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FAQs: Express Scripts Medicare

FAQs: Express Scripts Medicare


General Questions  |   ID Cards  |   Pharmacies, Formulary, and Drug Coverage
Eligibility Questions  |   Medicare-specific Terminology

General Questions

What is Medicare Part D?

Express Scripts Medicare for TRS-Care is a Medicare Part D plan. Medicare Part D is prescription drug coverage that is available to everyone with Medicare to help cover the cost of prescription drugs. Coverage under the Medicare Part D program can be direct to individuals who qualify for Medicare Part A and/or B or can be a group benefit sponsored by a former employer or retiree group, such as the plan being offered by TRS.

What is a group sponsored Medicare prescription drug plan (such as Express Scripts Medicare for TRS-Care)?

Express Scripts Medicare for TRS-Care is a prescription plan offered through the Medicare Part D program, sponsored by TRS, and approved by the Centers for Medicare & Medicaid Services. This benefit offers more coverage than a standard individual Part D plan and ensures that retired participants and their covered Medicare-eligible dependents will receive benefits that are better than the coverage currently provided by TRS-Care under the standard TRS-Care 2 and 3 plans.

What is the difference between Express Scripts Medicare for TRS-Care and an individual Medicare Part D plan?

This plan is being created specifically for TRS-Care and is only available to its participants and covered Medicare-eligible dependents. Most individual plans typically have a donut hole (also known as the Coverage Gap stage) during which participants may be responsible for higher costs. Participants in the Express Scripts Medicare for TRS-Care plans will continue to pay their TRS copays during the Coverage Gap stage and will not experience an increase in copays. Unlike an individual plan, you do not need to take extra steps to enroll in the TRS-sponsored plan. You will automatically be covered. Please remember, itís important that you do not enroll in an individual Medicare Part D prescription drug plan benefit if you participate in TRS-Care Plans 2 or 3 for the 2013 plan year.

Do I have a choice about whether or not I want this prescription drug coverage?

Yes. You may ďopt outĒ of this coverage; however your prescription drug coverage will then revert to the Standard plan offering which has higher copays; this decision will not have any impact on the premium you pay for your prescription/medical benefit. In addition, if you opt out or leave this plan, you will not be able to return to the TRS-sponsored Medicare Part D plan until the following annual enrollment period. Coverage will not take effect until the beginning of the new plan year after you elect coverage.

What is a late enrollment penalty?

The late enrollment penalty is an amount that may be added to your Part D premium. You may owe a late enrollment penalty if, at any time after your initial enrollment period is over, there is a period of 63 or more days in a row when you don't have Part D or other creditable prescription drug coverage. The cost of the late enrollment penalty depends on how long you went without creditable prescription drug coverage. If you are responsible for a late enrollment penalty, Express Scripts Medicare will send you a notification indicating how much you owe. TRS-Care Plans 2 and 3 have been determined to be creditable coverage for the 2012/2013 plan year.

How is TRS saving money by offering TRS-Care participants a Medicare Part D plan?

The new prescription drug benefits offered under the Express Scripts Medicare plans make TRS-Care eligible for additional funding from drug manufacturers. Because savings from the new plans are so significant, TRS was able to pass some of the savings on to retirees.

When will I receive more information about the plan change?

TRS-Care has communicated the upcoming change via its bulletin sent to participants in mid-July. You will also receive mailings from Express Scripts with additional details.

Will my benefit change as a result of this plan change?

TRS-Care reviews benefits on an annual basis. As a result of this change, TRS has been able to lower the copays for this prescription drug coverage. Overall drug coverage is also expected to remain comparable to your current coverage. However, there are certain CMS requirements that need to be met by all Medicare Part D plans. Retirees that will be impacted by any coverage changes will be notified directly.

Do I need to do anything to be enrolled in this new plan?

No. If you qualify for coverage under this new plan, you will be automatically covered by the plan on January 1, 2013.

Will I need to pay an additional premium for this coverage?

No. An additional premium will not be charged for this prescription drug coverage. However, some people will need to pay an extra amount directly to the Federal government because of their yearly income. If your adjusted gross income is $85,000 or above for an individual (or married individuals filing separately) or $170,000 or above for married couples, you will receive a separate notification from the Federal government regarding the additional amount and ways to pay it.

Will communications look different?

Yes. The Centers for Medicare & Medicaid Services (CMS) requires that all members of Medicare Part D plans receive uniform communications. You may notice that you will be receiving more communications as a result of this transition.

You can identify mailings related to your prescription drug coverage by looking for both the Express Scripts Medicare and TRS-Care logos. While the TRS-Care logo will appear on these mailings, please understand the volume and frequency of mailings are due to government regulations and not something that TRS can influence or control.

