IMPORTANT INFORMATION ABOUT YOUR PRESCRIPTION DRUG COVERAGE It is very important for you to read the information in this mailing carefully. Retain all information you receive from SilverScript (Employer PDP) about your retiree prescription drug coverage from Southern California Edison for future reference. Effective Jan. 1, 2015, SilverScript (Employer PDP) is the new prescription drug plan for participants in Southern California Edison’s Medicare Part D prescription drug plan and Edison retirees and their spouses who become eligible for Medicare. This prescription drug plan is provided by SilverScript® Insurance Company and administered by CVS/caremark. Much of the information you receive from SilverScript (Employer PDP) is required by Medicare. It contains general language that does not explain the additional coverage from Southern California Edison. If you have any questions, please call SilverScript (Employer PDP) Customer Care at (866) 634-6558, available 24 hours a day, seven days a week. TTY users should call (866) 236-1069. Key points you need to know •
SilverScript (Employer PDP) is a Medicare Part D prescription drug plan (PDP) with additional coverage provided by Southern California Edison. This additional coverage means that you have more coverage than the standard Medicare Part D plan.
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You don’t have to do anything to enroll in the plan. You automatically will be enrolled.
•
You will have similar prescription drug benefits to what you currently have.
•
You will have the same copayment or coinsurance you currently pay through all the Medicare Part D coverage stages, including the coverage gap, also known as the “Donut Hole.”
•
You will have the same Edison annual prescription drug out-of-pocket maximum of $1,215 and same $150 out-of-pocket maximum per prescription. Once you reach the annual out-of-pocket maximum, you pay nothing for the rest of the year for covered expenses.
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There will be no interruption in your coverage. You will be covered by Express Scripts Medicare through Dec. 31, 2014. On Jan. 1, 2015, you will be covered by SilverScript (Employer PDP).
Y0080_52113_EXP_CLT.SCE_2015
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You will get a new ID card from SilverScript (Employer PDP) in December. Do not use this new card until Jan. 1, 2015. At that point, you should discard your old ID card from Express Scripts.
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If your spouse is not eligible for Medicare, he or she will continue to be covered by his or her current prescription drug benefit administered by CVS/caremark.
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SilverScript (Employer PDP) has most of the same network pharmacies that are in the CVS/caremark pharmacy network and many of the same network pharmacies as Express Scripts Medicare.
•
You continue to get your prescriptions filled at your local retail pharmacy or through a mail-order pharmacy.
•
You will be able to get up to a 90-day supply of your medication at a retail pharmacy. However, the price may be higher than getting that same prescription filled through the mailorder pharmacy.
What you need to do You don’t have to do anything to become a member of the plan. You will automatically be enrolled. However, there are some things that you should do, or may need to do to make sure you have the medications you need. •
Open and read any information you receive from SilverScript (Employer PDP). You will be receiving letters, statements about your drug costs called “Explanation of Benefits” and other information required by Medicare. Some of the materials will be for your information, but there may be letters that require you to take an action in order to keep your coverage.
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Save all information you receive from SilverScript (Employer PDP) for future reference.
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Get your prescriptions refilled in December through Express Scripts Medicare. If you will need to refill your prescription early in January, you may want to get your refill in December, if possible, to make sure you have enough of your medication during the transition to SilverScript (Employer PDP).
•
Get a new prior authorization after January 1, if needed. Some drugs may need prior authorizations under the new plan. You will receive a letter in December from SilverScript (Employer PDP) if this affects you. You may want to get your prescription refilled in December, if possible, through Express Scripts Medicare. This way, you have time to get a new prior authorization with SilverScript (Employer PDP) in January.
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Pay an additional premium if required by Medicare. If your income is over $85,000 for an individual or $170,000 for married filing jointly, Medicare requires that you pay an additional premium based on your income. You will be notified by Social Security if this affects you. Southern California Edison will pay your regular Part D premium through our payments to SilverScript (Employer PDP). The additional premium, called the Income Related Monthly Adjustment Amount (IRMAA), will be deducted from your Social Security check or you will be billed by Medicare. The additional amount is not paid to Southern California Edison or SilverScript (Employer PDP). It is important that you pay this additional amount if required. If you don’t pay it, Medicare will disenroll you from the plan. We won’t have any choice. If you are required to pay the additional premium, Southern California Edison will reimburse you for the amount of the additional premium. You will need to provide proof of your Medicare Part D IRMAA payment with your request for reimbursement. Please call EIX Benefits Connection at (866) 693-4947 for more information.
