Schedule M - 2019 MSPERS Pharmacy Summary of Benefits_Medicare.pdf

Optum Insurance of Ohio, Inc. is a Medicare approved Part D sponsor and administers this plan through its pharmacy benefit manager, OptumRx, on behalf of the Michigan Public School

Employees’ Retirement System. If you need this information in another language or alternate format (Braille, large print, audio), please contact OptumRx Member Services at the number located on the back of your ID card.

S8841_19_MC-DS13_MPS

OptumRx Medicare Prescription Drug Plan administered for

Michigan Public School Employees’ Retirement System by OptumRx

January 1, 2019 - December 31, 2019

Summary of Benefits

This Summary of Benefits describes some features of the OptumRx Medicare Prescription Drug

Plan, administered by OptumRx for the Michigan Public School Employees’ Retirement System.

It does not list every covered drug, or every limitation or exclusion. It does not list every covered drug, or every limitation or exclusion. For a complete list of benefits, please refer to your

Evidence of Coverage.

Please Note: The OptumRx Medicare Prescription Drug Plan is provided in conjunction with your retirement system’s Blue Cross Blue Shield of Michigan Medicare Plus Blue Group PPO.

If you choose a different Medicare Advantage plan, you will be automatically disenrolled from the OptumRx Medicare Prescription Drug Plan.

For help or information, please contact OptumRx Member Services. We are available to assist you 24 hours a day, 7 days a week.

OptumRx Member Services:

Toll-free: 1-855-235-1405

TTY: 711

For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You may also visit medicare.gov on the web.

Where is the service area for the OptumRx Medicare Prescription Drug Plan?

The service area for this plan includes all United States, the District of Columbia, Guam, and

Puerto Rico. If you move out of the service area, please contact the Office of Retirement

Services (ORS) at 1-800-381-5111 and OptumRx Member Services at 1-855-235-1405 to update your information. If you move out of the service area, you will be disenrolled from the OptumRx

Medicare Prescription Drug Plan.

Who is eligible?

Members of this plan must be eligible for benefits from the Michigan Public School Employees’

Retirement System, entitled to Medicare Part A and enrolled in Medicare Part B, live in the plan’s service area, and 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 coverage is NOT provided by the Michigan Public School Employees’ Retirement System, your enrollment 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.

Where can I get my prescriptions?

OptumRx has a network of 67,000 retail pharmacies nationwide. You must use a network pharmacy to receive plan benefits. To get a covered drug, simply present your member ID card and your prescription at a network pharmacy and pay your coinsurance/copayment amount.

For greater convenience, use the OptumRx Home Delivery pharmacy (mail-order services). You may be able to save on your maintenance medications by changing your 31-day retail supply to a

90-day supply.

In addition, the plan includes a preferred Specialty Pharmacy (BriovaRx®). Your coinsurance is lower when you use BriovaRx for specialty medications.

Except in certain cases, we will not cover your prescriptions if you use an out-of-network (non-participating) pharmacy. If you choose to go to a non-participating pharmacy, you must pay for the prescription in full and file a claim with OptumRx for reimbursement. If the claim is approved, you will be responsible for the copayments/coinsurance 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 towards your $1,500 Annual

Coinsurance Maximum amount.

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

You have an additional 10% coinsurance starting with the 4th fill of a 31-day supply of maintenance medications. It is important to note that the 10% is not based on a calendar year basis and does not start over each year. You can avoid this additional expense by filling a 90-day supply at an in-network retail or OptumRx Home Delivery (mail-order) pharmacy .

You may be able to receive up to a 90-day supply of your prescription medication at a retail pharmacy, however, not all drugs are available at a 90-day supply, and not all retail pharmacies offer a 90-day supply. Please refer to your Pharmacy Directory, or contact

OptumRx Member Services at 1-855-577-6517 for more information.)

Please note: Some retail pharmacies may offer independent promotions that could result in your out-of-pocket cost being less than your coinsurance/copayment in this plan.

Such out-of-pocket costs do not accumulate towards your $1,500 Annual Coinsurance

Maximum.

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

Home delivery offers a convenient and cost-effective way to obtain up to a 90-day supply of maintenance medication through the mail.

Option 3: Fill your prescriptions with our Specialty Pharmacy (BriovaRx).

The OptumRx Prescription Drug Plan offers a Preferred Specialty Pharmacy, BriovaRx, if you need to fill prescriptions for certain specialty drugs that treat complex conditions.

Your copayment will be lower if you use BriovaRx

. 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 31-day supply.

What is a formulary ("Drug List”)?

A formulary is a list of covered drugs, also referred to as the “drug list.” Drugs on the formulary 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. Specifically:

when you must first try one drug to treat your condition before another drug will be covered for that condition, when there is a limit to the quantity you can receive of a drug, and when your provider must get prior authorization from OptumRx for your drug to be covered.

