Schedule I4 Medicare Prescription Drug Summary of Benefits.pdf

S8841_24_MC-DS13_C_MPS

Optum Rx Medicare Prescription Drug Plan Your 2024 Summary of Benefits Administered for the Michigan Public School Employees’ Retire-ment System by Optum Rx

Effective January 1, 2024–December 31, 2024

When you retire, you, your spouse, and dependents are eligible for the Michigan Public School Employees’ Retirement System’s prescription drug coverage. This Summary of Benefits de-scribes some features of the retirement system’s coverage, but it does not list every covered drug or every limitation or exclusion. For a complete list of benefits, refer to your Evidence of Coverage.

Note: This prescription drug coverage is offered together with your Blue Cross Blue Shield of Michigan Medicare Plus Blue Group PPO medical coverage. If you choose a Medicare Prescrip-tion Drug Plan other than the Optum Rx Medicare Prescription Drug Plan, you will need to find other medical coverage at your own expense.

Office of Retirement Services Phone (toll-free): 1-800-381-5111, TTY 711 Hours of operation: Monday - Friday, 8:30 a.m. - 5 p.m. Eastern time

Optum Rx Member Services Phone (toll-free): 1-855-577-6517, TTY 711 Hours of operation: Monday - Friday, 8 a.m. - 8 p.m. Eastern time except holidays Website: optumrx.com

SCHEDULE I4 - MEDICARE PRESCRIPTION DRUG BENEFITS

RFP NO. 230000003226

Who is eligible?

Members of this plan must meet all Michigan Public School Employees’ Retirement System eli-gibility requirements, be entitled to Medicare Part A and enrolled in Medicare Part A & B, live in the Optum Rx service area, and be enrolled in the retirement system’s Blue Cross Blue Shield of Michigan Medicare Plus Blue Group PPO.

You can only be in one Medicare Prescription Drug Plan at a time. If you are currently enrolled in a Medicare Advantage Plan that includes Medicare prescription drug coverage, and that cov-erage is NOT provided by the Michigan Public School Employees’ Retirement System, your en-rollment in this plan will end that enrollment. In addition, you may not be enrolled in an individual Medicare Advantage Plan—even one without prescription drug coverage—at the same time as this plan.

Note: Once you are enrolled in the Michigan Public School Employees’ Retirement System Medicare Prescription Drug Plan, if you then enroll in most Medicare Advantage Plans, you will automatically be disenrolled from this plan when your new plan’s coverage begins. However, if you choose a Private Fee-for-Service Plan without Part D drug coverage, a Medicare Medical Savings Account Plan, or a Medicare Cost Plan, you can enroll in that plan and keep our plan for your drug coverage. If you do not want to keep our plan, you can choose to enroll in another Medicare Prescription Drug Plan or drop Medicare prescription drug coverage.

If you disenroll from a Medicare Prescription Drug Plan and go without creditable prescription drug coverage for 63 or more days in a row, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. “Creditable drug coverage” is drug coverage that meets Medicare’s minimum standards.

Where is the service area for the Optum Rx Medicare Prescription Drug Plan?

The service area for this plan includes the United States, District of Columbia, Guam, Puerto Rico, the US Virgin Islands, Northern Mariana Islands, and American Samoa. If you move out of the service area, you will be disenrolled from this plan. It is important that you notify both Optum Rx and the Office of Retirement Services (ORS) at 1-800-381-5111 if you plan to move outside the service area.

Where can I get my prescriptions filled?

In most instances, you must use a pharmacy that is in the Optum Rx network to receive plan benefits. The Optum Rx network includes more than 67,000 pharmacies nationwide, and you will pay the same cost-sharing amount for your prescription drugs at any network pharmacy.

The Optum Rx Medicare Prescription Drug Plan allows you to get your prescriptions filled in 3 ways below.

For greater convenience, use the Optum Rx Home Delivery pharmacy (mail-order services).