What information you will get from SilverScript (Employer PDP) There are three important mailings you will receive from SilverScript (Employer PDP). The first mailing includes a letter and Summary of Benefits. The letter explains that SilverScript (Employer PDP) is your new prescription drug plan and tells you that you will be enrolled automatically. You don’t have to do anything. It will also tell you that you have the choice to opt-out of this plan. We are required by law to give you the chance to opt-out of the plan. However, we do not recommend you do that and here’s why. Your prescription drug coverage is offered as part of your Edison retiree health coverage. If you opt-out of the SilverScript (Employer PDP), you will lose your Edisonsponsored prescription drug coverage, unless you enroll in Kaiser Senior Advantage plan provided by Edison. Also, you can be enrolled in only one Medicare prescription drug plan at a time. If you enroll in another Medicare Part D plan or a Medicare Advantage Plan (MAP) with or without prescription drug coverage, Medicare will disenroll you from our plan. The only exception is if you enroll in an MAP provided by Edison. Before making any decision about another plan, please call the EIX Benefits Connection to make sure you understand what will happen to your medical and prescription drug coverage.
The second mailing is your Welcome Kit. It will be sent to you after you are enrolled in the plan and includes: •
• •
Formulary (List of Covered Drugs) – the list of drugs covered by the Medicare Part D portion of the plan. Additional coverage is provided by Edison to improve the Part D benefits. To find out what drugs are covered through this additional coverage, contact SilverScript (Employer PDP) Customer Care. Pharmacy Directory – the list of network pharmacies Evidence of Coverage – details about the plan and your rights and responsibilities
The third mailing is your ID card. It will be sent in a separate mailing shortly after your Welcome Kit is mailed. Do not use this card until Jan. 1, 2015. Questions about your new Medicare Part D prescription drug coverage or drugs covered by the plan? Call SilverScript (Employer PDP) Customer Care at (866) 634-6558, available 24 hours a day, seven days a week. TTY users should call (866) 236-1069. Questions about eligibility, enrollment or your premium? Call the EIX Benefits Connection at (866) 693-4947, Monday through Friday, 7:30 a.m. to 5:30 p.m., Pacific time, except holidays. TTY/TDD users should call (800) 833-8334.
P.O. Box 52424, Phoenix, AZ 85072-2424
2015 Summary of Benefits
SilverScript (Employer PDP) sponsored by Southern California Edison a Medicare Prescription Drug Plan (PDP) offered by SilverScript® Insurance Company with a Medicare contract Prime Care Retirees January 1, 2015 – December 31, 2015
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SECTION 1 Introduction to Summary of Benefits SilverScript (Employer PDP) sponsored by Southern California Edison is a Medicare-approved Part D prescription drug plan with additional coverage provided by Southern California Edison to expand the Part D benefits. The Plan is offered by SilverScript® Insurance Company and administered by CVS/caremark. You have choices about how to get your Medicare prescription drug benefits
Southern California Edison is offering you a plan not offered to the public. As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options: • • • •
SilverScript (Employer PDP) sponsored by Southern California Edison A Medicare Advantage Plan (MAP) through Kaiser Permanente sponsored by Southern California Edison with prescription drug coverage Non-Edison-sponsored individual coverage through another Medicare Part D prescription drug plan Non-Edison-sponsored individual coverage through another 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.
You make the choice. If you decide not to be enrolled in SilverScript (Employer PDP), you will lose your Edison-sponsored prescription drug coverage, unless you enroll in the Kaiser Senior Advantage plan provided through Southern California Edison. Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what SilverScript (Employer PDP) covers and what you pay. • •
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If you want to compare the SilverScript (Employer PDP) plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. 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 http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048. To get a complete list of our benefits, please call SilverScript (Employer PDP) and ask for the Evidence of Coverage.
Sections in this booklet
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Things to Know About SilverScript (Employer PDP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Prescription Drug Benefits 1
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 at 1-866-634-6558, 24 hours a day, seven days a week. TTY users should call 1-866-236-1069. 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 1-866-634-6558, las 24 horas del día, los 7 días de la semana. Los usuarios de teléfono de texto (TTY) deben llamar al 1-866-236-1069.