If you are currently taking a drug that is not on the drug list or one that is subject to additional coverage rules or limits, call OptumRx Member Services to see if you can get a temporary supply of the drug, or for details about our drug transition policy.

What is not covered by the plan?

There are three general rules about drugs not covered by our plan:

The drug is covered under Medicare Part A or Part B.

The drug is purchased outside the United States and its territories.

The drug has been prescribed for “off-label use.” (Refer to your Evidence of Coverage for more information).

Also, these categories of drugs are not covered:

Non-prescription drugs (also called over-the-counter drugs)

Drugs used to promote fertility, for the relief of cough or cold symptoms, for cosmetic purposes or to promote hair growth, for the treatment of sexual or erectile dysfunction, or for treatment of anorexia, weight loss, or weight gain

Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparations

Outpatient drugs for which the manufacturer seeks to require that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale

What is the Medication Therapy Management (MTM) Program?

The MTM Program is a free service we offer. The program can help make sure members are using the drugs that work best to treat their medical conditions and 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 notify us, and we will withdraw your participation in the program.

Two Stages of Coverage for our plan

Stage 1:

Initial Coverage Stage

During this stage, our plan pays its share of the cost and you pay your share of the cost of your drugs. How much you pay for a drug depends on which “tier” the drug is in and if you have met your

$1,500 Annual Coinsurance Maximum. Your share of the cost, and what does and does not count toward your Annual Coinsurance

Maximum, is described on the next page.

Stage 2:

Catastrophic Coverage

Stage

Most members do not reach this Stage because your plan benefits include a $1,500 Annual Coinsurance Maximum.

However, if your year-to-date payments for drugs covered by

Medicare Part D do reach a total of $5,100 before your $1,500 plan-specific Annual Coinsurance Maximum, you enter the

Catastrophic Coverage Stage, and through the remainder of the year you will pay:

• The greater of 5% coinsurance or:

o $3.40 copayment for covered generic drugs

(including brand drugs treated as generics) o $8.50 copayment for all other covered drugs

Coinsurance and copayments for covered drugs

Retail Network

Pharmacy

31-day supply

Retail Network

& Mail-Order

Pharmacy

90-day supply

Preferred

Specialty

Pharmacy

31-day supply

Non-Preferred

Specialty

Pharmacy

31-day supply

Cost-Sharing

Tier 1

Generic drugs

20% coinsurance

$10 minimum /

$40 maximum

20% coinsurance

$25 minimum /

$100 maximum

20% coinsurance

$10 minimum /

$40 maximum

40% coinsurance

$10 minimum / no maximum*

Cost-Sharing

Tier 2

Preferred Brand

& Preferred

Specialty drugs†

20% coinsurance

$10 minimum /

$40 maximum

20% coinsurance

$25 minimum /

$100 maximum

20% coinsurance

$10 minimum /

$40 maximum

40% coinsurance

$10 minimum / no maximum*

Cost-Sharing

Tier 3

Non-Preferred

Brand drugs

40% coinsurance

$10 minimum / no maximum*

40% coinsurance

$25 minimum / no maximum**

40% coinsurance

$10 minimum / no maximum*

40% coinsurance

$10 minimum / no maximum*

Cost-Sharing

Tier 4

Non-Preferred

Specialty drugs†

40% coinsurance

$10 minimum / no maximum*

N/A

Limited to 31 day supply

40% coinsurance

$10 minimum / no maximum*

40% coinsurance

$10 minimum / no maximum*

† Drugs that cost $670 or more for up to a 31-day maximum supply.

* Only 20% coinsurance, up to a $40 maximum, is credited to the annual coinsurance maximum.

** Only 20% coinsurance, up to a $100 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 $1,500, 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 $1,500, your cost share will be reduced by 20% (subject 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 $1,500, the $700 drug cost will be reduced by 20% ($40 max) which means you now pay a $240 copayment for the same drug.

Maintenance Medications at Retail

Beginning from your effective date of coverage, you are allowed to fill certain medications (up to a 31-day supply) at a retail pharmacy only three times before an additional 10% coinsurance is applied upon the fourth fill regardless of the day supply for each of those three fills. This means, once you have received three fills (up to a 31-day supply), you will be charged an additional 10% coinsurance for any subsequent fill that is less than a 90-day supply. It is important to note that the 10% is not based on a calendar year basis and does not start over each year. If you fill a 90-day supply of maintenance medications at retail, the additional 10% coinsurance will not be applied. Also, if you fill less than a 90-day supply through mail-order, the additional 10% coinsurance will not be applied. For reference, maintenance medications are drugs that you take on a regular basis for a chronic or long-term medical condition.

How can I get Extra Help with my prescription drug plan costs?

You may be able to get Extra Help to pay for your cost sharing. To see if you qualify for Extra

Help, call:

1-800-MEDICARE (1-800-633-4227) 24 hours a day, 7 days a week. (TTY users should call 1-877-486-2048); also see www.medicare.gov “Programs for People with Limited

Income and Resources” in the Medicare & You handbook.

