C and O Employees' Hospital Association
SUMMARY OF BENEFITS PLANS 7 AND 10
2017 Summary of Benefits
C and O Employees’ Hospital Association
Medicare Part D Prescription Plan
Thank you for your interest in the C and O Employees’ Hospital Association ("COEHA") Medicare Part D Prescription Drug Plan, a Medicare approved Part D sponsor. Our plan is administered by Navitus Health Solutions ("Navitus"). This Summary of Benefits tells you some features of our plan. It doesn’t list every drug we cover, every limitation orexclusion. 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 fromdifferent Medicare prescription drug coverageoptions. One option is to get prescription drugcoverage through a Medicare Prescription DrugPlan, like theC and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan. Anotheroption is to get your prescription drug coveragethrough a Medicare Advantage Plan that offersprescription drug coverage. You make the choice.
How can I compare my options?
The chart in this Summary lists some importantdrug benefits. You can use this Summary ofBenefits to compare the benefits offered bythe C and O Employees’ Hospital Association Medicare Part D Prescription Drug Plan to the benefitsoffered by other Medicare Prescription DrugPlans or Medicare Advantage Plans withprescription 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 ofthe country, please call COEHA Customer Service to updateyour 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?
Navitushas formed anetwork of pharmacies. You must use a networkpharmacy to receive plan benefits. We will notpay for your prescriptions if you use an out-of-networkpharmacy, 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 COEHAfor 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 localNavitusparticipating 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 Planplan does notcover drugs that are covered under Medicare PartB as prescribed and dispensed. Generally, weonly cover drugs, vaccines, biological productsand medical supplies that are covered under theMedicare Prescription Drug Benefit (Part D) andthat are on our drug list.
What is a Prescription Drug Listing (Formulary)?
The COEHA Medicare Part D Prescription Drug Plan uses a formulary. Aformulary is a list of drugs covered by your planto meet patient needs. We may periodically add,remove, or make changes to coverage limitationson certain drugs or change how much you pay fora drug. If we make any formulary change thatlimits our members’ ability to fill theirprescriptions, we will notify the affected enrolleesbefore the change is made. Our members will receive a copy of the 2016 Abridged Formulary. For a complete listing of drugs, please visit our website athttp://www.coeha.comor call COEHA Customer Service.
Some drugs may have quantity limitsand some may require approval in advance or step therapy.If you are currently taking a drug that is not onour formulary or subject to additionalrequirements or limits, you may be able to get atemporary supply of the drug. You can contact usto request an exception or switch to an alternativedrug listed on our formulary with yourphysician’s help. Call us to see if you can get atemporary supply of the drug or for more detailsabout 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 yourprescription drug premiums and costs as well asget help with other Medicare costs. To see if youqualify for extra help, call:
What are my protections in this plan?
All Medicare Prescription Drug Plans agree tostay in the program for a full year at a time. Eachyear, the plans decide whether to continue foranother year. Even if a Medicare PrescriptionDrug Plan leaves the program, you will not loseMedicare coverage. If a plan decides not tocontinue, it must send you a letter at least 90 daysbefore your coverage will end. The letter willexplain your options for Medicare coverage inyour area.
As a member of the COEHA Medicare Part D Prescription Drug Plan,you have the right to request a coveragedetermination, which includes the right to requestan exception, the right to file an appeal if we denycoverage for a prescription drug, and the right tofile 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 Coveragefor 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 beinvited to participate in a program designed foryour specific health and pharmacy needs. Youmay decide not to participate but it isrecommended that you take full advantage of thiscovered service if you are selected. ContactCOEHA 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 $200.00.
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 $200.00 yearly deductible, you pay the following until your total yearly drug costs reach $3,700.00.
*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 $4950.00limit 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 at http://www.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 new members, these documents, along with your COEHA Identification Card, will be mailed to you in an acceptance packet once your enrollment has been approved.
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, 7 days a week. TTY users should call 1-877-486-2048.
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: http://www.coeha.com
You can contact Navitus after our weekday hours and 24 hours on Saturday and Sunday.
