C and O Employees' Hospital Association
Introduction to the Summary of Benefits for C and O Employees’ Hospital Association Medicare Part D Prescription Plan
January 1, 2013 - December 31, 2013
Thank you for your interest in the C and O Employees’ Hospital Association ("COEHA") Medicare Part D Prescription Drug Plan. Our plan is administered by Navitus Health Solutions ("Navitus"), a Medicare approved Part D sponsor. This Summary of Benefits tells you some features of our plan. It doesn’t list every drug we cover, every limitation or exclusion. To get a complete list of our benefits, please call COEHA Customer Service and ask for the "Evidence of Coverage."
You have choices in your Medicare prescription drug coverage.
As a Medicare beneficiary, you can choose from different Medicare prescription drug coverage options. One option is to get prescription drug coverage through a Medicare Prescription Drug Plan, like the C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. Another option is to get your prescription drug coverage through a Medicare Advantage Plan that offers prescription drug coverage. You make the choice.
How can I compare my options?
The chart in this Summary list some important drug benefits. You can use this Summary of Benefits to compare the benefits offered by the C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan to the benefits offered by other Medicare Prescription Drug Plans or Medicare Advantage Plans with prescription drug coverage.
Where is the service area for the C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan?
The service area for this plan includes the entire United States. Your coverage is portable—you will never lose coverage by moving to another state. If you move out of the country, please call COEHA Customer Service to update your information.
Who is eligible to join?
You are eligible for membership in our plan as long as you are enrolled in the original Medicare Plan, Parts A and B. If you currently pay a premium for Medicare Part A and B, you must continue paying your premium in order to keep your Medicare Part A and B and remain a member of this plan and also fall in one of the following categories:
Where can I get my prescriptions?
Navitus has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We will not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Navitus offers national in-network prescription coverage at over 64,000 pharmacies. However, if you choose to go to a non-participating pharmacy, you must pay for the prescription in full and file a claim with COEHA for reimbursement. You will be responsible for the co-payments outlined in the co-payment table plus a penalty charge that includes the difference in the participating pharmacy network cost and the amount the pharmacy charged.
The COEHA Medicare Part D Prescription Drug Plan allows you to get your prescription(s) filled through:
1. Local Retail Pharmacy:The plan allows you to receive up to a 90-day supply of prescription medication at some local Navitus participating pharmacies. (Walmart, Kroger, Rite Aid, CVS and Target are a few of the chain retail pharmacies that will handle 90-day fills for mail-order copayments. There are also a few independent pharmacies that have agreed to do this.) Simply present your existing COEHA Medicare Part D Prescription Drug Plan ID card along with your prescription to a participating pharmacy. If you go to a participating pharmacy, you will pay only your co-payment amount.
2. Prescription Mail Order Service: The COEHA Medicare Part D Prescription Drug Plan offers participants an option to receive maintenance medications through WellDyne Rx. WellDyne Rx offers a convenient and cost effective way to obtain up to a 90-day supply of maintenance medication through the mail. Maintenance drugs are those drugs taken for an ongoing or chronic condition such as high blood pressure, heart disease or thyroid condition.
Does my plan cover Medicare Part B or Part D drugs?
The COEHA Medicare Part D Prescription Drug Plan plan does not cover drugs that are covered under Medicare Part B as prescribed and dispensed. Generally, we only cover drugs, vaccines, biological products and medical supplies that are covered under the Medicare Prescription Drug Benefit (Part D) and that are on our drug list.
What is a Prescription Drug Listing (Formulary)?
The COEHA Medicare Part D Prescription Drug Plan uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. For a complete listing of drugs available, please visit our website atwww.coeha.com, visit the Navitus website at www.navitus.com or call COEHA Customer Service.
Some drugs may have quantity limits and some may require approval in advance. This means your provider must get prior authorization from COEHA Customer Service for certain drugs. If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.
Can I have two Medicare Part D Prescription Drug Plans?
No. You can only join one Medicare Part D Prescription Drug Plan at a time.
How can I get extra help with my prescription drug plan costs or get extra help with other Medicare costs?
You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call:
What are my protections in this plan?
All Medicare Prescription Drug Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Prescription Drug Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days
before your coverage will end. The letter will explain your options for Medicare coverage in your area.
As a member of the COEHA Medicare Part D Prescription Drug Plan, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or you believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of the Navitus network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage for more information on how to request an exception or file an appeal or grievance.
What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we offer through Navitus. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact COEHA Customer Service for more details.
Summary of Benefits
Your monthly premium is $285.00 which includes payment for membership in the COEHA Supplemental Plan.
You annual deductible is $150.00.
The COEHA Medicare Part D Prescription Drug Plan features a three-tier prescription benefit. The next page shows a chart with the copayment amounts that you will be required to pay for your Medicare prescription drugs.
Initial Coverage Level:
After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $5,000.00.
*Penalty amounts may vary depending on the pharmacy’s charges. In addition to the co-payment noted in the table, you will also be responsible for a penalty charge that includes the difference in the participating pharmacy network cost and the amount the pharmacy charged.
You qualify for the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $4,750 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.
During this stage, you will pay:
Plan information, including the Evidence of Coverage, the pharmacy network listing, and formulary information are available for your reference on our website atwww.coeha.com. To request these documents be mailed to you, please contact COEHA Customer Service for the Evidence of Coverage, pharmacy network listing, and formulary information.
For more information about Medicare, please call Medicare at 1-800-MEDICARE
(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or visitwww.medicare.gov on the Web.
If you have questions, we are here to help.
Call COEHA Customer Service toll-free at: 1-800-679-9135
For local residents in the Clifton Forge, VA area: 862-5728
TTY/TTD users: 711 for all states
Hours of Operation are Monday - Friday: 8:30 am to 5:00 pm (EST)
Visit our web site at:www.coeha.com
Effective January 1, 2013, you can contact Navitus, after our weekday hours and 24 hours on Saturday and Sunday at:
Call Navitus Customer Care toll-free at: 1-866-270-3877
Hours for Monday-Thursday: 5:01 pm to 8:29 am (EST)