In addition, the Medicare Part D program requires that all communications be sent to each individual participant and not at the household level. This means that both you and each of your covered eligible dependents will receive separate mailings from Express Scripts Medicare, including separate prescription ID cards. Again, this is due to Federal government regulations and is not something that TRS can control.

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ID Cards

Will I be getting a new ID card with this plan?

Yes. You and any covered dependents that are Medicare-eligible should each receive a separate new ID card prior to your new planís effective date, January 1, 2013. This will occur as soon as Medicare approves your enrollment and your covered dependentís enrollment into the plan.

What if I donít receive my prescription drug ID card?

If you havenít received your new Express Scripts Medicare ID card prior to your effective date, request a card by calling TRS-Care Customer Service at 1-800-367-3636, Option 2, 24 hours a day, 7 days a week.

Will both my husband/wife and I receive our own ID cards?

Yes. Once your enrollment and your dependentsí enrollment are approved by the Centers for Medicare & Medicaid Services, each individual will receive his or her own ID card in their Express Scripts welcome kit.

Note: Since ID cards are sent based on when CMS approves enrollments and all enrollments may not be approved on the same day, participants at the same address may receive kits/ID cards several days or weeks apart.

Should I continue to use my current ID card for medical coverage?

Yes. Continue using your existing medical card for medical coverage unless instructed otherwise. You will continue to have two separate ID cards Ė one for medical and one for prescriptions.

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Pharmacies, Formulary, and Drug Coverage

Where can I get my prescriptions filled?

There are currently more than 64,000 pharmacies in Express Scriptsí national pharmacy network.Most of the retail pharmacies that participate in the current Standard plan will participate in your newMedicare plan. The Medco Pharmacy will continue to be part of this new planís network of pharmacies. Your welcome kit will include a pharmacy directory that will provide information on the closest pharmacies to you.

Am I still able to use VA pharmacies? / How will my enrollment in this plan impact my existing VA benefits?

Due to CMS rules, 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 those benefits. However, the cost of those medications and what you pay out of pocket will not count toward your Medicare Part D total yearly drug costs or yearly out-of-pocket drug costs. Review your new plan benefit against your VA benefit copayments to determine which option makes the most sense for you.

Will I need to get a new prescription for medications I am currently taking?

No. Your current prescriptions and refill history with your current retail network pharmacies and/or Medco Pharmacy will be automatically transferred to your new prescription drug plan.

Do I need to do anything if the drug Iím taking requires prior authorization?

Yes. Due to clinical criteria differences, prior authorizations that you currently have on file will not carry over into the new plan, so you may have to get a new prior authorization when your new benefit starts. If a drug you are currently taking is impacted, you will receive a separate letter from Express Scripts Medicare notifying you of this requirement and what your next steps should be.

In the meantime, you will be allowed up to a 31–day transition supply of Part D medications after January 1 while you obtain a new prior authorization.

How will I know if my drug requires a prior authorization or has any other special requirements?

Once your enrollment into the plan is approved by the Centers for Medicare & Medicaid Services, Express Scripts will send you a welcome package that will contain important plan materials, including the planís Formulary (List of Covered Drugs). This document will include a listing of the most commonly prescribed drugs covered by your new plan as well as information regarding prior authorizations and other requirements. Most drugs covered under the Standard plan will be covered under the Medicare prescription drug plan however there may be a limited circumstance where a drug may not be covered under the Medicare plan.

What is the plan formulary?

The plan formulary is a list of commonly used Part D drugs covered by your plan. The drugs on this list are selected by Express Scripts Medicare with the help of doctors and pharmacists, and include both brand-name and generic drugs. Not all drugs covered by the plan are included in the formulary. If your drug is not included in the formulary, you can contact Express Scripts Customer Service to determine if your drug is covered and how much it will cost.

What are tiers?

Tiers are a way of organizing different types of drugs on a planís formulary (drug list). They are used as a means to keep costs down for participants by placing less expensive drugs on a lower tier. In general, drugs on a lower cost-sharing tier cost less than drugs on a higher cost-sharing tier. Every drug on this planís formulary is in one of three tiers.

The three cost-sharing tiers on our drug list are:

Tier 1: Generic Drugs
This tier includes many commonly prescribed low-cost drugs. (Lowest cost)

Tier 2: Preferred Brand Drugs
This tier includes preferred brand-name drugs as well as some generic drugs. (Mid-range cost)

Tier 3: Non-Preferred Brand DrugsThis tier includes non-preferred brand-name drugs as well as some generic drugs. (Highest cost)

Note: Participants in Express Scripts Medicare will not be subject to paying the difference in cost for brand drugs where a generic is available.

Are all drugs available at a 90-day supply?

While most drugs are available at a 90-day supply at both retail and mail order, some pharmacies do not dispense 90-day supplies at the planís copayment amounts. If you have questions, contact TRS-Care Customer Service at 1-800-367-3636, Option 2.