Call Navitus Customer Care toll-free at: 1-866-270-3877
Hours for Monday-Thursday: 5:01 pm to 8:29 am (EST)
ATENCIÓN: sihablaespañol, tiene a sudisposiciónserviciosgratuitos de asistencialingüística. Llame al 1-800-270-3877 (TTY: 711).
주의: 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-800-270-3877 (TTY: 711)번으로전화해주십시오.
CHÚ Ý: NếubạnnóiTiếngViệt, cócácdịchvụhỗtrợngônngữmiễnphídànhchobạn. Gọisố 1-800-270-3877 (TTY: 711).
(رقمهاتف800-270-3877-1 ملحوظة: إذاكنتتتحدثاذكراللغة،فإنخدماتالمساعدةاللغويةتتوافرلكبالمجان. اتصلبرقم
ACHTUNG: WennSie Deutsch sprechen, stehenIhnenkostenlossprachlicheHilfsdienstleistungenzurVerfügung. Rufnummer: 1-800-270-3877 (TTY: 711)
ATTENTION : Si vousparlezfrançais, des services d'aidelinguistiquevoussontproposésgratuitement. Appelez le 1-800-270-3877 (ATS : 711).
ВНИМАНИЕ: Есливыговоритенарусскомязыке, товамдоступныбесплатныеуслугиперевода. Звоните 1-800-270-3877 (телетайп: 711).
PAUNAWA: Kung nagsasalitaka ng Tagalog, maaarikanggumamit ng mgaserbisyo ng tulongsawikanangwalangbayad. Tumawagsa 1-800-270-3877 (TTY: 711).
Wann du Deitsch (Pennsylvania German / Dutch) schwetzscht, kannscht du mitausKoschteebbergricke, ass dihrhelftmit die englischSchprooch.RufselliNummeruff: Call 1-800-270-3877 (TTY: 711).
توجه: اگربهزبانفارسیگفتگومیکنید،تسهیلاتزبانیبصورترایگانبرایشمافراهممی باشد. با1-800-270-3877 (TTY: 711)تماسبگیرید.
ማስታወሻ: የሚናገሩትቋንቋኣማርኛከሆነየትርጉምእርዳታድርጅቶች፣በነጻሊያግዝዎትተዘጋጀተዋል፡ወደሚከተለውቁጥርይደውሉ 1-800-270-3877 (መስማትለተሳናቸው: 711).
خبردار: اگر آپ اردو بولتے ہیں، تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں ۔ کال کریں1-800-270-3877 (TTY: 711).
XIYYEEFFANNAA: AfaandubbattuOroomiffa, tajaajilagargaarsaafaanii, kanfaltiidhaanala, niargama. Bilbilaa 1-800-270-3877 (TTY: 711).
C and O Employees’ Hospital Association complies
with applicable Federal civil rights laws and does not discriminate on the basis
of race, color, national origin, age, disability or sex. C and O Employees’
Hospital Association does not exclude people or treat them differently because
of race, color, national origin, age, disability or sex. C and O Employees’
Hospital Association provides free aids and services to people with disabilities
to communicate effectively with us, such as: qualified sign language
interpreters and written information in other formats (large print, audio,
accessible electronic formats, other formats). C and O Employees’ Hospital
Association provides free language services to people whose primary language is
not English such as: qualified interpreters and information written in other
languages. If you need these services, contact the C and O Employees’ Hospital
Association Customer Care Center at 800-679-9135. If you believe that C and O
Employees’ Hospital Association has failed to provide these services or
discriminated in another way on the basis of race, color, national origin, age,
disability, or sex, you can file a grievance. If you need help filing a
grievance, COEHA Grievance and Appeals is available to help you. You can file a
grievance in person or by mail, fax, or email:
Co-Administrators, COEHA, 511 Main Street, 2nd Floor, Clifton Forge, VA 24422
Phone: 800-679-9135 or Email: firstname.lastname@example.org
You can also file a civil rights complaint with the
U.S. Department of Health and Human Services, Office for Civil Rights,
electronically through the Office for Civil Rights Complaint Portal, available
at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: