 -5337 TTY: (404) 657 -1929 Mangiloa, Guam 96913 TTY: (866) 810 -4379
TTY: (800) 955 -8770 Phone: (671) 735 -7011
or (671) 735 -7382
TTY: (671) 735 -7415
Idaho Illinois Indiana Iowa
Senior Health Insurance Senior Health Insurance State Health Insurance Senior Health Insurance
Benefits Advisors (SHIBA) Program (SHIP) Assistance Program Information Program (SHIIP)
700 West State St., 3rd Floor One Natural Resources (SHIP) 601 Locust St., 4th Floor
P.O. Box 83720 Way, #100 311 W. Washington St. Des Moines, IA 50309
Boise, ID 83720 Springfield, IL 62702 Ste. 300 Phone: (800) 351 -4664
Phone: (800) 247 -4422 Phone: (800) 252 -8966 Indianapolis, IN 46204 TTY: (800) 735 -2942
TTY: (888) 206 -1327 Phone: (800) 452 -4800
TDD: (866) 846 -0139
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 142
Appendices
Kansas Kentucky Louisiana Maine
Senior Health Insurance State Health Insurance Senior Health Insurance Maine State Health
Counseling for Kansas Assistance Program Information Program Insurance Assistance
(SNICK) (SHIP) (SHIIP) .Program (SHIP)
503 S. Kansas Ave. 275 E. Main St. PO Box 94214 SHS 11
New England Bldg. Frankfort, KY 40621 1702 N. 3rd St. Augusta, ME 04333
Topeka, KS 66603 Phone:: (877) 293 -7447 P.O. Box 94214 Phone: (877) 353 -3771
Phone: (800) 860 -5260 Baton Rouge, LA 70802 TTY: 711
Phone: (800) 259 -5300
Maryland Massachusetts Michigan Minnesota
Senior Health Insurance Serving Health MMAP, Inc. Minnesota State Health
Assistance Program (SHIP) Information Needs of 6105 W St. Joseph Hwy, Insurance Assistance
301 West Preston St. - Elders (SHINE) Ste. 204 Program Senior LinkAge
Room 1007 1 Ashburton Place, 5th Lansing, MI 48917 Line
Baltimore, MD 21201 Floor Phone: (800) 803 -7174 PO Box 64976
Phone: (800) 243 -3425 - Boston, MA 02108 Saint Paul, MN 55164
TTY: 711 Phone: (800) 243 -4636. Phone: (800) 333 -2433
TTY: 711
Mississippi Missouri Montana Nebraska
MS Dept. of Human Services- CLAIM Montana State Health Nebraska Senior Health
Division of Aging & Adult - 200 N. Keene St. Insurance Assistance Insurance Information
Services Ste. 101 Program (SHIP) Program (SHIIP)
750 N. State St. Columbia, MO 65201 2030 11th Ave. 941 0 St., Ste. 400
Jackson, MS 39202 Phone: (800) 390 -3330 Helena, MT 59601 Lincoln, NE 68508
Phone: (800) 948 -3090 Phone: (800) 551 -3191 Phone: (800) 234 -7119
•
TTY: (800) 833 -7352
Nevada New Hampshire New Jersey New Mexico
State Health Insurance NH SHIP- ServiceLink & State Health Insurance Benefits Counseling
Advisory Program (SHIP) Disability Resource : Assistance Program Program
3416 Goni Rd., Ste. D -132 Center (SHIP) 2550 Cerrillos Rd.
Carson City, NV 89706 129 Pleasant St. Division of Aging Santa Fe, NM 87505
Phone: (800) 307 -4444 Gallen State Office Park Services Phone: (800) 432 -2080
Concord, NH 03301 P.O. Box 715
Phone: (866) 634 -9412 Mercerville, NJ 08625
Phone: (800) 792 -8820
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 143
Appendices
New York North Carolina North Dakota Ohio
Health Insurance Information Seniors' Health Senior Health Insurance Ohio Senior Health
Counseling and Assistance Insurance Information Counseling (SHIC) Insurance Information
Program (HIICAP) Program (SHIIP 600 East Blvd. Program (OSHIIP)
2 Empire State Plaza 11 South Boylan Ave. Bismarck, ND 58505 50 West Town St., 3rd Floor
New York City, NY 12223 Raleigh, NC 27603 Phone: (888) 575 -6611 Ste. 300
Phone: (800) 701 -0501 Phone: (855) 408 - 1212 TTY: (800) 366 -6888 Columbus, OH 43215
TTY: 711 Phone: (800) 686 -1578
Oklahoma Oregon Pennsylvania Puerto Rico
Senior Health Insurance Senior Health Insurance APPRISE State Health Insurance
Counseling Program (SHIP) Benefits Assistance 555 Walnut St. 5th Floor Assistance Program (SHIP)
Five Corporate Plaza (SHIBA) Harrisburg, PA 17101 P.O. Box 191179
3625 NW 56th St., Ste. 100 P.O. Box 14480 Phone: (800) 783 -7067 San Juan, PR 00919
Oklahoma City, OK 73112 Salem, OR 97309 Phone: (877) 725 -4300
Phone: (800) 763 -2828 Phone: (800) 722 -4134
Rhode Island South Carolina South Dakota Tennessee
Senior Health Insurance (I -CARE) Insurance Senior Health Information Tennessee SHIP
Program (SHIP) Counseling Assistance & Insurance Education 502 Deaderick St, 9th Floor
74 West Rd., 2nd Floor and Referrals for Elders (SHIINE) Nashville, TN 37243
Cranston, RI 02920 1301 Gervais St. 700 Governors Dr. Phone:; (877) 801 -0044
Phone: (401) 462 -3000 Ste. 350 Pierre, SD 57501 TTY: (615)532 -3893
TTY: (401) 462 -0740 Columbia, SC 29201 Phone: Eastern (800)
Phone: (800) 868 -9095 536 -8197, Central (877)
331 -4834, Western (877)
286 -9072
Texas ' Utah Vermont Virginia
Texas Dept. of Aging & Senior Health Insurance State Health Insurance Virginia Insurance
Disability Services . Information Program Assistance Program Counseling and Assistance
701 West 51st St. (SHIP) (SHIP) Program ( VICAP)
Austin, TX 78751 195 North 1950 West 481 Summer St. 1610 Forest Ave. , Ste. 100
Phone: (800) 252 -9240 Salt Lake City, UT 84116 Suite 101 Henrico, VA 23229
TTY: (800) 735 -2989 Phone: (800) 541 -7735 St. Johnsbury, VT 05819 Phone: (800) 552 -3402
Phone: (800) 642 -5119 TTY: 711
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 144
Appendices
Washington Washington D.C. West Virginia Wisconsin
Statewide Health Insurance Health Insurance West Virginia State Wisconsin SHIP (SHIP)
Benefits Advisors (SHIBA) Counseling Project Health Insurance One West Wilson St.
