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850244.1013 Y0096_MRK_OK_PDSALPRE15 APPROVED 10012014 600398.0814 bcbsok.com Your presenter today: Bob Archer Health Insurance Enrollment Center.

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Presentation on theme: "850244.1013 Y0096_MRK_OK_PDSALPRE15 APPROVED 10012014 600398.0814 bcbsok.com Your presenter today: Bob Archer Health Insurance Enrollment Center."— Presentation transcript:

1 Y0096_MRK_OK_PDSALPRE15 APPROVED bcbsok.com Your presenter today: Bob Archer Health Insurance Enrollment Center

2 Today’s Topics Medicare Part D overview Your 2015 Blue Cross MedicareRx (PDP) SM Plan Options Enrolling in Blue Cross MedicareRx SM Questions 2

3 Your Presenter Today I am an Authorized Agent licensed to sell health insurance in Oklahoma and have been certified to sell Prescription Drug Plan products for Blue Cross and Blue Shield of Oklahoma. I may be compensated based upon your enrollment in a plan. I am here to help you make an informed decision about selecting a Medicare Prescription Drug Plan. 3

4 4 Medicare Part D helps to pay for your covered prescription medications Also referred to as prescription drug coverage or prescription drug plan (PDP) Medicare Part D Overview

5 Must have Medicare Part A and/or Part B Must live in the Part D plan’s service area If you are covered by an employer or union: Could affect your benefits Call Benefits Administrator Read plan communications 5 Eligibility

6 6 There are three enrollment periods: 1. Annual Enrollment Period (AEP) October 15 to December 7 Enroll for the first time or switch plans Effective date: January 1 Note: If you like what you have, there is no need to switch Medicare Part D Enrollment

7 7 2. Initial Enrollment Period (IEP) Enroll when you first become eligible: 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65 Effective date: Generally, first of the month following enrollment, or first of birthday month Medicare Part D Enrollment

8 8 3. Special Enrollment Period (SEP) Enroll or switch plans due to special circumstances Moving to a new state Enrolling in or disenrolling from a Part C Plan Eligible for Low Income Subsidy assistance Enrolling in both Medicare and Medicaid Retiree losing group health coverage Other situations that may be applicable Effective date: Generally, first of the month following enrollment Medicare Part D Enrollment

9 9 You may have higher premiums unless you had “creditable” coverage You will be assessed 1% of the Medicare base beneficiary premium for every month in which you were eligible to enroll but did not enroll Note: You will not be charged a late enrollment penalty if your situation changes and you need to buy Part D, as long as you had creditable coverage and you apply within 63 days of the end of your creditable coverage. What Happens If You Postpone Enrollment?

10 10 Some group health plans’ retiree coverage State pharmacy assistance program Veterans Affairs coverage Military coverage, including TRICARE Examples of Creditable Coverage

11 11

12 $2,970 $4, Annual Deductible: $320 This means you pay the first $320 in approved drug costs before your Part D benefits begin Catastrophic Initial Limit The Gap $2,930 $4,700 $320 Deductible Let’s look at the 2015 CMS designated plan design: Medicare Part D Phases

13 $4, Catastrophic Initial Limit The Gap $2,960 $4,700 $320 Deductible Initial Coverage Limit: $2,960 What counts toward the Initial Coverage Limit? Once you have met your deductible, you typically pay a fixed amount (copay) to fill an approved prescription Your Part D plan pays the balance of the drug cost for the prescription Medicare Part D Phases

14 14 Catastrophic Initial Limit $2,960 $320 Deductible $4,700 ( = Deductible + Initial Limit + Out- Of-Pocket Costs ) Coverage Gap: $2,960 to $4,700 You will reach the Coverage Gap after you and your plan have reached $2,960 in drug costs You will then be responsible for all costs while in the Coverage Gap, until you reach $4,700 in True Out-Of-Pocket (TrOOP) costs Note: During this time, you may be eligible for a 55% discount on brand name drugs and a 35% discount on generic drugs at the time of purchase TrOOP Medicare Part D Phases

15 15 Catastrophic Coverage: $4,700 Medicare pays 95% of your approved drug costs once you reach the True Out-Of-Pocket (TrOOP) maximum at $4,700 Catastrophic Initial Limit TrOOP $4,700 $320 Deductible $2,960 Medicare Part D Phases

16 16 The TrOOP maximum amount is the amount of money you need to spend to reach Catastrophic Coverage Thereafter you pay a minimum cost share of $2.65 for generic or $6.60 for brand name drugs, and 5% for specialty drugs for the remainder of 2015 TrOOP consists of: Deductible = $320 in 2015 Copays or coinsurance you pay in 2015 Once you reach $4,700 out of your own pocket, the Medicare Catastrophic Coverage benefit begins TrOOP – True Out-Of-Pocket Costs

