City of New York/GHI Enhanced Medicare Part D Prescription Drug

summary of
benefits
2016 GHI Enhanced Medicare
Prescription Drug Plan
City of New York
S5966_126172 Group
Medicare Summary of Benefits
INTRODUCTION
Introduction to the Summary
of Benefits for GHI Enhanced
Medicare Prescription Drug Plan
January 1, 2016 — December 31, 2016
not have or obtain other Medicare prescription drug
coverage or creditable coverage, you may have to pay a
late enrollment penalty in addition to your premium
when you obtain Medicare prescription drug coverage.
By joining this Medicare prescription drug plan,
you acknowledge that the City of New York/GHI
Enhanced Medicare Part D program will release your
The City of New York/GHI Enhanced Part D program information to Centers for Medicare and Medicaid
is available to City of New York retirees who also enroll Services (CMS) and other plans as is necessary for
treatment, payment and health care operations. You
in the City of New York GHI Senior Care program.
also acknowledge that the City of New York/GHI
If you are a member of a Medicare Advantage Plan
(like an HMO or PPO) or, if you have health coverage Enhanced Medicare Part D program will release your
information, including your prescription drug event
from an employer or union, joining the City of New
data to CMS, who may release it for research and other
York/GHI Enhanced Medicare Part D program may
purposes which follow all applicable federal statutes
change how your current coverage works. If you are
and regulations.
enrolled in another Medicare Advantage plan, joining
the City of New York/GHI Enhanced Medicare Part
This Summary of Benefits tells you some features
D program could end your membership in your other of the plan. It doesn’t list every drug we cover, every
Medicare Advantage plan. If you have questions, you
limitation or exclusion. To get a complete list of our
should contact the Medicare Advantage plan or, in the benefits, please call the GHI Medicare Prescription
case of health coverage provided through an employer
Drug Plan at 1-800-585-5786.
or union, you should contact the administrator of
the program.
What is the City of New York/
GHI Enhanced Medicare Part D
The City of New York/GHI Enhanced Medicare Part
Prescription Drug Plan?
D program is a Medicare drug plan and is in addition
to your coverage under Medicare; therefore, you will
This plan is a group plan that provides a level of
need to keep your Medicare coverage. As noted above, benefits that exceeds the Standard Medicare Part D
you can only be in one Medicare prescription drug
benefit design as required by law. This plan is only
plan at a time. It is your responsibility to inform the
offered to Medicare-eligible retirees and dependents
City of New York/GHI Enhanced Medicare Part D
that worked for the City of New York.
program of any prescription drug coverage that you
have or may get in the future.
How Do I Enroll In This Plan?
The City of New York/GHI Enhanced Medicare Part
If you are a Medicare-eligible retiree or a MedicareD program is considered to be “creditable coverage”
eligible dependent of a retiree of the City of New
– meaning that it provides coverage that is equal to
York and enrolled in the City of New York GHI
or better than the standard coverage established by
Senior Care program with the optional rider for
Medicare for Part D plans. In the event you decide to
prescription drugs, you will be automatically enrolled
cancel your coverage through the City of New York/
in this program.
GHI Enhanced Medicare Part D program and you do
City of New York
S5966_126172 Group
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Do I Have to Enroll In This Plan?
No. You can disenroll from this plan by contacting,
in writing, the City of New York, Office of Labor
Relations, 40 Rector Street, New York, NY 10006.
Please note, we strongly urge you to carefully consider
your personal health needs before deciding to disenroll
and to keep in mind that this plan offers benefits that
exceed the Medicare Standard Part D plan design.
Additionally, should you decide to disenroll from this
plan, you will also be disenrolled from the 365-Day
Senior Care hospital rider.
How Can I Compare My Options?
At the end of this brochure, there is a comparison of
the benefits covered under this plan and the Standard
Medicare Part D plan design. You can also go on the
CMS Web site at www.medicare.gov and view programs
offered by other private insurance companies in your area.
How Much Will This Plan Cost Me?
The cost of this plan along with the cost of the 365
Day Senior Care hospital rider will be deducted from
your monthly pension check. These monthly costs are
as follows:
• Enhanced Medicare Part D: $116.00*
• 365 Day Senior Care Hospital Rider: $2.08
* The monthly cost for COBRA retirees is $116.00.
