Regence Medicare ScriptTM Enhanced (PDP) and Regence Medicare ScriptTM Basic (PDP)You have Javascript and/or stylesheets
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| Type of Plan: | Medicare Part D prescription drug plan |
| Deductible: | $0 for Regence Medicare Script Enhanced or $195 for Regence Medicare Script Basic |
| Copay: | As low as $5 per prescription for each 30-day supply for Tier 1 generic medications |
Copay and Deductible Overview |
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| Regence Medicare Script Enhanced |
Regence Medicare Script Basic |
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| Deductible for prescription drugs | $0 | $195 |
| Tier 1 copay for generic drugs | $5 | $7.50 |
| Tier 2* copay for non-preferred generics | $33 | $33 |
| Tier 3 copay for preferred brand-name drugs | $40 | $40 |
| Tier 4 copay for non-preferred brand-name drugs | $85 | $85 |
| Tier 5** coinsurance for specialty tier drugs | 33% | 28% |
Tier 6** coinsurance for injectable drugs |
33% | 28% |
Coverage during the "coverage gap" After you’ve paid your yearly deductible (if you have one) and the yearly drug costs (paid by you and Regence) reach $2,930, you enter the Coverage Gap. |
$5 copay per prescription for each 30-day supply of Tier 1 preferred generics; 86% coinsurance for all other covered Part D generics during the Coverage Gap; and 50% for some brand-name drugs discounted through the Coverage Gap Discount Program. After your out-of-pocket costs (paid by you in all phases and by the drug manufacturer(s) in the Coverage Gap) reach $4,700, you go to Catastrophic Coverage for the remainder of the year. |
86% coinsurance for all covered Part D generics and 50% for some brand-name drugs discounted through the Coverage Gap Discount Program. After your out-of-pocket costs (paid by you in all phases and by the drug manufacturer(s) in the Coverage Gap) reach $4,700, you go to Catastrophic Coverage for the remainder of the year. |
| Catastrophic coverage | You pay the greater of 5% coinsurance or $2.60/$6.50 copay, depending on the tier. | |
*Tier 2 contains non-preferred generics, which is a limited list of generic medications with less expensive equivalents. Please see our formulary for more information.
**Tiers 5 and 6 products are limited to a 30-day supply and may contain generic products.
Coverage Information
Here are some helpful documents to understand our coverage better:
Summary of Benefits
This brochure contains detailed benefit 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
This booklet is sent to members after they enroll. It explains the health plan coverage including:
- Service area
- Applicable conditions and limitations
- Premiums
- Cost sharing (e.g., copays, coinsurance and deductibles)
- Any conditions associated with receipt or use of benefits
- Out-of-network coverage
- Potential for contract termination
- How to obtain an aggregate number of grievances, appeals and exceptions
Benefits, pharmacy network, premium and co-payments/coinsurance may change on January 1, 2013. Please contact Regence Medicare Script for details.
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). For more information you may open the plan ratings document below, or you may go to www.medicare.gov and select "Health and Drug Plans”, then “Compare Health and Drug Plans” to compare the plan ratings for Medicare Advantage and Part D plans in your area.
Pharmacies & Covered Drugs
Network Pharmacies
We have contracts with almost 60,000 pharmacies that equal or exceed CMS requirements for pharmacy access in your area. Our pharmacy network includes 90-day supply, retail, mail order and specialty, chain, 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 more information relating to quantity limitations and requirements for mail-order drug service. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
90-Day Pharmacy Listing
These pharmacies are able to dispense up to a 90-day
supply of most medications. For additional network pharmacy information, contact Regence Medicare Script Customer Service.
Covered Prescription Drugs (Formulary)
Online Formulary Search »
Search for a prescription drug.
Abridged Formulary
This is a partial listing of the drugs on our formulary.
Comprehensive Formulary
This is a comprehensive listing of all of the drugs on our
formulary.
Notice of Formulary Changes
This is a description of recent changes to our formulary drugs.
Our Transition Policy
Information for new enrollees on our Part D prescription drug plans.
Prior Authorization Requirements
Listing of Prior Authorization requirements for consideration of coverage for specific drugs.
Help with prescription drug premiums and costs if you have Part D prescription drug coverage: You may be able to get Extra Help paying for your prescription drug premiums and costs. To see if you qualify for extra help, call any of the following:
- Medicare – 1-800-MEDICARE (1-800-633-4227). TTY or TDD users should call 1 (877) 486-2048. Offices are open 24 hours a day, seven days a week.
- Social Security – 1 (800) 772-1213. TTY or TDD users should call 1 (800) 325-0778. Offices are open from 7 a.m. to 7 p.m., Monday through Friday.
- Your State Medicaid Office.
(PDF) I Have Limited Income What Should I Do? - Idaho residents
(PDF) I Have Limited Income What Should I Do? - Utah residents
- Best Available Evidence for Low Income Subsidy 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
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.
Grievances & Appeals
COVERAGE DECISIONS, 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 S5D 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:
- 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. Our telephone hours are 8:00 a.m. to 8:00 p.m. Monday through Friday. From October 15 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and send it to us along with your grievance. We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.
COVERAGE DECISIONS AND APPEALS
| Contact: | Medicare Part D Fax number for coverage decisions: Number to call to request a redetermination (appeal): |
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:
- Formulary exceptions*
- 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 completely 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:
- Our decision not to cover a drug, vaccine or other Part D benefit.
- Our decision not to reimburse you for a Part D drug that you paid for.
- 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, including a signature. 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. 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."
For more information, you may contact Customer Service at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m. Monday through Friday. From October 15 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.
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.
Contract Information
Regence Medicare Script is a stand-alone prescription drug plan with a Medicare contract. Medicare renews this contract annually. Your Medicare Script plan may not be available next year because by law, CMS may refuse to renew our contract, or Regence can choose not to renew our contract with CMS, or Regence can choose to reduce its service area, which would result in your plan's termination or renewal.
The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.
Benefits, premiums, and/or copayments/coinsurance may change on Jan. 1, 2013. Formularies and pharmacy networks may change during 2012 and/or on Jan. 1, 2013. Certain eligibility periods and requirements apply.
Limitations, copayments and restrictions may apply.
If you have to go to an out-of-network pharmacy due to non routine circumstances, you may have to pay more. Quantity limitations and restrictions may apply.
Certain eligibility periods and requirements apply. Individuals must have both Part A and Part B to enroll in a Medicare Advantage plan.
You must continue to pay your Part B premium.
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Last Updated 10/01/2011
Y0062_2012_MEDICARE_ADVANTAGE_ AND_SCRIPT CMS APPROVED 10252011
Contact Us
Call Customer Service:
Our telephone hours are 8:00 a.m. to 8:00 p.m. Monday through Friday. From October 15 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. Call us:
1 (800) 541-8981
TTY users should call:711