You may be able to save on your maintenance medications by changing your 30-day retail sup-ply to a 90-day supply.

In addition, the plan includes a preferred specialty pharmacy through Optum Rx. Your coinsur-ance is lower when you use the Optum Rx Specialty Pharmacy for your specialty medications. If you choose to go to a non-network pharmacy, you must pay for the prescription in full and file a claim with Optum Rx for reimbursement. Your claim will not be covered unless you meet the coverage criteria. If the claim is approved, you will be responsible for the copayments/coinsur-ance outlined in the copayment table, plus an additional fee, which includes the difference in the participating pharmacy network cost and the amount the out-of-network pharmacy charged. In addition, any costs you pay out-of-pocket at an out-of-network pharmacy will not accumulate to-wards your $1,750 Annual Coinsurance Maximum amount.

Option 1: Fill your prescription at your local retail pharmacy.

• The plan allows you to receive up to a 90-day supply of prescription medication at any Optum Rx network pharmacy. Simply take your prescription ID card, along with your prescription, to a network pharmacy. If you go to a network pharmacy, you will only pay your copayment/coinsurance amount.

Option 2: Fill your prescription with Optum Rx Home Delivery (mail-order service).

• The plan also allows you to receive maintenance (long-term) medications through home delivery. Home delivery offers a convenient and cost-effective way to get up to a 90-day supply of maintenance medication through the mail.

Option 3: Fill your prescriptions with our Optum Rx specialty pharmacy.

• The Optum Rx Prescription Drug Plan offers a preferred specialty pharmacy if you need to fill prescriptions for certain specialty drugs that treat complex conditions. Your copay-ment will be lower if you use the Optum Rx specialty pharmacy. It may cost you more if you use other specialty pharmacies available in our network.

o Please note: High-cost/Specialty drugs are limited to a 30-day supply.

Note: You may be able to save on your maintenance medications by changing your 30-day re-tail supply to a 90-day supply through our home delivery pharmacy.

Important Message About What You Pay for Vaccines - Our plan covers most Part D vac-cines at no cost to you. Call Member Services for more information.

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.

What is a formulary?

A formulary is a list of drugs covered by your plan. We call it the “Drug List.” Drugs on the Drug List are selected by a team of doctors and pharmacists and meet requirements set by Medicare.

Periodically, drugs may be added or removed from the Drug List. In addition, changes may be made to how much you pay or to additional rules for covering certain drugs. We will notify you before a change is made that affects a drug you are taking.

The drug list shows when additional rules or limits apply to your drug coverage. For example:

• When you must first try one drug to treat a condition before another drug will be covered for that condition.

• When there is a limit to the quantity you can receive of a drug (which means you can only get a certain amount of a drug within a specified timeframe).

• When your provider must get prior authorization (approval) from Optum Rx for your drug to be covered.

What can I do if I am taking a drug that is not on the Drug List or that has limits or requirements that I cannot meet?

With your physician’s help, you may be able to get a temporary supply of the drug, ask for an exception, or switch to a different drug that is listed on the Drug List. For more details, call Optum Rx. Our contact information is on the front cover of this document.

How can I get help paying my out-of-pocket costs?

People with limited income may qualify for Extra Help to pay for prescription drug costs. To see if you qualify for Extra Help, you can:

• Call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, 24 hours a day, 7 days a week.

• Go to medicare.gov and review "Programs for People with Limited Income and Re-sources" in the Medicare & You handbook.

• Call the Social Security Administration at 1-800-772-1213, TTY 1-800-325-0778, 8 a.m.–7 p.m., Monday–Friday.

• Call your state Medicaid office.

How can I prevent fraud, waste, and abuse?

Fraud, waste, and abuse is a serious matter. It is in your best interest to protect yourself from fraudulent schemes. The Centers for Medicare & Medicaid Services (also called CMS or Medi-care) has partnered with a national Medicare Drug Integrity Contractor (MEDIC) to help detect, correct, and prevent fraudulent behavior within Medicare Part C and Medicare Part D. In collab-oration with CMS, the MEDIC has developed several pamphlets that are designed to provide you with critical information related to fraud, waste, and abuse. They include information on what to look for and how to report it if you suspect that you may have been subjected to fraud.