If you are eligible for the Medicare Part D low-income
subsidy, your cost will be less depending on the
amount of the subsidy that is approved by CMS.
Where Can I Get My Prescriptions?
You have access to an extensive, nationwide network of
pharmacies. With more than 61,000 pharmacies in our
network, GHI makes it easy for you to find a pharmacy
when filling a prescription. For future reference, to
find out if your pharmacy is in our network, you can
call Express Scripts Inc. 7 days a week, 24 hours a day,
toll free at 1-800-585-5786. TDD/TTY users can call
1-800-899-2114.
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What Are My Protections In
This Plan?
Once you are a member of the City of New York/
GHI Enhanced Medicare Prescription Drug Plan
(PDP), you have the right to appeal plan decisions
about payment or services if you disagree. Read the
Evidence of Coverage from the City of New York/GHI
Enhanced Medicare PDP when you get it, to know
which rules you must follow to receive coverage with
this Medicare prescription drug plan.
The City of New York/GHI Enhanced Medicare
Prescription Drug Plan is a Medicare drug plan and
is in addition to your coverage under Medicare Part A
or Part B. Your enrollment in the City of New York/
GHI Enhanced Medicare Prescription Drug Plan
affects your coverage under Medicare Part A or Part B.
It is your responsibility to inform the GHI Enhanced
Medicare PDP plan.
Must I Use a Mail Service
Pharmacy?
No. However, the plan includes the Express Scripts
mail service pharmacy program where you can fill your
prescriptions easily and conveniently. We encourage
you to use the mail service pharmacy because the cost
of prescription drugs filled through mail service is
generally less expensive than drugs filled through retail
pharmacies. The lower cost of a drug reimbursed under
the plan will mean lower out-of-pocket cost to you. It is
for these same reasons that we encourage you to request
lower cost generics when appropriate.
Does This Plan Have a Drug
Formulary?
A formulary is a list of drugs covered by your plan. This
plan uses an “open” formulary that includes drugs covered
by Medicare Part D and certain non-Part D drugs.
Are There Drugs with Prior
Authorization and Step Therapy?
Yes. Together with Express Scripts, GHI is implementing special safeguards to help ensure that prescription
drug coverage is provided only for services and items
that are appropriate and safe. These clinical guidelines,
known as Prior Authorization, are comprised of
Medical Necessity, Step Therapy and Drug Quantity
Management. You may utilize our Web site at
www.emblemhealth.com or contact the Express
Scripts Call Center at 1-800-585-5786 for a list
of drugs that may require Prior Authorization,
Step Therapy or may be subject to Drug Quantity
Management requirements.
If you are denied any of the drugs listed under Prior
Authorization (i.e., Medical Necessity, Step Therapy
Program or Drug Quantity Management programs),
you need to take the following action to address
the issue:
1. Ask your doctor to call the GHI Prior Authorization Line at 1-888-447-8175 and request a
Coverage Determination.
2. If your diagnosis meets approved guidelines for that
drug and is within the scope of the coverage of the
plan, a prior authorization will be set up so your
prescription can be filled.
Where Can Members Get
Information About Their True
Out-Of-Pocket (TrOOP) Balance?
True Out-of-Pocket expense is the total of your
out-of-pocket expense for Part D covered drugs.
TrOOP is calculated on a calendar year basis.
Contact the Express Scripts call center at
1-800-585-5786.
Balance information will be included on the
production of the monthly Explanation of Benefits
(EOB) statements.
Where Can Members get
Information About Their Copay/
Price of Drug Post Enrollment?
Please call the Express Scripts call center at
1-800-585-5786. Information will be available on
Express Scripts website www.express-scripts.com.
Important telephone numbers to call for assistance
Express Scripts Inc. (ESI):
1-800-585-5786, 24 hours a day, 7 days a week. TTY/TDD 1-800-899-2114. www.express-scripts.com
Group Health Incorporated (GHI):
1-212-501-4444, Monday through Friday, 9 am to 5 pm. TTY/TDD 1-866-248-0640.
www.emblemhealth.com
Centers for Medicare and Medicaid Services (CMS):
1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD 1-877-486-2048.
www.medicare.gov
If you have questions about the plan’s benefits or costs, please contact Express Scripts, Inc. (ESI) Customer
Service at 1-800-585-5786; TTY/TDD 1-800-899-2114, 24 hours a day, seven days a week.
