Transcript full presentation. - Southeastern Massachusetts Health Group

Medex 2 & Medicare Part D
Southeastern
Massachusetts
Health Group
What’s the Same?
• Medical benefits do not change.
• Medicare is still the primary payer for all of medical
claims.
• You do not have to change doctors or providers.
• Use the same local pharmacies you enjoy today.
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What’s the Difference?
•
The monthly premium is lower
•
The prescription drug plan will change from Express Scripts to a
CVS/Caremark Medicare Part D plan. The RX plan is called Blue MedicareRX.
•
The list of covered drugs is unique to this plan and differs slightly from
Medex covered list of drugs.
•
Mail order co-pays will be 2X retail. You get a 90 day supply for 2 copays –
not 3!
•
For Mail order medications – When your Doctor files your prescriptions for
mail order CVS will call for medication approvals in order for medications to
ship, they will also call before all refills are shipped.
•
Shingles vaccine is covered at participating pharmacies.
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Blue MedicareRx Benefit Design
Member Cost Share
Part D Benefit
Phase
Member Pays
Yearly Deductible
$0
Initial Coverage
30-Day Supply Retail
Tier 1 Generic Drugs:
$5
Tier 2 Preferred Brand Drugs:
$10
Tier 3 Non-Preferred Brand Drugs: $25
90-Day Supply Mail Order
Tier 1 Generic Drugs:
$10
Tier 2 Preferred Brand Drugs:
$20
Tier 3 Non-Preferred Brand Drugs: $50
Coverage Gap
Catastrophic
Coverage
(Member cost share after
member pays $4,700)
The Town provides supplemental coverage that
keep your copayments the same as what you pay
in Initial Coverage.
Generic drugs (including brand drugs
treated as generic): $2.65
All other drugs:
$6.60
Specialty drugs are limited to a 30-day supply.
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Formulary
Drug Coverage
The Blue MedicareRx list of Covered Drugs (Formulary) is reviewed and approved
annually by the Centers for Medicare & Medicaid Services (CMS). The Formulary
must abide by all CMS regulations for Part D plans.
Formulary Facts
•Consists of 3 drug tiers – Generic, Preferred Brand &
Non-Preferred Brand
•Covers over 2,800 drugs, including Specialty drugs.
•Some covered drugs may have additional
requirements or limits like Prior Authorization,
Quantity Limits or Step Therapy.
•Formulary changes are reported annually.
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Formulary
Drug Coverage
Medicare Part D Excluded Drugs
•
Non-prescription drugs, (OTC – over the counter drugs)
• Examples would be non-prescribed drugs including those for cough and cold
symptoms
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Prescription vitamins and mineral products
Drugs when used for cosmetic purposes or to promote hair growth
Lifestyle drugs when used for the treatment of fertility, sexual or erectile
dysfunction, such as Viagra, Cialis, Levitra and Caverject.
Drugs when used for treatment of anorexia, weight loss or weight gain
Embrel - a medication used to treat moderate to severe psoriasis and
rheumatoid arthritis. *A coverage determination process can be requested for
individual consideration of coverage.
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Formulary
Drug Coverage
Vaccines
•
Blue MedicareRx provides coverage for a number of Part D
vaccines, including the shingles vaccine (Zostavax) when
administered at the pharmacy.
Diabetic Testing Supplies and Insulin
•
•
Diabetic testing supplies (including test strips
and lancets) are not covered under Part D;
they are covered under Part B.
Insulin and medical supplies used to deliver
insulin (including needles, syringes, alcohol
swabs, gauze, insulin pens and pen supplies)
are covered under Part D when they are listed
on the Blue MedicareRx formulary.
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Formulary
Drug Coverage
Specialty Drugs
•
There are a number of specialty drugs covered by Blue MedicareRx.


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Generic specialty drugs are on Tier 1.
Brand specialty drugs are on Tier 2.
Specialty drugs are limited to a 30 day supply and process through the retail
pharmacy copayment structure only.
Specialty Pharmacy Access
•
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Members are not restricted to using CVS Caremark Specialty Pharmacy.
Specialty drugs can be filled at any network pharmacy (including standard retail
pharmacies) that are able to dispense the drug.