PO Box 40256 (HICP) Assistance Program (WV Madison, WI 53703
Olympia, WA 98504 650 20th St., NW SHIP) Phone: (800) 242 -1060
Phone: (800) 562 -6900 Washington, DC 20052 1900 Kanawha Blvd. TTY: (888) 701 -1251
TTY: (360) 586 -0241 Phone: ((202) 739 -0668 Charleston, WV 25305
TTY: (202) 994 -6656 Phone: (877) 987 -4463
Wyoming
Wyoming State Health
Insurance Information
Program (WSHIIP)
106 W. Adams
Riverton, WY 82501
Phone: (800) 856 -4398
•
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 145
Appendices
Appendix B - Quality Improvement Organizations
States: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York,
Pennsylvania, Puerto Rico, Rhode Island and Vermont:
Address Toll -free Number Fax Number
Livanta, LLC. 866- 815 -5440 Appeals: 855 - 236 -2423
BFCC -QI0 Program TTY: 1-866-868-2289 All other reviews:
9090 Junction Drive, Suite 10 844 - 420 -6671
Annapolis Junction, MD 20701
States: District of Columbia, Delaware, Florida, Georgia, Maryland, North Carolina, South
Carolina, Virginia and West Virginia
Address Toll -free Number Fax Number
KEPRO 844- 455 -8708 844 - 834 -7129
5201 W. Kennedy Blvd.,
Suite 900
Tampa, FL 33609
States: Alabama, Arkansas, Colorado, Kentucky, Louisiana, Mississippi, Montana, North Dakota,
New Mexico, Oklahoma, South Dakota, Tennessee, Texas, Utah and Wyoming
Address Toll -free Number Fax Number
KEPRO 844- 430 -9504 844 - 878 -7921
5700 Lombardo Center Dr., •
Suite 100 •
Seven Hills, OH 44131
States: Iowa, Illinois, Indiana, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio and
Wisconsin
Address Toll -free Number Fax Number
KEPRO 855- 408 -8557 844 - 834 -7130
5201 W. Kennedy Blvd.,
Suite 900
Tampa, FL 33609
States: Alaska, Arizona, California, Hawaii, Idaho, Nevada, Oregon and Washington
Address Toll -free Number Fax Number
Livanta, LLC. 877 - 588 -1123 Appeals: 855 - 694 -2929
BFCC -QI0 Program TTD: 1-855-887-6668 All other reviews:
9090 Junction Drive, Suite 10 844 - 420 -6672
Annapolis Junction, MD 20701
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 146
Appendices
Appendix C - State Medicaid Agencies
Alabama Alaska Arizona Arkansas
Medicaid Agency of Alabama Alaska Dept. of Health AHCCCS Dept. of Human Services
501 Dexter Ave. and Social Services 801 E. Jefferson St. of Arkansas
Montgomery, AL 36104 350 Main St. MD 4100 Donaghey Plaza South
Phone: (800) 362 -1504 Rm. 103 Phoenix, AZ 85034 P 0 Box 1437, Slot s401
Juneau, AK 99811 Phone: (800) 523 -0231 Little Rock, AR 72203
Phone: (907) 465 -3347 Phone: (800) 482 -5431
S panish: (800) 482 -8988
California Colorado Connecticut Delaware
California Dept. of Health Health First Colorado Dept. of Social Services Delaware Health and
Services 1570 Grant St. of Connecticut Social Services
P 0 Box 997413 Denver, CO 80203 25 Sigourney St. 1901 N. DuPont Highway
Sacramento, CA 95899 Phone: (800) 221 -3943 Hartford, CT 06106 PO Box 906, Lewis Bldg.