17 During the gap, all plans offer a manufacturer discount on brand name drugs* 17 Brand Drug A = $60 Gap Coverage = None Member Pays $27.00 Plan’s payment responsibility: $3.00 Manufacturer Discount $30 Amount toward TrOOP: $57.00 Your cost share for generics is decreasing each year* Generic Drug B = $20 Gap Coverage = None, but 35% discount applies Member Pays $13.00 (65% of the $20 generic Rx cost) Discount $7.00 (35% of the $20 Generic Rx cost) Amount toward TrOOP: $13.00 *Discounts during the gap are available to members who do not receive extra help. Members who receive extra help have limited income and qualify for up to 100% of drug costs including monthly premium, annual deductibles and copays/coinsurance. Gap Discounts

18 Phasing Out the Coverage Gap: Part D Cost Sharing Source: CMS Generic Drugs in the Gap You pay Part D plan pays 65 % Brand-Name Drugs in the Gap 45 % Rx Mfr Discount

19 19 Part D-IRMAA stands for Part D income-related monthly adjustment amount Effective January 1, 2011 An additional amount for Medicare Part D drug coverage Pay your Part D-IRMAA directly to Medicare, not to your plan Required by law to pay the Part D-IRMAA based on your income, even if you have drug benefits through a union or employer-sponsored Medicare drug plan Part D-IRMAA

20 20 List of prescription drugs covered by a health insurance company Varies between health insurance companies Formulary

21 21 Under certain conditions, a Part D plan can make changes during the year by: Adding or removing drugs based on safety concerns Moving a drug to a higher or lower cost sharing tier (usually only when a brand goes off its patent) Adding utilization management (step therapy, prior authorization, quantity limits, etc.) Formulary: Could It Change?

22 22 The Exception Process ensures access to medically necessary Medicare-covered prescription drugs Enrollees can request an exception if: The enrollee is using a drug that has been removed from the formulary A non-formulary drug is prescribed and medically necessary The cost-sharing tier of a drug an enrollee is using changes A drug covered under a more expensive cost-sharing tier is prescribed because the less expensive drug is medically inappropriate Medicare Part D Formulary Exceptions

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25 25 Monthly Premium* $28.10$xx.xx Annual Deductible $320 for All Tiers $275 for Tiers 3, 4 & 5 $0 Initial Coverage Period Copays (30-day supply) Preferred Pharmacy / Non-Preferred Pharmacy Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $1 / $6 $6 / $11 $39 / $45 $90 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $6 / $11 $37 / $42 $85 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $2 / $7 $33 / $40 $80 / $95 Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 33% Gap Coverage You will receive a discount on Brand Name Drugs and pay only 65% of the costs of Generic Drugs. $0 / $5 copay for Preferred Generic Drugs; $2 / $7 copay for Non-Preferred Generic Drugs. You will receive a 55% discount on Brand Name Drugs. After the Gap Copays You pay whichever is greater: Tier 1 Preferred Generic Drugs: Tier 2 Non-Preferred Generic Drugs: Tier 3 Preferred Brand Drugs: Tier 4 Non-Preferred Brand Drugs: Tier 5 Specialty Drugs : $2.65 copay or 5% coinsurance for your drug $6.60 copay or 5% coinsurance for your drug 5% coinsurance for your drug *You must continue to pay your Medicare Part B premium The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

26 26 Monthly Premium* $28.10$54.80$xx.xx Annual Deductible $320 for All Tiers $275 for Tiers 3, 4 & 5 $0 Initial Coverage Period Copays (30-day supply) Preferred Pharmacy / Non-Preferred Pharmacy Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $1 / $6 $6 / $11 $39 / $45 $90 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $6 / $11 $37 / $42 $85 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $2 / $7 $33 / $40 $80 / $95 Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 33% Gap Coverage You will receive a discount on Brand Name Drugs and pay only 65% of the costs of Generic Drugs. $0 / $5 copay for Preferred Generic Drugs; $2 / $7 copay for Non-Preferred Generic Drugs. You will receive a 55% discount on Brand Name Drugs. After the Gap Copays You pay whichever is greater: Tier 1 Preferred Generic Drugs: Tier 2 Non-Preferred Generic Drugs: Tier 3 Preferred Brand Drugs: Tier 4 Non-Preferred Brand Drugs: Tier 5 Specialty Drugs : $2.65 copay or 5% coinsurance for your drug $6.60 copay or 5% coinsurance for your drug 5% coinsurance for your drug *You must continue to pay your Medicare Part B premium The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