Things to Know About SilverScript (Employer PDP) SilverScript (Employer PDP) Phone Numbers and Website
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If you are a member of this plan, call toll-free 1-866-634-6558. TTY users should call 1-866236-1069. If you are not a member of this plan, call toll-free 1-866-634-6558. TTY users should call 1866-552-6288. Our website: edison.silverscript.com.
Hours of Operation
You can call us 24 hours a day, seven days a week. Who can participate?
To participate in SilverScript (Employer PDP) sponsored by Southern California Edison, you must • • •
Be entitled to Medicare Part A and/or enrolled in Medicare Part B, and Live in our service area, which is the United States and its territories, and Meet any additional requirements established by Southern California Edison.
Which drugs are covered?
You can see the complete plan formulary (list of covered Part D prescription drugs) and any restrictions on our website at edison.silverscript.com. Or, call us and we will send you a copy of the formulary. The formulary can change throughout the year. Drugs may be added or removed or restrictions may be added or changed. Additional coverage is provided by Edison to expand the Medicare Part D benefits.
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The plan covers generic and brand name drugs: •
• • •
Generic drugs – most cost effective drugs to buy. The active ingredients in generic drugs are exactly the same as the active ingredients in brand name drugs whose patents have expired. They are required by the Food and Drug Administration (FDA) to be as safe and effective as the brand name drug. Preferred Brand Name drugs – brand name drugs that do not have a generic equivalent and are included on a preferred drug list. They are usually available at a lower cost than Non-Preferred Brand name drugs. Non-Preferred Brand Name drugs – brand name drugs that are not on a preferred drug list and usually are a higher cost. Specialty drugs – high-cost biotech and other unique drugs and include both brand name and generic drugs.
SilverScript (Employer PDP) sponsored by Southern California Edison has elected to cover certain drugs not covered under Medicare Part D through the additional coverage provided by Southern California Edison, such as: • • • • • •
Prescription drugs when used for anorexia, weight loss or weight gain Prescription drugs when used to promote fertility Prescription drugs when used for the symptomatic relief of cough or cold Prescription vitamins and mineral products not covered by Part D Prescription drugs when used for the treatment of sexual or erectile dysfunction Part B products, such as oral chemotherapy agents
These drugs are not subject to the appeals and exceptions process. Please contact SilverScript (Employer PDP) Customer Care for any questions regarding your additional coverage from Southern California Edison. Which pharmacies can I use?
The plan has a network of pharmacies. You must use a network pharmacy to have your coinsurance and copayments count toward your Medicare total drug costs and Medicare out-ofpocket costs, unless it is an emergency or non-routine circumstance. If you use an out-of-network pharmacy, you may have to pay the full cost of the drug at the pharmacy. In this case, you must complete a paper claim and send it to the plan to request reimbursement. You will be reimbursed the amount you paid minus your 10% out-of-network coinsurance. Please note: Veterans Affairs (VA) pharmacies are not permitted to be included in Medicare Part D pharmacy networks. If you are eligible for VA benefits, you can still use VA pharmacies under your VA benefits. However, the cost of those medications and what you pay out-of-pocket will not count toward your Medicare Part D drug spend or out-of-pocket costs. The pharmacies in our network can change at any time. Call SilverScript (Employer PDP) Customer Care for the network pharmacies in your area.
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Section II – Summary of Benefits How Medicare Works The standard Medicare Part D plan has four stages or benefit levels. This is how these stages work without your additional coverage provided by Southern California Edison: •
Deductible – $320 in 2015
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Initial coverage period – after an individual meets the deductible, he or she pays 25% of the drug cost until he or she reaches $2,960 in total drug costs.
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Coverage gap – also called the “donut hole”, this is when an individual pays a large portion of the cost, either 45% of the cost of brand-name drugs or 65% of the cost of generic drugs in 2015.
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Catastrophic coverage – after an individual reaches Medicare’s maximum annual outof-pocket cost of $4,700, he or she pays the greater of 5% or a minimum copayment of $2.65 for generic drugs or $6.60 for brand-name drugs.
In 2015, the standard Medicare Part D plan maximum out-of-pocket expense of $4,700 includes the deductible, any amount you have paid for your coinsurance, any amount you have paid during the coverage gap, any manufacturer discounts on your brand-name drugs in the coverage gap, and any amount paid by Extra Help or other governmental or assistance organizations on your behalf. Medicare’s maximum out-of-pocket cost does not include the monthly premium, if any, the cost of any prescription drugs not covered by Medicare, any amount paid by SilverScript (Employer PDP), or any amount paid through the additional coverage provided by Southern California Edison. Your Prescription Drug Benefits – Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services SilverScript (Employer PDP) How much is the monthly premium?
