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2020 Evidence of Drug Coverage

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2020 Evidence of Drug Coverage January 1 – December 31, 2020 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of Express Scripts Medicare (PDP) for LODA – Medicare Primary This document gives you general information about your Medicare prescription drug coverage from January 1 – December 31, 2020. 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. For specific plan information, please refer to your Benefit Overview or Annual Notice of Changes. This plan, Express Scripts Medicare® (PDP), is offered by Medco Containment Life Insurance Company. (When this Evidence of Coverage says “we,” “us” or “our,” it means Medco Containment Life Insurance Company. When it says “plan” or “our plan,” it means Express Scripts Medicare.) Express Scripts Medicare Customer Service: 1.800.572.4098 (TTY users call: 1.800.716.3231) For more help or information, please contact Express Scripts Medicare Customer Service at the numbers above (also on the back of your member ID card) or go to our plan website at express-scripts.com. Calls to Customer Service are free. Customer Service is available 24 hours a day, 7 days a week. Customer Service has free language interpreter services available for non-English speakers. This information is available in braille. Please contact Customer Service at the numbers above if you need plan information in another format. This information is available for free in other languages. Please contact Customer Service at the numbers on the back of your member ID card and the front of this document for additional information. Customer Service is available 24 hours a day, 7 days a week. Esta información está disponible sin cargo en otros idiomas. Comuníquese con el Servicio de atención al cliente de Express Scripts Medicare llamando a los números que figuran al dorso de su tarjeta de identificación de miembro para obtener información adicional. El Servicio de atención al cliente está disponible las 24 horas, los 7 días de la semana. Benefits, premium and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. CRP1907_00293.1 E00CVB0A 2020 Evidence of Coverage for Express Scripts Medicare Table of Contents 2 2020 Evidence of Coverage Table of Contents Chapter 1. Getting started as a member of Express Scripts Medicare ............................................. 6 Tells what it means to be in a Medicare prescription drug plan and how to use this document. Tells about materials we will send you, your plan premium, your member ID card and your membership. SECTION 1 Introduction ............................................................................................................. 6 SECTION 2 What makes you eligible to be a plan member? .................................................. 7 SECTION 3 What other materials will you get from us? ......................................................... 8 SECTION 4 Your monthly premium for Express Scripts Medicare ..................................... 10 SECTION 5 Please keep your plan membership record up to date....................................... 12 SECTION 6 We protect the privacy of your personal health information ........................... 12 SECTION 7 How other insurance works with our plan ......................................................... 13 Chapter 2. Important phone numbers and resources ...................................................................... 14 Tells you how to get in touch with our plan, Express Scripts Medicare, and with other organizations, including Medicare, Social Security and programs that help people pay for their prescription drugs. Contact information for these organizations is located in the Appendix. SECTION 1 Express Scripts Medicare contacts (how to contact us, including how to reach Express Scripts Medicare Customer Service) ................... 14 SECTION 2 Medicare (how to get help and information directly from the Federal Medicare program)............................................................................... 18 SECTION 3 State Health Insurance Assistance Program (free help, information, and answers to your questions about Medicare) ..................................................... 19 SECTION 4 Quality Improvement Organizations (paid by Medicare to check on the quality of care for people with Medicare) .............................................................. 19 SECTION 5 Social Security ....................................................................................................... 19 SECTION 6 Medicaid (a joint Federal and state program that helps with medical costs for some people with limited income and resources) ............................................. 20 2020 Evidence of Coverage for Express Scripts Medicare Table of Contents 3 Chapter 3. Using the plan’s coverage for your Part D prescription drugs ..................................... 21 Explains rules you need to follow when you get your Part D drugs. Tells how to find out which drugs are covered or not covered, what type of restrictions may apply to coverage, and where to get your prescriptions filled. Tells about the plan's programs for drug safety and managing medications. SECTION 1 Introduction ........................................................................................................... 21 SECTION 2 Fill your prescription at a network pharmacy or through the plan’s home delivery service............................................................................................ 22 SECTION 3 The plan’s Drug List ............................................................................................. 26 SECTION 4 There are restrictions on coverage for some drugs ............................................ 27 SECTION 5 What if one of your drugs is not covered in the way you’d like it to be covered? .......................................................................... 28 SECTION 6 What if your coverage changes for one of your drugs? ..................................... 30 SECTION 7 What types of drugs are not covered by the plan? ............................................. 32 SECTION 8 Show your member ID card when you fill a prescription ................................. 33 SECTION 9 Part D drug coverage in special situations ......................................................... 33 SECTION 10 Programs on drug safety and managing medications ....................................... 36 Chapter 4. Paying for your Part D prescription drugs .................................................................... 38 Tells about the four stages of drug coverage for a standard Medicare Part D plan and their effect on what you pay. Tells about the Medicare Coverage Gap Discount Program, the Part D–IRMAA, the late enrollment penalty (LEP) and programs to help you pay for your prescription drugs. SECTION 1 Introduction ........................................................................................................... 38 SECTION 2 What you pay for a drug depends on the plan selected by your LODA Benefits Administrator and which drug payment stage you are in when you get the drug ........................................................................ 39 SECTION 3 We will send you a Part D Explanation of Benefits (Part D EOB) which explains payments for your drugs and which payment stage you are in ......... 40 SECTION 4 If the Deductible stage applies to your LODA Health Benefits Plans, you pay the full cost of your drugs during this stage ....................................................... 42 SECTION 5 During the Initial Coverage stage, the plan pays its share of your drug costs, and you pay your share ........................................................ 42 SECTION 6 Refer to your Benefit Overview or Annual Notice of Changes to see what you pay and what the plan pays during the Coverage Gap stage............................ 45 SECTION 7 During the Catastrophic Coverage stage, the plan pays most of the cost for your drugs ..................................................................................... 48 SECTION 8 What you pay for vaccinations covered by Part D depends on how and where you get them .......................................................................... 48 SECTION 9 Do you have to pay the Part D late enrollment penalty (LEP)? ....................... 50 SECTION 10 Do you have to pay an extra Part D amount because of your income? ........... 52 SECTION 11 Information about programs to help people pay for their prescription drugs .................................................................................. 53 2020 Evidence of Coverage for Express Scripts Medicare Table of Contents 4 Chapter 5. Asking us to pay our share of the costs for covered drugs............................................. 57 Describes what you need to do when you want to ask us to pay you back for our share of the cost. SECTION 1 Situations in which you should ask us to pay our share of the cost of your covered drugs ......................................................................... 57 SECTION 2 How to ask us to pay you back............................................................................. 59 SECTION 3 We will review your request for payment and say yes or no ............................. 59 SECTION 4 Other situations in which you should save your receipts and send copies to us ...................................................................................................
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