Regence Life and Health (RLH) Medicare ScriptTM Enhanced (PDP) and RLH Medicare ScriptTM (PDP)You have Javascript and/or stylesheets
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| Type of Plan: | Medicare Part D prescription drug plan |
| Deductible: | $100 for RLH Medicare Script Enhanced (PDP) or $200 for RLH Medicare Script (PDP) |
| Copay: | As low as $4 per prescription for each 30-day supply for Tier 1 generic medications |
Copay and Premium Overview |
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| RLH Medicare Script Enhanced (PDP) |
RLH Medicare Script (PDP) | |
| Monthly premium | $94.50 | $76.50 |
| Deductible for prescription drugs | $100 | $200 |
| Tier 1 copay for generic drugs | $4 | $4 |
| Tier 2 copay for preferred brand-name drugs | $30 | $30 |
| Tier 3 copay for non-preferred brand-name drugs | $56 | $61 |
| Tier 4* coinsurance for miscellaneous injectables | 30% | 27% |
| Tier 5* coinsurance for specialty medications | 30% | 27% |
| Coverage during the "coverage gap" (The coverage gap begins when total yearly drug costs – paid by you and your plan – reach $2,830.) | You pay $4 copay per prescription for each 30-day supply for Tier 1 generics, or 100% of discounted drug costs for all other covered drugs, until the total out-of-pocket costs for the year reach $4,550. | You pay 100% of discounted drug costs until the total out-of-pocket costs for the year reach $4,550. |
| Catastrophic coverage | You pay the greater of 5% coinsurance or $2.50/$6.30 copay, depending on the tier. | |
*Tiers 4 and 5 products are limited to a 30-day supply and may contain generic products.
Deductible, copays and coinsurance are based on a 30-day supply of medications (31-day supply for long-term care) and are effective January 1, 2010 through December 31, 2010.
You must go to a network pharmacy to receive coverage.
Benefits, formulary, pharmacy network, premium and co-payments/coinsurance may change on January 1, 2011. Please contact Regence Life and Health Medicare Script for details.
Benefit Information
Information Brochure
This brochure is an overview of plan benefits, including premiums, cost-sharing and a partial listing of covered services (benefits at-a-glance).
Summary of Benefits
This brochure contains detailed information about this plan, including applicable conditions and limitations, premiums, cost-sharing (e.g., copays, coinsurance and deductibles), and any conditions associated with receipt or use of benefits.
Evidence of Coverage
These are the 2010 Evidence of Coverage Brochures.
This booklet is sent to members after they enroll. It explains the plan coverage including:
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Service area
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Applicable conditions and limitations
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Premiums
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Cost sharing (e.g., copays, coinsurance and deductibles), including a description of how an individual may obtain additional information on the plan's tiered or copay level applicable to each drug
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Any conditions associated with receipt or use of benefits
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60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug
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Out-of-network coverage
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Quality assurance policies and procedures, including medication therapy management, and drug and/or utilization management
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Potential for contract termination
- How to obtain an aggregate number of grievances, appeals and exceptions
Plan Ratings
The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). You may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area.
Find a Pharmacy or Search for Covered Prescription Drugs
Network Pharmacies
Search for participating pharmacies including pharmacy address and type.
Pharmacy Directory
We have contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. Our pharmacy network includes 90-day supply, retail, chain, mail order and specialty, home infusion, long-term care and Indian Health Service/Tribal/Urban Indian Health Program pharmacies. Please see the Summary of Benefits or your Evidence of Coverage for information relating to quantity limitation and requirements for mail-order prescription drug service.
90-Day Pharmacy Listing
Listing of pharmacies that are able to dispense up to a 90-day supply of most medications.
For additional network pharmacy information, contact Regence Life and Health (PDP) Customer Service at the number to the right.
Formulary
Online Search » Search an online list of prescription medications to determine your copay/coinsurance amounts.
Abridged Formulary
This is a partial listing of the drugs on our formulary.
Comprehensive Formulary
This is a complete list of the drugs on our formulary.
Notice of Formulary Changes Idaho and Utah residents - Coming soon
Our Transition Policy
Information for new enrollees on our Part D prescription drug plans.
Prior Authorization
Listing of Prior Authorization requirements for consideration of coverage for specific drugs.
Payment Information
Planning to Enroll Later? It Could Cost You Extra
To avoid paying extra for your prescription drug plan, you'll need to enroll as soon as you're eligible. How much more you pay depends on how long you wait to enroll. To calculate your penalty, Medicare uses the following information:
- First count the number of full months that you delayed enrolling in a Medicare drug plan, after you were eligible to enroll. Or count the number of full months in which you did not have credible prescription drug coverage, if the break in coverage was 63 days or more. The penalty is 1% for every month that you didn't have creditable coverage. For our example let’s say it is 14 months without coverage, which will be 14%.
- Then Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2010, this average premium amount is $31.94.
- You multiply together the two numbers to get your monthly penalty and round it to the nearest 10 cents. In the example here it would be 14% times $31.94, which equals $4.47, which rounds to $4.50. This amount would be added to the monthly premium for someone with a late enrollment penalty.
Keep in mind that the base prescription premium can increase each year, so your penalty amount can increase with it. You must pay this penalty as long as you have Medicare prescription drug coverage. That's why it pays to enroll right away!
Best Available Evidence for Late Enrollment Penalty Eligibility
We follow the Best Available Evidence guidelines that are outlined by the Centers for Medicare & Medicaid Services. For more information regarding these guidelines, please see: www.cms.hhs.gov/PrescriptionDrugCovContra/
17_Best_Available_Evidence_Policy.asp.
Limited Income
Individuals on limited income, applying for prescription drug plans (such as Regence Medicare Script (PDP)), may qualify for reduced premiums and/or copayments. Please check the Regence Medicare Script Information Brochure or log onto the CMS web site at www.medicare.gov for more information on eligibility guidelines. Please refer to the Low Income Subsidy flyer for more information on help available for people with limited incomes.
I Have Limited Income What Should I Do?
Grievances and Appeals
Members have several options for expressing dissatisfaction with our services or with those of a pharmacy or other provider.
| Contact: | Medicare Advantage/Medicare Part D Appeals and Grievances S6D PO Box 12625 Salem, OR 97309-0625 Fax number for appeals and grievances: 1 (888) 309-8784 |
Grievances
A grievance is any complaint you make about us or one of our plan providers. This does not involve payment or coverage disputes.
Examples of grievances include:
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Dissatisfaction with the customer service you receive.
- Dissatisfaction with the length of time spent waiting on the phone or in the pharmacy.
- Dissatisfaction with the length of time required to fill a prescription or the accuracy of filling a prescription.
Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling customer service at 1 (800) 541-8981, TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.
You may also fill out a Grievance form and return it to us. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your grievance form.
We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.
Coverage Decisions
A coverage decision is made when we make a decision about the prescription drug benefits you can receive under the plan, and the amount you may pay for a drug.
Examples of coverage decisions include:
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Formulary exceptions*
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Copayment tiering exceptions*
Coverage decisions will be responded to within 72 hours for standard requests and 24 hours for expedited requests.** Coverage decisions can be submitted by you or your prescribing physician by filling out completely the Coverage Determination form and returning it to us. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your Coverage Determination form.
*If you are asking for a formulary or tiering exception, your prescribing physician must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to the generic drugs.
**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician’s support, we will decide if your health condition requires a fast decision.
Appeals
An appeal is any complaint you make when you want us to reconsider a decision we have made about your Part D prescription drug benefits.
Examples of appeals include:
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Our decision not to cover a drug, vaccine or other Part D benefit.
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Our decision not to reimburse you for a Part D drug that you paid for.
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Our denial of a coverage determination.
Appeals must be filed within 60 days of the payment or coverage denial. You must send an appeal to us in writing by using our appeal form. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your appeal form.
We must notify you of the outcome of your appeal within 7 calendar days after receiving your appeal.
Additional information may be found by referring to the Evidence of Coverage in the section titled "What to do if you have a problem or complaint."
Quality Improvement and Medication Therapy Management
Quality Improvement
Regence works hard to provide quality programs for our members. We’re here to help ensure that medication options for our members are appropriate, safe and effective. We have concurrent drug utilization review and safety initiatives geared to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions or therapy duplications.
Our medication policies and procedures are based on careful review of scientific information and input from practicing physicians. Our ultimate goal is to enhance health outcomes with improved medication use for our members.
Medication Therapy Management
Medication Therapy Management (MTM) is a covered service offered to members of our Medicare Part D prescription drug plans. MTM is a voluntary program that is offered to our members, with limited eligibility requirements, to assist with controlling chronic disease. The MTM program is not actually a plan benefit, it is an educational program offered to members.
The MTM program is currently available to assist members in controlling the following conditions:
- Asthma
- Diabetes
- High Cholesterol
- Mental Health
For additional information about the program and eligibility, members should contact us at 1 (800) 541-8981.
Rights and Responsibilities
Your rights and responsibilities upon disenrollment
- You must continue to use network pharmacies until you are disenrolled from our plan.
- You may only disenroll or switch prescription drug plans under certain circumstances.
- You have the right to make a complaint if we ask you to leave our plan.
Our rights and responsibilities upon your disenrollment
We will let you know, in writing, the date your coverage ends. We have the right to disenroll you for the following reasons:
- You are no longer eligible for Medicare prescription drug coverage.
- If we are no longer contracting with Medicare or we leave your service area.
- When you move out of our service area.
- You materially misrepresent third-party reimbursement.
- You fail to pay your plan premium.
- You provide fraudulent information when you enroll or let someone else use your enrollment card to get covered services.
Additional Information
Annual Renewal of Contract
Regence Life and Health (PDP) is a stand-alone prescription drug plan with a Medicare contract. CMS renews this contract annually and availability of this coverage beyond the end of the 2010 contract year is not guaranteed.
Notification in the event of Medicare contract termination
We have a contract with the Centers for Medicare & Medicaid Services (CMS), which is the government agency that runs Medicare. This contract may be renewed each year. However, we or CMS can decide to end the contract at any time. You will generally be notified 60 days in advance if this situation occurs. However, your advance notice may be 30 days or less if CMS ends our contract in the middle of the year.
Individual Eligibility
Anyone residing in the service area and who is eligible for Medicare benefits under Part A or is enrolled in Part B or Part B only is eligible to enroll.
Part D Enrollment
Medicare beneficiaries may be enrolled in only one Part D prescription drug plan at a time. If a beneficiary is also enrolled on a Medicare Advantage plan that includes Part D coverage, the beneficiary may not enroll in a separate Part D plan unless they disenroll from their current Medicare Advantage plan.
Medicare Premium Payment
Regence Medicare Script (PDP) members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.
Premium Withholding
If you decide to switch to premium withhold from your Social Security payments or switch from premium withhold to direct bill, it could take up to three months for it to take effect and you will still be responsible for those premiums.
Last updated 01/01/2010
C0001_2010 WEB MEDICARE SCRIPT 10/2009
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Contact
Us
We're available Monday through Friday
8 a.m. - 5 p.m., Pacific time.
Call us:
1 (888) REGENCE
(1-888-734-3623)
TTY users should call:
711
Already a member? Call customer service:
We're available seven days a week, 8 a.m. - 8 p.m. Call us:
1 (800) 541-8981
TTY users should call:711
