P.O. Box 52424, Phoenix, AZ 85072-2424
2016 Summary of Benefits
HealthSelectSM Medicare Rx provided through the Employees Retirement System of Texas (ERS) (a Medicare Prescription Drug Plan (PDP) offered by SilverScript® Insurance Company with a Medicare contract) January 1, 2016 – December 31, 2016
Y0080_52001_SB_CLT.ERS_2016
Section I – Introduction to Summary of Benefits This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. You have two choices on how to get your Medicare prescription drug benefits: •
You can enroll in a Medicare Prescription Drug Plan, like HealthSelect Medicare Rx provided through ERS, or
•
You can get prescription drug coverage through a Medicare Advantage Plan (like an HMO or PPO) or another Medicare health plan that offers Medicare prescription drug coverage. You get all of your Part A and Part B coverage, and prescription drug coverage (Part D), through these plans.
This booklet summarizes what HealthSelect Medicare Rx covers and what you pay. Tips for comparing your Medicare choices •
If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on www.medicare.gov.
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If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling (800) MEDICARE (800) 633-4227, 24 hours a day, 7 days a week. TTY users should call (877) 486-2048.
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To get a complete list of our benefits, please call HealthSelect Medicare Rx and ask for the Evidence of Coverage.
Sections in this booklet •
Things to Know About HealthSelect Medicare Rx
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Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
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Prescription Drug Benefits
This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us toll-free at (855) 344-0938, 24 hours a day, 7 days a week. TTY users should call 711. Este documento está disponible en otros formatos tales como Braille y en letras grandes. Este documento podría estar disponible en un idioma distinto al inglés. Para obtener información adicional, llámenos al (855) 344-0938, las 24 horas del día, los 7 días de la semana. Los usuarios de teléfono de texto (TTY) deben llamar al 711.
Things to Know About HealthSelect Medicare Rx Hours of Operation You can call us toll-free 24 hours a day, 7 days a week. HealthSelect Medicare Rx Phone Numbers and Website •
(855) 344-0938, TTY: 711
•
www.HSmedicarerx.com
Who can join? To join HealthSelect Medicare Rx, you must be retired from state employment, entitled to Medicare Part A and/or be enrolled in Medicare Part B, and live in our service area. Our service area includes the United States and its territories. Which drugs are covered? To see the complete plan formulary (list of Part D prescription drugs) and any restrictions, call SilverScript Customer Care and we will send you a copy of the formulary, or visit our website at www.HSmedicarerx.com. ERS has elected to cover certain drugs not covered under Medicare Part D as described and dispensed as part of a supplemental benefit. These are not subject to the appeals and exceptions process. Please contact SilverScript Customer Care for any questions regarding your supplemental benefit. How will I determine my drug costs? Our plan groups each medication into one of three “tiers.” Use your formulary to locate what tier your drug is on so you can determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document, we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Please note: ERS provides supplemental coverage that may differ in structure from the primary benefit and cover additional medications. There may be instances where your cost share may be more or less when it is paid by the supplemental coverage. If you are unsure about the cost share on the supplemental coverage, or on which drugs may or may not be covered, please call SilverScript Customer Care to verify drug coverage. Which pharmacies can I use? We have a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. Your cost may be greater if you use an out-of-network pharmacy to fill your prescriptions. If you use an out-of-network pharmacy, you must submit a paper claim to get reimbursed. To see our plan's Pharmacy Directory, call SilverScript Customer Care and we will send you a copy. If you have any questions about this plan’s benefits or costs, please contact SilverScript for details.
Section II – Summary of Benefits Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services HealthSelect Medicare Rx How much is the monthly premium?
How much is the deductible?
Members do not pay a separate monthly premium for prescription drug coverage.
Your annual deductible is $50.00.
Prescription Drug Benefits Initial Coverage
HealthSelect Medicare Rx After you pay your yearly deductible, you pay the amounts below until your total yearly drug costs reach $3,310.00. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail-order pharmacies.
Your Costs Under the HealthSelect Medicare Rx Plan
When To Use Your Benefit:
Tier 1
Tier 2
Tier 3
Day Supply Limit:
Standard Retail Cost Sharing (In-Network)
Retail Pharmacy in the Extended Days Supply (EDS) Network
Mail-Order Cost Sharing
Long-Term Care (LTC) Cost Sharing
For up to a 30day supply of immediate or short-term medication needs
For a 31- to 90-day supply of maintenance or long-term medication needs
For up to a 90-day supply of maintenance or long-term medication needs
For up to a 31-day supply of immediate or short-term medication needs
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$10 for nonmaintenance
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$20 for a 31-60 day supply
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$20 for a 31-60 • day supply
$10 for nonmaintenance
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$10 for maintenance
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$30 for a 61-90 day supply
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$30 for a 61-90 • day supply
$10 for maintenance
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$35 for nonmaintenance*
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$70 for a 31-60 day supply*
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$70 for a 31-60 • day supply*
$35 for nonmaintenance*
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$45 for maintenance*
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$105 for a 6190 day supply*
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$105 for a 6190 day supply*
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$45 for maintenance*
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$60 for nonmaintenance*
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$120 for a 3160 day supply*
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$120 for a 3160 day supply*
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$60 for nonmaintenance*
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$75 for maintenance*
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$180 for a 6190 day supply*
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$180 for a 6190 day supply*
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$75 for maintenance*
30-day supply
31-90 day supply
up to a 90-day supply
up to a 31-day supply
*If a generic is available and you choose to buy the brand-name drug, you will pay the generic copay plus the cost difference between the brand-name and the generic drug. As these claims will pay under the supplemental coverage offered by ERS, they will not qualify for any “Extra Help” you might receive. Amounts paid will not be included in the out-of-pocket maximum limits to qualify for Catastrophic Coverage.
Coverage Gap
HealthSelect Medicare Rx ERS will provide supplemental coverage that will keep your copays consistent through the Coverage Gap, therefore you will see no change in your copays until you qualify for Catastrophic Coverage. Once you reach an out-of-pocket cost of $4,850.00, you qualify for Catastrophic Coverage.
Catastrophic Coverage
HealthSelect Medicare Rx You qualify for Catastrophic Coverage once your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail-order) reach $4,850.00. During Catastrophic Coverage, you will pay no more than your regular copays as described in the chart on the previous page for medications covered under Medicare Part D. HealthSelect Medicare Rx will pay the rest. Since your employer group is providing supplemental coverage on your plan, you may pay less.
HealthSelect Medicare Rx is an Employer Prescription Drug Plan provided by ERS and administered by SilverScript Insurance Company, which has a contract with Medicare. Enrollment in HealthSelect Medicare Rx depends on SilverScript’s contract renewal with Medicare.
P.O. Box 52424, Phoenix, AZ 85072-2424
Important Plan Information Información Importante Sobre el Plan