Phone: (916) 552 -9200 Phone: (800) 842 -1508 New Castle, DE 19720
TTYITDD: (800) 842- Phone: (800) 372 -2022
4524)
Florida Georgia Hawaii Idaho
Agency for Health Care Georgia Dept. of Dept. of Human Services Idaho Dept. of Health and
Administration of Florida Community Health of Hawaii Welfare
1317 Winewood Blvd. 2 Peachtree St., N.W. 801 Dillingham Blvd. 450 W. State St., 10th Floor
Bldg. 1, Room 202 Atlanta, GA 30303 3rd Floor P.O. Box 83720
Tallahassee, FL 32399 Phone: (877 -423 -4746) Honolulu, HI 96817 Boise, ID 83720
Phone: (888) 419 -3456 Phone: (808) 586 -5390 Phone: (877) 456 -1233
TDD: 1-800-955-8771 TTY: (800) 603 -1201
Spanish: (800) 316 -8005
Illinois Indiana Iowa Kansas
Illinois Dept. of Healthcare Family and Social Dept. of Human Services Kansas Medical
and Family Services Services Administration of Iowa Assistance Program
100 South Grand Ave. East of Indiana 100 Army Post Rd. P.O. Box 3571
Springfield, IL 62762 402 W. Washington St. Des Moines, IA 50315 Topeka, KS 66601
Phone: (866) 468 -7543 P.O. Box 7083 Phone: (800) 338 -8366 Phone: (800) 766 -9012
TTY: (877) 204 -1012 Indianapolis, IN 46207
Phone: (800) 457 -4584
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Appendices
Kentucky Louisiana Maine Maryland
Cabinet for Health Services Louisiana Dept. of Health Maine Dept. of Health and Dept of Health and Mental
of Kentucky 628 N. 4th St Human Services Hygiene
275 East Main St. Baton Rouge, LA 70821 11 State House Station 201 W. Preston St.
Frankfort, KY 40621 Mailing: 242 State St. Baltimore, MD 21201
Phone: (800) 635 -2570 P.O. Box 91278 Augusta, ME 04333 Phone: (410) 767 - 1594
Baton Rouge, LA 70821 Phone: (800) 977 -6740
Phone: (888) 342 -6207 TTY: 711
Massachusetts Michigan Minnesota Mississippi
Office of Health and Human Michigan Dept. of Health Dept. of Human Services Mississippi Division of
Services of Massachusetts & Human Services of Minnesota Medicaid
55 Summer St. 333 S. Grand Ave P.O. Box 64838 550 High St., Ste. 1000
Boston, MA 02110 P.O. Box 30195 St. Paul, MN 55155 Jackson, MS 39202
Phone: (800) 841 -2900 Lansing MI 48909 Phone: (800) 657 -3739 Phone: (800) 421 2408
TTY: (800) 497 -4648. Phone: (517) 373 -3740
TTY: 711
Missouri Montana Nebraska Nevada
Dept. of Social Services of MT Dept. of Public Nebraska Dept. of Health Nevada Dept. of Health
Missouri Health & Human and Human Services and Human Services
615 Howerton Court Services P.O. Box 95026 Division of Welfare and
P.O. Box 6500 1400 Broadway Lincoln, NE 68509 Supportive Services
Jefferson City, MO 65102 Cogswell Bldg. Phone: (800) 254 -4202 3330 E. Flamingo Rd #55
Phone: (573) 751 -3425 Helena, MT 59620 Las Vegas, NV 89121
Phone: (800) 362 -8312 Phone: (877) 543 -7669
New Hampshire New Jersey New Mexico New York
New Hampshire Dept. of Dept. of Human Services Dept. of Human Services NY State Dept. of Health
Health and Human Services of New Jersey of New Mexico Office of Medicare
129 Pleasant St. Quakerbridge Plaza P.O. Box 2348 Management
Concord, NH 03301 Bldg. 7 Sante Fe, NM 87504 800 N Pearl Street
Phone: (800) 852 -3345 P.O. Box 712 Phone: (888) 997 -2583 Albany, NY 12204
TDD: (800) 735-2964 Trenton, NJ 08619 Phone: (800) 541 -2831
Phone: (800) 356 -1561
North Carolina ' North Dakota Ohio Oklahoma
North Carolina Dept. of ; Dept. of Human Services Dept. of Medicaid Health. Care Authority of
Health and Human Services of North Dakota - 50 West Town St., Ste. Oklahoma
2501 Mail Service Center Medical Services 400 4345 N. Lincoln Blvd:
Raleigh, NC 27699 600 E. Blvd. Ave. Columbus, OH 43215 Oklahoma City, NE 73105
Phone: (800) 662 -7030 Dept. 325 Phone: (800) 324 -8680 Phone: (800) 987 -7767
Bismarck, ND 58505
Phone: (800) 755 -2604
TTY: 711
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Appendices
Oregon Pennsylvania Puerto Rico Rhode Island
Oregon Health Plan Dept. of Human Services Medicaid Office of Puerto Dept. of Human Services
500 Summer St., N.E. of Pennsylvania Rico and Virgin Islands of Rhode Island
Salem, OR 97301 P.O. Box 2675 P.O. Box 70184 Louis Pasteur Bldg,
Phone: (800) 699 -9075 Harrisburg, PA 17105 San Juan, Puerto Rico 57 Howard Ave.
Phone: (800) 692 -7462 93681 Cranston, RI 02921
TDD: (800) 451 -5886. Phone: (787) 765-2929 Phone: (401) 462 -5300
South Carolina South Dakota Tennessee Texas
South Carolina Dept. of Dept. of Social Services TennCare Health and Human
Health and Human Services of South Dakota 310 Great Circle Rd. Services Commission of
P.O. Box 8206 700 Governors Dr. Nashville, TN 37243 Texas
Columbia, SC 29202 Richard F Kneip Bldg. Phone: (855) 259 -0701 4900 N Lamar Blvd.