Your prescription drug premium is shown on your Enrollment Worksheet or on the EIX Benefits Connection website. If you have any questions, please contact EIX Benefits Connection at 1-866-693-4947. TTY users dial 711.
If your individual income is over $85,000, or if your income is over $170,000 and you are married filing your taxes jointly, you will be required to pay an income-related additional monthly premium in order to maintain your Medicare prescription drug coverage. This premium is adjusted based on your income. You will receive a letter from Social Security letting you know if you have to pay this extra amount. This letter will explain how they determined the amount you must pay and the actual Income Related Monthly Adjustment Amount (IRMAA). 4
If you are responsible for an additional premium the extra amount will be deducted automatically from your Social Security check. If your Social Security check is not enough to cover the additional premium, Medicare will send you a bill. You do not pay this amount to the plan. You send your payment to Medicare. If you are required to pay this additional premium, Edison will reimburse you. You will need to provide proof of your Medicare Part D IRMAA payment with your request for reimbursement. Contact EIX Benefits Connection at 1-866-693-4947 for more information. It is important that you make the payment, if required. If not, Medicare will notify SilverScript (Employer PDP) that it must stop your prescription drug coverage and you will be disenrolled from the plan. For more information about the withholdings from your check, visit www.socialsecurity.gov/mediinfo.htm, call 1-800-772-1213, or visit your local Social Security office. For more information about Part D premiums based on income, call Medicare at 1-800MEDICARE (1-800-633-4227).
SilverScript (Employer PDP) How much is the deductible?
This plan does not have a deductible.
Initial Coverage
SilverScript (Employer PDP)
You pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs for Part D drugs paid by both you and the plan. Edison provides additional coverage to reduce your share of the costs. You may get your drugs at network retail pharmacies and mail order pharmacies.
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SilverScript (Employer PDP) Up to a 34-day supply at a retail network pharmacy
Up to a 90-day supply at a retail network pharmacy
Tier 1 Generic
$0
$0
Tier 2 Preferred Brand
$0
$0
Tier 3 Non-Preferred Brand
$0
$0
Tier 4 Specialty
$0
$0
Tier
SilverScript (Employer PDP) Tier
Up to a 90-day supply through the mail order pharmacy
Tier 1 Generic
$0
Tier 2 Preferred Brand
$0
Tier 3 Non-Preferred Brand
$0
Tier 4 Specialty
$0
SilverScript (Employer PDP) Tier
Up to a 31-day supply at a long-term care (LTC) facility
Tier 1 Generic
$0
Tier 2 Preferred Brand
$0
Tier 3 Non-Preferred Brand
$0
Tier 4 Specialty
$0 6
Coverage Gap
SilverScript (Employer PDP)
Due to the additional coverage provided by Southern California Edison, you pay the same coinsurance or copayment you paid during the Initial Coverage stage. You will see no change in your coinsurance or copayment until you qualify for Catastrophic Coverage.
Catastrophic Coverage
SilverScript (Employer PDP)
After you reach $4,700 in Medicare out-of-pocket costs for the year, you pay the lower of: • •
Your Southern California Edison coinsurance or copayment, or Medicare’s Catastrophic Coverage, which is the greater of o 5% of the cost, or o $2.65 copayment for generic, including brand drugs treated as generic, or o $6.60 copayment for all other drugs
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This information is available for free in other languages. Please call SilverScript (Employer PDP) Customer Care number at 1-866-634-6558, 24 hours a day, seven days a week. TTY users should call 1-866-552-6288. Esta información está disponible gratuitamente en otros idiomas. Llame a nuestro Servicio al Miembro, al 1-866-634-6558 (teléfono de texto (TTY: 1-866-552-6288), 24 horas al día 7 días a la semana. You must continue to pay your Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on Jan. 1, 2016. SilverScript (Employer PDP) is a Prescription Drug Plan. This plan is offered by SilverScript Insurance Company, which has a Medicare contract. Enrollment depends on contract renewal.
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P.O. Box 52424, Phoenix, AZ 85072-2424
Important Plan Information Información Importante Sobre el Plan