27 27 Monthly Premium* $28.10$54.80$ Annual Deductible $320 for All Tiers $275 for Tiers 3, 4 & 5 $0 Initial Coverage Period Copays (30-day supply) Preferred Pharmacy / Non-Preferred Pharmacy Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $1 / $6 $6 / $11 $39 / $45 $90 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $6 / $11 $37 / $42 $85 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $2 / $7 $33 / $40 $80 / $95 Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 33% Gap Coverage You will receive a discount on Brand Name Drugs and pay only 65% of the costs of Generic Drugs. $0 / $5 copay for Preferred Generic Drugs; $2 / $7 copay for Non-Preferred Generic Drugs. You will receive a 55% discount on Brand Name Drugs. After the Gap Copays You pay whichever is greater: Tier 1 Preferred Generic Drugs: Tier 2 Non-Preferred Generic Drugs: Tier 3 Preferred Brand Drugs: Tier 4 Non-Preferred Brand Drugs: Tier 5 Specialty Drugs : $2.65 copay or 5% coinsurance for your drug $6.60 copay or 5% coinsurance for your drug 5% coinsurance for your drug *You must continue to pay your Medicare Part B premium The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

28 28 Monthly Premium* $28.10$54.80$ Annual Deductible $320 for All Tiers $275 for Tiers 3, 4 & 5 $0 Initial Coverage Period Copays (30-day supply) Preferred Pharmacy / Non-Preferred Pharmacy Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $1 / $6 $6 / $11 $39 / $45 $90 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $6 / $11 $37 / $42 $85 / $95 Tier 1 Preferred Generic Drugs Tier 2 Non-Pref. Generic Drugs Tier 3 Preferred Brand Drugs Tier 4 Non-Pref. Brand Drugs $0 / $5 $2 / $7 $33 / $40 $80 / $95 Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 25% Tier 5 Specialty Drugs 33% Gap Coverage You will receive a discount on Brand Name Drugs and pay only 65% of the costs of Generic Drugs. $0 / $5 copay for Preferred Generic Drugs; $2 / $7 copay for Non-Preferred Generic Drugs. You will receive a 55% discount on Brand Name Drugs. After the Gap Copays You pay whichever is greater: Tier 1 Preferred Generic Drugs: Tier 2 Non-Preferred Generic Drugs: Tier 3 Preferred Brand Drugs: Tier 4 Non-Preferred Brand Drugs: Tier 5 Specialty Drugs : $2.65 copay or 5% coinsurance for your drug $6.60 copay or 5% coinsurance for your drug 5% coinsurance for your drug *You must continue to pay your Medicare Part B premium The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

29 29 Save money by switching to a generic Talk to your doctor or pharmacist To receive benefits, use Blue Cross MedicareRx network pharmacies or mail-order service except in an emergency With preferred network pharmacies and mail-order, you may purchase a 90-day supply of an eligible prescription drug and pay only two and a half months of copays instead of three Some network pharmacies are NOT preferred; they do not offer lower copays for a 90-day supply Blue Cross MedicareRx Formulary

30 Save at any one of these or other preferred network pharmacies and their affiliates: Walgreens, CVS, Walmart Other pharmacies are available in our network Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Limitations, copayments, and restrictions may apply. Pharmacies nationwide Peace of mind while traveling 30 Blue Cross MedicareRx Pharmacy Network

31 31 Online Plan Selector and Online Formulary Finder

32 32

33 Three Enrollment Periods 1. Annual Enrollment Period (AEP) October 15 to December 7 Enroll for the first time or switch plans Effective date: January 1 2. Initial Enrollment Period (IEP) Enroll when you first become eligible 7-month period that starts 3 months before the month you turn 65, includes the month you turn 65, and ends 3 months after the month you turn 65 Effective date: generally, first of the month following enrollment, or first of birthday month 3. Special Enrollment Period (SEP) Enroll or switch plans due to special circumstances Effective date: generally, first of the month following enrollment 33

34 34 Next Steps  Meet with an Authorized Agent  Review the Summary of Benefits  Complete the Enrollment Application Ready to Enroll?

35 35 The Disenrollment Period January 1 to February 14: If you would like to change your Medicare coverage, you may choose to disenroll from your Medicare Part D prescription drug plan. During this period, you cannot do the following: Switch from Original Medicare to a Medicare Advantage Plan Switch from one Medicare Advantage Plan to another Switch from one Medicare Prescription Drug Plan to another Join, switch, or drop a Medicare Medical Savings Account Plan

36 36

37 37 Medicare Phone: MEDICARE ( ) TTY hours a day / 7 days a week Web: Social Security Phone TTY Between 7 a.m. and 7 p.m., Monday – Friday Web: Resources

38 Prescription drug plan provided by Blue Cross and Blue Shield of Oklahoma, which refers to HCSC Insurance Services Company (HISC), an independent licensee of the Blue Cross and Blue Shield Association. A Medicare-approved Part D sponsor. Enrollment in HISC’s plan depends on contract renewal. 38

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