These pamphlets can be found online at optumrx.com on the “Forms” page.

Drug Coverage Determinations As a member of this Medicare Prescription Drug Plan, you have the right to request a coverage determination, which is a decision made by the plan about a drug you believe should be cov-ered. Coverage determinations include requests for exceptions.

What is an exception?

An exception is a type of coverage determination. You may ask us for an exception if you be-lieve you need a drug that is not on our list of covered drugs, or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to rules about when and how you can get drugs in the formulary (sometimes called utilization management rules), such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request.

What can I do if you deny coverage for my prescription drug(s)?

You have the right to file an appeal (ask us to reconsider our decision) about payment or ser-vices. For more information, call Optum Rx. Our contact information is on the front cover of this document.

What can I do if I have a problem with the plan or one of your network pharmacies that does not involve coverage for a prescription drug?

You have the right to file a grievance (complaint). If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state.

What is the Medication Therapy Management (MTM) Program?

The Medication Therapy Management (MTM) Program is a free service. The program can help make sure you are using drugs that work best to treat your medical conditions. It can also help us identify possible medication errors. If you meet the criteria, we will automatically enroll you in the program and send you information. If you decide not to participate, please let us know. We will remove you from the program.

If you have any questions about benefits or costs, please call Optum Rx toll free at the number on the first page of this document.

2 Coverage Stages

Stage 1:

Initial Coverage

During this stage, the retirement system pays its share of the cost and you pay your share of the cost of your drugs. The “Copayments and Coinsurance” table below shows your cost for drugs in each tier.

Your enhanced benefits include a plan-specific out-of-pocket maxi-mum of $1,750. Once you reach your enhanced plan out-of-pocket maximum of $1,750, the plan will pay all of your drug costs for the remainder of the year.

The Medicare annual out-of-pocket maximum during this stage is $8,000. If you reach this Medicare out-of-pocket limit, you enter the Catastrophic Coverage stage. Medicare sets this total and the rules for counting costs toward this amount.

Stage 2:

Catastrophic Coverage

Most members do not reach the Catastrophic Coverage Stage be-cause your enhanced benefits include a plan-specific out-of-pocket maximum of $1,750. Once you reach your out-of-pocket maximum of $1,750, the plan will pay most of your drug costs for the remain-der of the year.

If you do reach the Medicare calendar year maximum ((including manufacturer discounts) of $8,000, you pay nothing for covered Part D drugs. You may have cost sharing for excluded drugs that are covered under our enhanced benefit.

Your retirement system pays the rest of the cost.

If you have any questions about this plan’s benefits or costs, please call Optum Rx. Our contact information is on the front cover of this document.

The Michigan Public School Employees’ Retirement System Medicare Prescription Drug Plan features a 5-tier prescription drug benefit. Below is a chart showing the copayment amounts that you will be required to pay for your Medicare prescription drugs.

Our 5-Tier Prescription Drug Benefit

Drug Tier Helpful Tips

Tier 1 Most generic drugs are listed under Tier 1 and have the lowest copay-ments.

Tier 2 Drugs listed under Tier 2 generally include preferred brand-name drugs that have lower copayments than non-preferred brand-name drugs.

Tier 3 Drugs listed under Tier 3 generally have higher copayments than pre-ferred brand-name drugs.

Tier 4 Drugs listed in Tier 4 include preferred specialty or high-cost drugs. These drugs cost $950 or more for up to a 30-day maximum supply, and gener-ally have a lower copayment than drugs in the non-preferred Tier below.

Tier 5 Drugs listed in Tier 5 include non-preferred specialty or high-cost drugs.

These drugs cost $950 or more for up to a 30-day maximum supply, and generally have a higher copayment than drugs in the preferred tier above.