Phone: (888) 549 -0820 Pierre, SD 57501 TTY: (877) 779 -3103 Austin, TX 78751
TDD: (888) 842 -3620 Phone: (800) 597 -1603 Spanish: (866) 311 -4290 Phone: (877) 541 -7905
TTY: (512) 407 -3250
Utah Vermont Virginia Washington
Utah Dept. of Health Agency of Human Dept. of Medical Dept. of Social and Health
288 North 1460 West Services of Vermont Assistance Services Services of Washington
Salt Lake City, UT 84114 280 State Dr. 600 E. Broad St. Cherry St. Plaza
Phone: (800) 662 -9651 Waterbury, VT 05671 Ste. 1300 626 8th Ave. SE
Phone: (800) 250 -8427 - Richmond, VA 23219 Olympia, WA 98501
TTY: 711 Phone: (804) 786 -7933 Phone: (800) 865 -7801
TDD:, (800) 343 - 0634.
Washington D.C. West Virginia Wisconsin Wyoming
Dept. of Health — District of West Virginia Dept. of Wisconsin Dept. of Health Wyoming Dept. of Health
Columbia Health & Human Services -. 2300 Capital Ave, Suite
899 N Capitol Street NE Resources 1 West Wilson St. 401 Hathaway Bldg
Washington, DC 20002 350 Capitol St. Madison, WI 3 Cheyenne, WY 82002
Phone: (202) 442 -5955 Charleston, WV 25301 Phone: (800) 362 -3002 Phone: (866) 571 -0944
Phone: (304) 558 -1700 TTY: 711
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 149
Appendices
Appendix D - State Pharmacy Assistance Programs
Colorado Connecticut Delaware Idaho
Colorado Bridging the Gap Connecticut Delaware Prescription Idaho AIDS Drug
4300 Cherry Creek Dr. South Pharmaceutical Assistance Program Assistance Program
Denver, CO 80246 Assistance Contract to (PDAP) (IDAGAP)
Phone: (303) 692 -2783 or the Elderly and Disabled PO Box 950. Dept. of Health & Welfare
(303) 692 -2716 (ConnPACE) New Castle, DE 19720 PO Box 83720
PO Box 5011 Phone: ( (800) 996 -9969, Boise, ID 83720
Hartford, CT 06102 EXT: 2 Phone: (208) 334 -5943 or
Phone: (800) 423 -5026 (800) 926 -2588
or (800) 269 -2029
Indiana Maine Maryland Maryland (cont)
Hoosier Rx Low Cost Drugs for the Maryland Senior Maryland Kidney Disease
402 W. Washington St., Elderly and Disabled Prescription Drug Program
RoomW374, MS07 Program Assistance Program 201 W. Preston St., Room
Indianapolis, IN 4 242 State St. c/o Pool Administrators SS -3
Phone: (866) 267 -4679 Augusta, ME 04333 628 Hebron Ave., Ste. Baltimore, MD 21201
(317) 234 -1381 Phone: (866) 796 -2463 100 Phone: (800) 767 -5000 or
TTY: (800) 606 -0215 Glastonbury, CT 06033 (410) 226 -2142
Phone: (800) 551 -5995
Maryland (cost) Massachusetts Missouri Montana
Primary Adult Care Program Massachusetts Missouri Rx Plan Big Sky Rx Program
(PAC) Prescription Advantage PO Box 6500 PO Box 202915
P.O. Box 386 PO Box 15153 Jefferson City, MO 65102 Helena, MT 59620
Baltimore, MD 21203 Worcester, MA 01615 Phone: (800) 375 -1406 Phone: (866) 369 -1233 or
Phone: (800) 226 -2142 Phone: (800) 243 -4636 (406) 444 -1233
EXT: 2
Nevada New Jersey New Jersey (cont) New Jersey (cont)
Nevada Senior Rx Senior Gold Prescription Pharmaceutical Division of Medical
Department of Health and Discount Program Assistance to the Aged Assistance and Health Ser.