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Important Information
City of New York GHI Enhanced Medicare Part D Program
There is no deductible under this plan.
The plan will pay 75% (and the member pays the remaining 25%) of eligible prescription drug expenses
between $0 and $3,310.
The member pays 58% of generic and 45% of brand prescription drug costs. Member out-of-pocket towards
TrOOP is $4,022.50.
The plan will provide unlimited catastrophic coverage of eligible prescription drug expenses subject to a
member copayment which is the greater of 5% or $2.95 for generic drugs and brand drugs (that are multisource drugs) and $7.40 for all other drugs.
Beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine
circumstances, and quantity limitations and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. 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 am and 7 pm,
Monday through Friday. TTY users should call, 1-800-325-0778; or Your Medicaid Office (only required for
pieces referencing Part D benefits or cost-sharing).
The difference is GHI
Since 1937, GHI has been a leader in health insurance, committed to quality health care coverage for all New
Yorkers, including those on limited incomes. The GHI Medicare Prescription Drug Plan is a great example:
making quality health care coverage simple and affordable for all who qualify for Medicare.
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The following is a partial list of drugs and drug classes that will require prior authorization or step therapy:
Prior Authorization
Actemra
Alpha-1 Proteinase Inhibitors
Ampyra
Androgel
Aralast
Aranesp
Arcalyst
Avonex
Betaseron
Bisphosphonates (IV)
Botox
Cimzia
Copaxone
Diflucan
Diphenhydramine HCL
Enbrel
Forteo
Glucagon-Like Peptide-1 Agonists
Growth Hormones
Humira
Immune Globulin Subcutaneous
Kineret
Letairis/Tracleer
Leuprolide (long acting)
Lidoderm
Metaxalone
Methocarbamol
Neulasta
Neupogen
Oral Transmucosal Fentanyl Drugs
Orencia
Orphenadrine Citrate
Orphenadrine Compound
Orphenadrine Compound Forte
Oxandrolone
Parafon Forte DSC
Pegasys
Peg-intron
Penlac
Phosphodiesterase-5 Inhibitors for PAH
Procrit/Epoetin
Provigil/Nuvigil
Rebif
Regranex
Remicade
Rituxan
Robaxin
Samsca
Simponi
Skelaxin
Solaraze
Sovaldi
Stelara
Symlin
Tazorac
Testim
Topamax/Zonegran Auto PA
Topical Retinoid Products
Tysabri
Vfend
Vistaril
Xenazine
Xolair
Zemaira
Zyvox
Step Therapy
ACE-I/ARB
Antidepressants-SNRI/SSRI
Bile Acid Sequestrants
Bisphophonates Oral
Brand NSAIDS
CCB-Dihydropyridine
CCB-Verapamil
COX-2
Fenofibrate
HMG
Long Acting Opioids
Metformin
Overactive Bladder
PPI Enhanced
Sedative Hypnotics
Thiazolidinedione
Topical Corticosteroids
Uloric
Ultram
DRUG QUANTITY MANAGEMENT
Tamiflu
Opioids (e.g., oxycodone)
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55 Water Street, New York, New York 10041-8190 | emblemhealth.com
Group Health Incorporated (GHI) is a stand-alone prescription drug plan with a
Medicare contract. GHI is an EmblemHealth company. This information is not a
complete description of benefits. Enrollment in GHI depends on contract renewal.
Contact the plan for more information. Limitations, copayments, and restrictions may
apply. Benefits and/or copayments/coinsurance may change on January 1 of each year.
The formulary and pharmacy network may change at any time. You will receive notice
when necessary.
Group Health Incorporated (GHI), HIP Health Plan of New York (HIP), HIP Insurance
Company of New York and EmblemHealth Services Company, LLC are EmblemHealth
companies. EmblemHealth Services Company, LLC provides administrative services to
the EmblemHealth companies.
S5966_126172 Group
86-7672-16 12/15