Copayments and Coinsurance

Covered Pre-scription Drugs

Retail Pharmacy

(up to a 30-day supply)

Retail Network & Home Delivery

Pharmacy (up to a 90-day supply)

Preferred Specialty Pharmacy

(up to a 30-day supply)

Non-Preferred Specialty Pharmacy

(up to a 30-day supply)

Cost-Sharing Tier 1 (Generic drugs)

20% coinsurance $15 minimum / $45 maximum

20% coinsurance $37.50 minimum / $112.50 maximum n/a n/a

Cost-Sharing Tier 2 (Preferred Brand)

20% coinsurance $15 minimum / $45 maximum

20% coinsurance $37.50 minimum / $112.50 maximum n/a n/a

Cost-Sharing Tier 3 (Non-Preferred Brand drugs)

40% coinsurance $15 minimum / no maximum*

40% coinsurance $37.50 minimum / no maximum** n/a n/a

Cost-Sharing Tier 4 (Preferred Specialty drugs) †

20% coinsurance $50 minimum

$100 maximum n/a

20% coinsurance $50 minimum

$100 maximum

40% coinsurance $50 minimum no maximum*

Cost-Sharing Tier 5 (Non-Preferred Spe-cialty drugs) †

40% coinsurance $50 minimum no maximum* n/a 40% coinsurance

$50 minimum no maximum*

40% coinsurance $50 minimum no maximum*

† Drugs that cost $950 or more for up to a 30-day maximum supply.

* Only 20% coinsurance up to a $45 maximum is credited to the Annual Coinsurance

Maximum.

** Only 20% coinsurance up to a $112.50 maximum is credited to the Annual Coinsurance

Maximum.

Annual Coinsurance Maximum:

For drugs subject to a 20% coinsurance: When your applicable coinsurance amounts (as noted above and subject to plan limits) total $1,750, your coinsurance will be waived, and you will pay $0 for these drugs for the remainder of the calendar year.

For drugs subject to a 40% coinsurance: Only 20% coinsurance (subject to plan minimum and maximum limits noted above) will be applied to the Annual Coinsurance Maximum. When your applicable coinsurance amounts total $1,750, your cost share will be reduced by 20% (sub-ject to plan minimum and maximum limits).

For example: If your medication cost was $700, 40% of that equals a $280 copayment that you will pay. Once your applicable coinsurance amounts have reached $1,750, the $700 drug cost will be reduced by 20% ($45 max) which means you now pay a $240 copayment for the same drug.

Nondiscrimination notice and access to communication services

Optum Rx and its family of affiliated Optum companies do not discriminate on the basis of race, color, national origin, age, disability, or sex in its health programs or activities.

We provide assistance free of charge to people with disabilities or whose primary language is not English. To request a document in another format, such as large print, or to get language assistance such as a qualified interpreter, please call the number located on the back of your prescription ID card (TTY 711). Representatives are available 24 hours a day, 7 days a week.

If you believe we have failed to provide these services or discriminated in another way based on race, color, national origin, age, disability, or sex, you can send a complaint to:

Optum Rx Civil Rights Coordinator 11000 Optum Circle Eden Prairie, MN 55344

Phone: 1-800-562-6223 (TTY 711)

Fax: 1-855-351-5495

Email: Optum_Civil_Rights@Optum.com

If you need help filing a complaint, please call the number located on the back of your prescrip-tion ID card (TTY 711). Representatives are available 24 hours a day, 7 days a week. You can also file a complaint directly with the U.S. Department of Health and Human Services online, by phone, or by mail:

Online: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf Complaint forms are available at:

https://www.hhs.gov/ocr/complaints/index.html

Phone: Toll-free 1-800-368-1019, 1-800-537-7697 (TDD)

Mail: U.S. Dept. of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201

This information is available in other formats like large print. To ask for another format, please call the telephone number listed on your prescription ID card.

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf