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2016 Evidence of Coverage for Express Scripts Medicare 1 Table of Contents

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2016 Evidence of Coverage for Express Scripts Medicare 1 Table of Contents | Value | Choice | Express Scripts Medicare® (PDP) offered by Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of Express Scripts Medicare (PDP) This booklet gives you the details about your Medicare prescription drug coverage from January 1 – December 31, 2016. 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, Express Scripts Medicare, is offered by Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located in New York State only). (When this Evidence of Coverage says “we,” “us,” or “our,” it means Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York. When it says “plan” or “our plan,” it means Express Scripts Medicare.) Express Scripts Medicare (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal. This information is available for free in other languages. Please contact our Customer Service numbers at 1.800.758.4574; New York State residents: 1.800.758.4570 for additional information. (TTY users should call 1.800.716.3231.) Hours are 24 hours a day, 7 days a week. Customer Service also has free language interpreter services available for non-English speakers. Esta información está disponible sin cargo en otros idiomas. Comuníquese con nuestros números de Servicio al cliente al 1.800.758.4574, o al 1.800.758.4570 si reside en el estado de New York, para obtener información adicional. (Los usuarios de TTY deben llamar al 1.800.716.3231.) El horario de atención es las 24 horas del día, los 7 días de la semana. El Servicio al cliente también dispone de servicios gratuitos de intérprete para quienes no hablan inglés. This information is available in braille. Please contact Customer Service at the phone numbers above if you need plan information in another format. Benefits, formulary, pharmacy network, premium, deductible, and/or copayments/coinsurance may change on January 1, 2017. OMB No. 0938-1051 EXPIRATION DATE: 03/31/2017 Y0046_E00SNS6A Accepted E00SNS6A 2016 Evidence of Coverage for Express Scripts Medicare 1 Table of Contents 2016 Evidence of Coverage Table of Contents This list of chapters and page numbers is your starting point. For more help in finding 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 .................................................................................4 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, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources..........................................................17 Tells you how to get in touch with our plan (Express Scripts Medicare) 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 ........................32 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 ...........................................54 Tells about the four stages of drug coverage (Deductible Stage, Initial Coverage Period, Coverage Gap Stage, Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the five cost-sharing tiers for your Part D drugs and tells what you must pay for a drug in each cost-sharing tier. Tells about the late enrollment penalty. Chapter 5. Asking us to pay our share of the costs for covered drugs ...............................87 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 ..........................................................................94 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. 2016 Evidence of Coverage for Express Scripts Medicare 2 Table of Contents Chapter 7. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) ..............................................112 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...............................................................135 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 .......................................................................................................144 Includes notices about governing law and about non-discrimination. Chapter 10. Definitions of important words..........................................................................147 Explains key terms used in this booklet. Appendix Important phone numbers and resources............................................................ I Includes contact information for the AIDS Drug Assistance Programs, the State Health Insurance Assistance Programs, the Quality Improvement Organizations, State Medicaid Offices, and the State Pharmaceutical Assistance Programs. CHAPTER 1 Getting started as a member 2016 Evidence of Coverage for Express Scripts Medicare 4 Chapter 1: Getting started as a member Chapter 1. Getting started as a member SECTION 1 Introduction ..................................................................................................... 5 Section 1.1 You are enrolled in Express Scripts Medicare, which is a Medicare Prescription Drug Plan .................................................................................... 5 Section 1.2 What is the Evidence of Coverage booklet about? .......................................... 5 Section 1.3 Legal information about the Evidence of Coverage ........................................ 5 SECTION 2 What makes you eligible to be a plan member?........................................... 6 Section 2.1 Your eligibility requirements .......................................................................... 6 Section 2.2 What are Medicare Part A and Medicare Part B? ........................................... 6 Section 2.3 Here is the plan service area for Express Scripts Medicare ............................ 6 SECTION 3 What other materials will you get from us? ................................................. 7 Section 3.1 Your plan membership card – Use it to get all covered prescription drugs .... 7 Section 3.2 The Pharmacy Directory: Your guide to pharmacies in our network ............. 7 Section 3.3 The plan’s List of Covered Drugs (Formulary) .............................................. 8 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 .................... 8 SECTION 4 Your monthly premium for Express Scripts Medicare ............................... 9 Section 4.1 How much is your plan premium? .................................................................. 9 Section 4.2 There are several ways you can pay your plan premium .............................. 11 Section 4.3 Can we change your monthly plan premium during the year? ...................... 13 SECTION 5 Please keep your plan membership record up to date .............................. 13 Section 5.1 How to help make sure that we have accurate information about you .......... 13 SECTION 6 We protect the privacy of your personal health information ................... 14 Section 6.1 We make sure that your health information is protected ............................... 14 SECTION 7 How other insurance works with our plan ................................................. 14 Section 7.1 Which plan pays first when you have other insurance? ................................ 14 2016 Evidence of Coverage for Express Scripts Medicare 5 Chapter 1: Getting started as a member SECTION 1 Introduction Section 1.1 You are enrolled in Express Scripts Medicare, which is a Medicare prescription drug plan You are covered by Original Medicare for your healthcare coverage, and you have chosen
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