What is the difference between generic, preferred brand, and non-preferred brand drugs?

An FDA approved generic drug is the same as its brand-name counterpart in safety, strength, quality, the way it works, how itís taken, and the way it should be used. Typically, generic drugs cost less than brandname drugs.

A preferred brand drug is a brand-name drug that is manufactured by the company that initially developed it. It will generally be at a higher cost than a generic drug, but at a lower cost than a non-preferred brand drug.

A non-preferred brand drug generally costs more than generic or preferred brand drugs.

Will there be a different appeals process for drug coverage determinations?

Express Scripts will review all coverage determinations, 1st and 2nd level appeals. 3rd level appeals (if your request meets the minimum required dollar amount) will be sent to an Administrative Law Judge who works for the Federal government and the Administrative Law Judge will review your 3rd level appeal.

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Eligibility Questions

How do I qualify for this coverage?

TRS-Care 2 and TRS-Care 3 retirees residing in the United States who also haveMedicare PartAand/or Part B will automatically be provided the advantage of these new improved plans. These plan options will also be offered to retirees and their dependents as they become eligible forMedicare and enroll inMedicare PartAand/or Part B.

What if Iím enrolled in an individual Medicare Advantage Plan or a different prescription drug plan that is NOT sponsored or coordinated by TRS-Care?

You can be in only one Medicare prescription drug plan at a time. If you are currently enrolled in any type of Medicare health or prescription plan that is not sponsored by or coordinated by TRS, enrollment in this plan will disenroll you from that plan. Note: This Medicare prescription plan is part of your TRS-sponsored benefit and will not conflict with your enrollment in the TRS-sponsored Medicare Advantage Plan.

What should I do if I am already enrolled in another Part D plan and I do not want to be enrolled in this plan?

Review the overall costs and coverage of your current benefit against the TRS-Care-provided benefit. You may contact Express Scripts Medicare Customer Service, to price all of your medications and to find network pharmacies near you. If you are currently enrolled in an individual Medicare prescription drug plan and are receiving low-income subsidy assistance from the Federal government, the assistance will also carry over to this new TRS-Care Medicare prescription plan.

Participant would like to remain in the current TRS-Care standard plan:

If you feel that you want to remain in the current TRS-Care standard plan, make sure you contact TRS-Care Customer Service at 1-800-367-3636, Option 2, to discuss opting out of the Express Scripts Medicare plan.

Participant would like to transition to new TRS-Care-sponsored Express Scripts Medicare coverage:

You do not need to do anything at this time; you will be automatically enrolled in the TRS-Care-sponsored coverage and disenrolled from your current plan.

My covered spouse is not currently Medicare-eligible. How will he or she be impacted if I join this plan?

If your covered spouse is not Medicare-eligible, he/she cannot transition to this plan at this time and will remain in his/her current TRS-Care plan.

Will I pay an additional premium to TRS for this plan?

No. The cost of this coverage is included in the amount you already pay TRS for your health and prescription drug coverage.

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Medicare-specific Terminology

What are the different stages of Part D prescription drug plan coverage and what do they mean?

There are four stages of coverage in standard Medicare prescription drug plans. Your TRS-sponsored plan does not have all of these stages. Your cost-share may vary throughout the plan year depending on the coverage stage you are in.

Stage 1 is the Deductible stage. This plan does not have a deductible stage.

Stage 2 is the Initial Coverage stage. This stage continues until your total yearly drug costs reach $2,970. During this stage, you pay the TRS copays.

Stage 3 is the Coverage Gap stage (or the ďDonut HoleĒ). This stage starts after your total yearly drug costs exceed $2,970. It continues until your yearly out-of-pocket drug costs reach $4,750. During this stage, you will continue to pay the TRS copays, if you are a participant in the Express Scripts Medicare Part D plan.

Stage 4 is the Catastrophic Coverage stage. This stage is reached after your total yearly out-of-pocket drug costs exceed $4,750. There is no upper limit on how much the plan will cover. During this stage, your copay may decrease.

What are total yearly drug costs?

This is the amount you and/or others pay on your behalf during the plan year for your drugs, and includes the amount paid by your Medicare Part D prescription drug plan.

Do I qualify for Extra Help to pay for my prescription drug premiums and costs?

People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and donít need to apply. Medicare mails a letter to those people who automatically qualify.

Many people are eligible for these savings and donít even know it. To see if you qualify for Extra Help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid Office.

Who should I contact with questions?

For plan specific questions, such as drug pricing, contact TRS-Care Customer Service 24 hours a day, 7 days a week, at 1-800-367-3636, Option 2.

For questions regarding enrollment, eligibility, or premiums, contact TRS Health Benefits at 1-800-223-8778, extension 6456.

General Questions  |   ID Cards  |   Pharmacies, Formulary, and Drug Coverage
Eligibility Questions  |   Medicare-specific Terminology

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