Due to special handling requirements and other factors, standard retail
pharmacies and CVS Caremark Mail Order Pharmacy may not be able to dispense
certain drugs in which case members would be referred to a specialty pharmacy.
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Blue MedicareRX
CMS Required Mailings
•
You will receive a 21 day letter from the account advising you will be auto enrolled into the
Blue MedicareRX product if you are enrolled in Medex today.
–
You will need to supply your residential address to be enrolled into this federally regulated product, P.O Boxes
will not be accepted for the initial enrollment. Please advise if you’d like your mail sent to a different address in
addition.
–
Do not enroll separately into any other outside Part D product or this will automatically disenroll you from the
Town’s coverage.
–
Power of Attorney (POA) or Appointment of Representation (AOR) – Be sure to file paperwork with Medex and
Blue MedicareRx plan when you enroll.
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First Packet from CVS - *****ID Card*****, Confirmation of Coverage Letter and Evidence of
Coverage Packet. Low Income subsidy/surcharge rider if applicable.
•
Second Packet from CVS - Formulary Book, Pharmacy Directory, Mail Order Form and
Instructions to complete, Claim Form and Appointment of Personal Representative Form
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Additional information from CVS - Coordination of Benefit Survey/Explanation of Benefits
Language/HIPAA-Privacy is Key
•
Annually sent notices: Annual Notice of Change (ANOC), Evidence of Coverage (EOC) and
Coordination of Benefits (COB)
Blue MedicareRX
Customer Care
•
Dedicated Call Center team of approximately 50 Customer Care Representatives (CCRs),
3 Senior Representatives, 3 call center Supervisors and 1 Quality/Training Analyst.
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Blue MedicareRx (BMRx) Service Model – “Concierge Service”:
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Assure that our members are aware of how their plan works, and are aware of the tools and resources available to make
important decisions in the future.
Ask productive questions and provide pro-active solutions.
Completely and accurately resolve inquiries during the first point of contact.
Provide detailed explanation and guidance to members.
•
Customer Care phone number: 1-888-543-4917, 24 hours a day, 7 days a week. TTY/TDD
users 1-866-236-1069.
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Insert for groups opting for Pre-Service Calls: Pre-Service line available for retirees
beginning [60 days prior to enrollment (for existing benefit options)/30 days prior to
enrollment (for new benefit options)]. CCRs will be available to answer plan design and
medication coverage questions in advance of your enrollment effective date. Phone
number: 1-866-832-9775.
•
Blue Cross Blue Shield of Massachusetts works in partnership with CVS Health to
develop, review and implement annual Customer Care training.
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The BMRx Call Center is monitored for call volume, trends and level of service offered to
members. Monitoring is performed via conference calls, onsite meetings and review of
materials and reports.
New Medex 2 Medical ID Card
ID Card #1
New Blue MedicareRX ID card
ID Card #2
CVS Discount Card
Extra Savings
For use only at CVS Retail Pharmacy Stores This card is similar to a regular retail store rewards card where members
can receive coupons and take advantage of specials for store branded
items and receive up to a 20% discount. *Restrictions apply.
Blue MedicareRX
Definition of Terms
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Formulary - A list of covered drugs.
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Step Therapy (ST) - Use of a formulary generic prescription first for treatment over the
more expensive formulary covered alternative.
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Quantity Limits (QL)- The amount of a drug allowed to be dispensed based on the drugs
application and usage.
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Generic Substitution- Massachusetts is a required generic substitution state, when a
generic is available it will be dispensed
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Prior Authorization (PA) - an approval needed before a drug can be dispensed.
Coverage Determination- A member or physician may request exception to a non
covered drug by submission of a form
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B vs D – Medications that can covered under Medicare Part B or Part D (Coverage
allowance will be based after review of PA)
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Specialty Drugs – Unique medications not readily available at the retail pharmacy and
that need to be supplied under certain circumstances.
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No Mail Order (NMO) - This includes speciality medications, controlled substances, and
other drugs requiring special handling.
• These medications must be filled through the retail pharmacy and retail pharmacy
copays will apply
Questions?
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