Human Services PO Box 715 and Disabled Program PO Box 712
3416 GoniRd. Trenton, NJ 08625 (PAAD). Trenton, NJ 08625
Ste. D -132 Phone: (800) 792 -9745 Dept. of Human Services Phone: (800) 356 -1561
Carson City, NV 89706 P.O. Box 715
Phone: (866) 303 -6323 or Trenton, NJ 08625
(775) 687 - 4210. Phone: (800) 792 -9745
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Appendices
New York ' North Carolina Pennsylvania Pennsylvania (cont)
Elderly Pharmaceutical North Carolina HIV Pharmaceutical PACE Needs
Insurance Coverage (EPIC) SPAP Assistance Contract for Enhancement Tier
PO Box 15018 1902 Mail Service Center the Elderly (PACE) (PACENET)
Albany, NY 12212 Raleigh, NC 27699 PACE/PACENET PACENET Program
Phone: (800) 332 -3742 Phone: (877) 466 -2232 Program P.O. Box 8806
or(919) 733 -7301 P.O. Box 8806 Harrisburg, PA 17105
Harrisburg, PA 17105 Phone: (800) 225 -7223 or
Phone: (800) 225 -7223 or (717) 651 -3600
(717) 651 -3600
Pennsylvania (cunt) Pennsylvania (cunt) Rhode Island Texas
Special Pharmaceutical Special Pharmaceutical Rhode Island Prescription Kidney Health Care
Benefits Program- HIV /AIDS Benefits Program- Assistance for the Elderly Program (KHC)
P.O. Box 8808 Mental Health (RIPAE) Dept of State Health
Harrisburg, PA 17105 SPBPMH ATTN: RIPAE Services, MC 1938
Phone: (800) 922 -9384 P.O. Box 8808 Hazard Bldg., 2nd Floor P.O. Box 149347
Harrisburg, PA 17105 74 West Rd. Austin, TX 78714
Phone: (800) 433 -4459 Cranston, RI 02920 Phone: (800) 222 - 3986 or
Phone: (401) 462 -3000 or (512) 776 =7150
(401) 462 -0740
Vermont Virginia Washington Wisconsin
V -Pharm Virginia HIV SPAP Washington State Health SeniorCare
312 Hurricane Ln. HCS Unit, 1st Floor Insurance Pool P.O. Box 6710
Ste. 201 James Madison Bldg. PO Box 1090 Madison, WI 53716
Williston; VT 05495 109 Governor St. Great Bend, KS 67530 Phone: (800) 657 -2038
Phone: (800) 250 -8427 Richmond, VA 23219 Phone: (800) 877 -5187
Phone: (855) 362 -0658
Wisconsin (cont) Wisconsin (cont) Wisconsin (cont)
Chronic Renal Disease Cystic Fibrosis Program Hemophilia Home Care
ATTN: Eligibility Unit Chronic Disease Chronic Disease program
P.O. Box 6410 program P.O. Box 6410
Madison, WI 53716 P.O. Box 6410 Madison, WI 53716
Phone: (800) 947 -9627 or Madison, WI 53716 Phone: (800) 947 -9627 or
(800) 362 -3002 Phone: (800) 94.7 - 9627 (800) 362 -3002.
or (800) 362 -3002
1
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Appendices
•
Appendix E — Advance Directives Assistance
Alabama Alaska Arizona Arkansas
Area Agency on Aging Dept of Health & Social Arizona Attorney General Division of Aging and Adult
4200 Highway 69 North Services Community Outreach Services
Northport, AL 35476 -0509 Division of. Public Health and Education PO Box 1437
Phone: (800) 243 -5463 350 Main Street, Room 1275 W. Washington St. Slot S -530
508 Phoenix, AZ 85007 -2926 Little Rock, AR 72203 -1437
Juneau, AK 99801 Phone: (800) 352 -8431 Phone : (501) 682 -2441
Phone: (907) 465 -3090 or (602) 542 -2123
California 'Colorado Connecticut ` Delaware
California Department of Colorado Commission on Connecticut Dept of Delaware Division of
Aging Aging Social Services Services for Aging and
1300 National Drive, Suite 1575 Sherman Street 55 Farmington Ave. Adults with Physical
200 Denver, Colorado 80203 Hartford, CT 06105 Disabilities
Sacramento, CA 95834 Phone: (888) 866 -4243 Phone:` (800) 842 -1508 1901 . N. Du Pont Highway
Phone: (916) 419 -7500 or (303) 866 -5288 TTY: (800) 842 -4524 Main Bldg.
TTY: (800) 735 -2929 New Castle, DE 19720
Dover, DE 19904
Phone: (800) 223- 9074 ,
Florida Georgia Hawaii Idaho
Florida Dept of Elder Affairs Georgia DHS Division of Dept of Health Idaho Commission on Aging
4040 Esplanade Way Aging Services Elderly Affairs Division 341 W Washington
Tallahassee, FL 32399 2 Peachtree Street, NW Standard Finance Bldg. Boise, ID 83702
Phone: (850) 414 -2000 Atlanta, GA 30303 -3142 715 South King Street, Phone: (800) 926 -2588 or
TDD: (850) 414 -2001 Phone: (866) 552 -4464 Suite 200 (208) 334 -3833
or (404) 657 -5258 Honolulu, Hawaii 96813
Phone: (808) 768 -7700
o_ r (808) 808 768 - 7705
Illinois Indiana Iowa Kansas
Illinois Dept on Aging Indiana Association of Iowa Dept on Aging ` Dept on Aging
One Natural Resources . Area Agencies on Aging Jessie M. Parker Bldg New England Bldg.
Way, Suite 100 4755 Kingsway Drive 510 East 12th St, Ste. 2 503 S. Kansas Ave.
Springfield, Illinois 62702- Suite 318 Des Moines, IA 50319 Topeka, KS 66603 -3404
1271 Indianapolis, IN 46205 Phone: (800) 532 - 3213 Phone: (800) 432 -3535
Phone: (800) 252 - 8966:, Phone: (317) 205 -9201 or (515) 725 -3333 _ TTY: (785) 291 -3167
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 152
Appendices
Kentucky Louisiana Maine Maryland
CHFS Dept of Health and OADS Aging Services Maryland Dept of Aging
Dept for Aging and Hospitals Maine Dept of Health 301 West. Preston Street
Independent Living Office of Aging and Adult and Human Services Suite 1007
400 Old Vine St. Services 11 State House Station Baltimore, MD 21201
Ste. 203 628 N 4th Street 41 Anthony Ave. Phone: (401) 767 -1100
Lexington, KY 40507 Baton Rouge, LA 70802 Augusta, ME 04333
Phone: (877) 293 -7447 Phone: (225) 219 -1917 Phone: (800) 262 -2232
or (207) 287 -9200
TTY: 711
Massachusetts Michigan Minnesota Mississippi
Executive Office of Elder Aging and Adult Services Minnesota Board on Dept of Human Services
Affairs Agency Aging Division of Aging and Adult
One Ashburton Place, 5th 300 E. Michigan Ave., 3rd Elmer L. Anderson Services
Floor Floor Human Services Building 750 North State Street
Boston, MA 02108 Lansing, MI 48933 540 Cedar Street Jackson, MS 39202
Phone: (800) 243 -4636 or Phone: (517) 373 -8230 St. Paul, MN 55155 Phone: (800) 948 -3090 or
(617) 727. -7750 Phone: (800) 882 -6262 (601) 359 -4929
TTY: (800) 872- 0166 or (651) 431 -2500
TTY: (800) 627 -3529
Missouri Montana Nebraska Nevada
Division of Senior and Dept of Public Health and Dept of Health and Dept of Health and Human
Disability Services Area Human Services Human Services Services
Agencies on Aging Area Agencies on State Unit on. Aging Aging and Disability
Missouri Department of Agencies P.O. Box 95026 Services Division
Health and Senior Services P.O. Box 1717 Lincoln, NE 68509 -5026 3416 Goni Road, Suite D-
P.O. Box 570 Helena, MT 59624 Phone: (800) 942 -7830 132
Jefferson City, MO 65102 Phone: (800) 551 -3191 Carson City, NV 89706
Phone: (573) 526 -4542 Phone: (775) 687 -4210
New Hampshire New Jersey New Mexico New York
New Hampshire Dept of Division of Aging Services New Mexico Aging and NYC Dept for the Aging
Health and Human Services New Jersey Department Long -Term Services Office of Public Affairs
Bureau of Elderly and Adult of Human Services Toney Anaya Bldg. 2 Lafayette Street
Services 12B Quakerbridge Plaza 2550 Cerrillos Rd. New York, NY 10007
129 Pleasant Street PO Box 715 Santa Fe, NM 87505 Phone: (212) 639 -9675
Concord, NH 03301 Mercerville, NJ 08625- Phone: (866) 451-2901
Phone: (800) 351 -1888 or 0715 or (505) 476 -4799
(603) 271 -9203 Phone: (877) 222 -3737
TDD: (800) 735 -2964
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Appendices
North Carolina North Dakota Ohio Oklahoma '
NC Health and Human Dept of Human Services Ohio Dept of Aging Oklahoma Dept of Human
Services 1237 W Divide Ave., Suite 246 N. High Street, 9th Services
Aging and Adult Services 6 Floor Aging Services
2101 Mail Service Center Bismarck, ND 58501 Columbus, Ohio 43215- 2401 NW 23r Street, Suite
Raleigh, NC 27699 -2101 Phone: (855) 462 -5465 2406 40
Phone: (919) 855 -3400 or (701) 328- 4601. Phone: (800) 2664346 Oklahoma City, OK 73107
TTY: (800) 366 -6888 TTY: 711 Phone:, (405) 521 -2281
Oregon Pennsylvania Rhode Island South Carolina
Oregon Department of Pennsylvania Dept of Rhode Island Dept of Office on Aging
Human Services Aging Human Service, Division 1301 Gervais St.
Seniors and People with 555 Walnut Street, 5t of Elderly Affairs Ste. 350
Disabilities Floor : 74 West Road Columbia, SC 29201
500 Summer Street NE E12 Harrisburg, PA 17101- Hazard Bldg, 2nd Floor Phone: (800) 868 -9095 or
Salem, OR 97301 -1073 1919 Cranston, . RI 02920. (803) 734 -9900
Phone: (800) 282 -8096 Phone: (717) 783 -1550 Phone: (401) 462 -3000
TTY: (800) 282 -8096. TTY: (401) 462 - 0740
South Dakota Tennessee Texas Utah
Adult Services and Aging . Tennessee Commission Texas Dept of Aging and Health and Human Services
700 Governors Drive on Aging and Disability Disability Services Aging and Adult Services
Pierre, SD 57501 502 Deaderick Street, 9th 701 W. 51st St. 195 North 1950 West
Phone: (605) 773 -3165 Floor Austin, TX 78751 Salt Lake City, UT 84116
Nashville, TN 37243 -0860 Phone: (512) 438 -3011 Phone: (877) 424 -4640 or
Phone: (615)741 -2056 (801) 538 -3910
Vermont Virginia Washington Washington, D.C.
Vermont Dept of Disabilities, Virginia Dept for the Washington State Dept D.C. Office on Aging
Aging and Independent Aging of Social and Health 500 K Street NE
Living 1610 Forest Ave. Ste. 100 Services, Aging and Washing ton, DC 20002
103 South Main Street Richmond, VA 23229 Long -Term Support Phone: (202) 724 -5622
Weeks Building Phone: (800) 552 -3402 Administration
Waterbury, VT 05671 TTY: 711 Area Agency on Aging
Phone: (802) 871 -3065 50 Simon Street SE
East Wenatchee, WA
98802
Phone: (800) 572 -4459
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 154
Appendices
West Virginia Wisconsin Wyoming
West Virginia Bureau of Dept of Health Services Dept of Health, Aging
Senior Services 1 West Wilson St. Division
1900 Kanawha Blvd E Madison, WI 53703 401 Hathaway Bldg.
Charleston, WV 25305 Phone: (608) 266 -1865 Cheyenne, WY 82002
Phone: (877) 987 -3646 or TTY: (888) 701 -1251 Phone: (866) 571 -0944
(304) 558 -3317 or (307) 777 -7656
Appendix F — AIDS Drug Assistance Programs
Alabama Alaska Arizona . Arkansas
HIV /AIDS Division Alaskan AIDS Assistance Arizona Dept of Health Arkansas Dept of Health
Alabama Dept of Public Association Services 4815 West Markham Street
Health 3601 C Street, Suite 540 150 N. 18th Avenue, Little Rock, Arkansas 72205
The RSA Tower Anchorage, Alaska 99503 Suite 110 Phone: (888) 499 -6544 or
201 Monroe S treet, Suite Phone: (907) 269 -8000 Phoenix, AZ 85007 (501) 661 -2408
1400 Phone;: (602) 364 -3610
Montgomery, Alabama Alaskan Statewide AIDS
36104 Helpline: (800) 478 -AIDS
Phone (866) 574 -9964 `..
California Colorado Connecticut Delaware
Office of AIDS CDPHE Care and Dept of Social Services Delaware HIV Consortium
PO Box 997377, MS 0500 Treatment Program Medical Operations Unit 100 W. 10th St., Suite 415
Sacramento, CA 95899- 4300 Cherry Creek Drive #4 Wilmington, DE 19801
7377 South 25 Sigourney Street Phone: (302) 654 -5471
Phone: (916) 558 -1784 Denver, CO 80246 Hartford, CT 06106
MCI TDD (800) 735 -2929 or Phone:' (800) 886-7689 Phone: (800) 233 -2503
MCI voice telephone (800) or (303) 692 -2000 TDDITYY: 800 - 842 -4524
735 -2922; Sprint TDD (888) TDD: (303) 691 =7700
877 -5378 or Sprint voice
telephone. (888) 877 -5379
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 155
Appendices
Florida Georgia Guam Hawaii
Section of HIV /AIDS Health and Human Ser. Guam Medicare STD /AIDS Prevention
AIDS Drug Assistance 2 Peachtree St., NW Assistance Program Branch HIV Drug
Program 15th Floor (Guam MAP) Assistance Program
4052 Bald Cypress Way Atlanta, GA 30303 130 University Drive, 3627 Kilauea Avenue,
Tallahassee, FL 32399 Phone: (800) 551 -2728 University Castle Mall, Room 306
Phone: (800) 352 -2437 Room 156 Honolulu, Hawaii 96816 -
Spanish: (800) 545 -7432 Guam, 96913 2399
Creole: (800) 243 -7101 Phone (671) 735 -7421 Phone: (808) 732 -0026
TTY: (888) 503 -7118 TTY: (671) 735 -7415.
Idaho Illinois Indiana Iowa
Idaho AIDS Drug Illinois ADAP Office Indiana State Dept of Iowa Dept of Public Health
Assistance Program 525 West Jefferson Health 321 E. 12th Street
(IDAGAP) Street, First Floor 2 N. Meridian St., 6 -C Lucas State Office Bldg 5th
40 West State Street Springfield, IL 62761 Indianapolis, IN 46204 Fir
Boise, ID 83720 Phone: (217) 782 -4977 Phone: (866) 588 -4948 Des Moines, IA 50319
Phone (208) 334 - 6527 or TTY: (800) 547 -0466 Phone: (800)445 -2437
(800- 926 -2588
Kansas Kentucky Louisiana Maine
Kansas Dept of Health and . KY Cabinet for Health and Louisiana Dept of Health Maine ADAP
Environment Family Services and Hospitals 40 State House Station
1000 SW Jackson, HIV /AIDS Branch 628 N. 4th Street Augusta, ME 04330 -9758
Suite 210 275 E Main Street, HS2E- Baton Rouge, LA 70802 Phone: (207) 287 -3747
Topeka, KS 66612 C Phone: (225) 342 -9500
Phone: (785) 296 -8701 Frankfort, KY 40621
Phone : 510 -0005
Maryland Massachusetts Michigan Minnesota
Maryland AIDS Massachusetts Attn: Michigan Drug HIV/AIDS Programs
Administration Community Research Assistance Program HIV Dept of Human Services
500 North Calvert Street, Initiative of New Care Section PO Box 64972
5th Floor England /HDAP Div. of Health, Wellness St. Paul, MN 55164
Baltimore, MD, 21202 38 Chauncy Street, and Disease Control, Phone: (800) 657 -3761 or
Phone: (800) 205 -6308 or Suite 500 Michigan Dept of Health (651) 431 -2414
(410) 767 -6535 Boston, MA 02111 and Human Services TTY: (800) 627 -3529
TTY: (800) 735 -2258 Phone: (800) 228 -2714 109 Michigan Avenue,
or (617) 502 -1700 9th Floor
Lansing, MI 48913
Phone: (888) 826 -6565
2018 Evidence of Coverage for EnvisionRxPlus Employer Group Retiree PDP 156
Appendices
Mississippi Missouri Montana Nebraska
State Dept. of Health Missouri Dept. of Health HIV Treatment Nebraska Dept. of Health &
570 East Woodrow Wilson and Senior Services Assistance Program Human Services
Dr. PO Box 570 Cogswell Building P.O. Box 95026
Jackson, MS 39216 Jefferson City, MO 65102 Room C -211 Lincoln, Nebraska 68509
Phone: (866) 458 -4948 or Phone: (573) 751 -6439 1400 Broadway Phone: (402) 559 -4673 or
AIDS Hotline: (800) 826- Helena, MT 59620 (800) 782 -2437
2961 Phone: (406) 444 -3565
Nevada New Hampshire New Jersey New Mexico
Nevada State Health DHHS - NH CARE NJ AIDS Drug New Mexico HIV /AIDS
Division Program Assistance Program Services Program - AIDS
4150 Technology Way, 29 Hazen Drive (ADAP),- NJ Drug Assistance Program
Suite 106 Concord, NH 03301 PO Box 722 (ADAP)
Carson City, NV 89706 Phone: (603)271 -4502 Trenton, NJ 08625 1190 St Francis Dr.
Phone: (800) 842 -2437 or Phone: (800) 624 -2377 Runnels Bldg S -1207
(775) 684 -3499 Santa Fe, NM 87502
Phone: (888) 882- 2497
New York North Carolina North Dakota Ohio
New York HIV Uninsured N.C. Dept. of Health and North Dakota Dept. of Ohio HIV Drug Assistance
Care Programs Human Services Health Program (OHDAP)
Empire Station Division of Public Health HIV /AIDS Program HIV Care Services Section
P.O. Box 2052 Purchase of Medical Care 2635 East Main Ave Ohio Dept of Health
Albany, NY. 12220 -0052 Services Bismarck, ND 58506 246 N. High Street
Phone: (800) 542 -2437 1907 Mail Service Center Phone: (701) 328 -2378 Columbus, OH 43215
TTY: (518) 459 -0121 Raleigh, NC 27699 or (800) 472 -2180 Phone: (800) 777 -4775
Phone: (919) 733 -9576
Oklahoma Oregon Pennsylvania Rhode Island
Oklahoma State Dept .of CARE Assist Bureau of Epidemiology RI Dept of Health,
Health 800 NE Oregon Street, Health and Welfare Office of HIV /AIDS & Viral
HIV /STD Services Division Suite 1105 Building, Room 933 Hepatitis
1000 NE 10th, Room 614 Portland, OR 97232 Harrisburg, PA 17108 3 Capitol Hill, Room 302
Oklahoma City, OK 73117 Phone: (800) 805 -2313 Phone: (717) 783 -4677 Providence, RI 02908
Phone: (405) 271 - 4636, or (971) 673 -0144 Phone: (401) 222 -4610
South Carolina South Dakota Tennessee Texas
South Carolina Dept. of South Dakota Dept of TN Dept of Health Texas HIV State Pharmacy
Health. and Environmental Health 425 5th Ave. North, Assistance Program (SPAP)
Control 615 East 4th Street Cordell Hull Bldg. 3rd Fl. ATTN: MSJA, MC 1873
2600 Bull Street Pierre, SD 57501 Andrew Johnson Tower PO Box 149347
Columbia, SC 29201 Phone: (650) 773- 3737 Nashville, TN 37243 Austin, Texas 78714
Phone: (800) 856 -9954 Phone: (615) 741 -7500 Phone: (800) 255- 10901x
(512) 533 -3000
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Appendices
Utah Vermont Virginia Washington
Utah Dept. of Health Division of Alcohol & Drug Virginia Dept. of Health Washington State Dept. of
Bureau of Epidemiology Abuse Programs, 109 Governor Street Health
288 North 1460 West Vermont Dept of Health Richmond, Virginia HIV Client Services
PO Box 142104 108 Cherry Street, Rm 23219 P.O. Box 47890
Salt Lake City, Utah 84114 202 Phone: (855) 362 -0658 Olympia, Washington 98504
Phone: (801) 538 -6397 P.O. Box 70, Drawer 27 Phone: (360) 236 -3426
Burlington, VT 05402-
0070
Phone: (802) 651 -1550
Washington, D.C. West Virginia Wisconsin Wyoming
Washington, DC Dept. of Office of Epidemiology & Wisconsin Dept. of Wyoming Dept. of Health
Health Prevention Services Health Services 401 Hathaway Building
899 North Capitol Street, 350 Capitol Street Division of Public Health Cheyenne, WY 82002
NE Room 125 Attn: ADAP Phone: (307) 777 -5856
Washington, DC 20002 Charleston, WV 25301 1 West Wilson Street
Phone: (202) 671 -4900 Phone: (800) 642 -8244 Madison, WI 53703
TTY: 711 Phone: (800) 991 -5532
or (608) 267 -6875
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Appendices
EnvisionRxPlus Employer Group Retiree PDP Member Services
Method Member Services—Contact Informatiion
CALL 1-844-293-4760
Calls to this number are free. Member Services, including TTY/TDD,
is open 24 hours a day, 7 days a week.
Member Services also has free language interpreter services available
for non-English speakers.
TTY 711
This number requires special telephone equipment and is only for
people who have difficulties with hearing or speaking.
Calls to this number are free. 24 hours a day, 7 days a week.
FAX 1-866-250-5178
WRITE EnvisionRxPlus
2181 E. Aurora Rd., Suite 201
Twinsburg, OH 44087
customerservice@envisionrxplus.com
WEBSITE www.envisionrxplus.com
State Health Insurance Assistance Program
State Health Insurance Assistance Program is a state program that gets money from the Federal
government to give free local health insurance counseling to people with Medicare. You can
find the name of your state SHIP in Appendix A.
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