The Social Security Administration at 1-800-772-1213 (TTY 1-800-325-0778) between 7 a.m. and 7 p.m., Monday through Friday.8

Your state Medicaid office.

Drug Coverage Determinations

As a member of this Medicare Prescription Drug plan, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want the plan to cover a Medicare Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on the Drug List, or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to additional coverage 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. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. 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.

OptumRx 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 that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can send a complaint to:

OptumRx 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 prescription 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/office/file/index.html

Phone: 1-800-368-1019 (Toll-Free)

1-800-537-7697 (TDD)

Mail: U.S. Department 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 plan ID card.

Multi-Language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Please call the toll-free phone number listed on your identification card.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列

的免付費會員電話 號碼。

XIN LƯU Ý: Nếu quý vị nói tiếng Việt (Vietnamese), quý vị sẽ được cung cấp dịch vụ trợ giúp về ngôn ngữ miễn phí. Vui lòng gọi số điện thoại miễn phí ở mặt sau thẻ hội viên của quý vị.

알림: 한국어(Korean)를 사용하시는 경우 언어 지원 서비스를 무료로 이용하실 수

있습니다. 귀하의 신분증 카드에 기재된 무료 회원 전화번호로 문의하십시오.

PAALALA: Kung nagsasalita ka ng Tagalog (Tagalog), may makukuha kang mga libreng serbisyo ng tulong sa wika. Pakitawagan ang toll-free na numero ng telepono na nasa iyong identification card.

ВНИМАНИЕ: бесплатные услуги перевода доступны для людей, чей родной язык является русском (Russian). Позвоните по бесплатному номеру телефона, указанному на вашей идентификационной карте.

ةيبرعلا(Arabic)، نإف تامدخ ةدعاسملا ةيوغللا ةيناجملا ةحاتم كل. ءاجرلا لاصتلاا ىلع مقر فتاھلا يناجملا دوجوملا ىلع

فرعم ةيوضعلا.هيبنت : اذإ تنك ثدحتت

ATANSYON: Si w pale Kreyòl ayisyen (Haitian Creole), ou kapab benefisye sèvis ki gratis pou ede w nan lang pa w. Tanpri rele nimewo gratis ki sou kat idantifikasyon w.

ATTENTION: Si vous parlez français (French), des services d’aide linguistique vous sont proposés gratuitement. Veuillez appeler le numéro de téléphone gratuit figurant sur votre carte d’identification.

UWAGA: Jeżeli mówisz po polsku (Polish), udostępniliśmy darmowe usługi tłumacza.

Prosimy zadzwonić pod bezpłatny numer telefonu podany na karcie identyfikacyjnej.

ATENÇÃO: Se você fala português (Portuguese), contate o serviço de assistência de idiomas gratuito. Ligue gratuitamente para o número encontrado no seu cartão de identificação.

ATTENZIONE: in caso la lingua parlata sia l’italiano (Italian), sono disponibili servizi di assistenza linguistica gratuiti. Per favore chiamate il numero di telefono verde indicato sulla vostra tessera identificativa.

ACHTUNG: Falls Sie Deutsch (German) sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Bitte rufen Sie die gebührenfreie Rufnummer auf der Rückseite Ihres Mitgliedsausweises an.

注意事項：日本語(Japanese)を話される場合、無料の言語支援サービスをご利用いた

だけます。健康保険 証に記載されているフリーダイヤルにお電話ください。

کارت هکر يو لتفن يناگيار شماره ل افط اب شام يم دشاب. يتخاار ناگيارد ر است، تامدخ دادما ينابز هب روط (Farsi) اگرز بناش ام يسراف

: وت جه تمسا ديريگب. اسانشيی امش ديق هدش

ध्यान दें : यदद आप ह िंदी (Hindi) बोलते है, आपको भाषा सहायता सेबाएं, दन:शुल्क उपलब्ध हैं। कृपया

अपने पहचान पत्र पर सूचीबद्ध टोल-फ्री फोन नंबर पर कॉल करें ।

CEEB TOOM: Yog koj hais Lus Hmoob (Hmong), muaj kev pab txhais lus pub dawb rau koj. Thov hu rau tus xov tooj hu deb dawb uas teev muaj nyob rau ntawm koj daim yuaj cim qhia tus kheej.

ចំណាប់អារម្មណ ៍ៈ បបើសិនអ្នកនិយាយភាសាខ្មែរ(Khmer)បសវាជំនួយភាសាបោយឥតគិតថ្លៃ

គឺមានសំរាប់អ្នក។ សូម្ទូរស័ព្ទបៅបេខឥតគិតថ្លៃ ដែេមានបៅបេើអ្តដសញ្ញា ណប័ណណ របស់អ្នក។

PAKDAAR: Nu saritaem ti Ilocano (Ilocano), ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Maidawat nga awagan iti toll-free a numero ti telepono nga nakalista ayan iti identification card mo.

DÍÍ BAA'ÁKONÍNÍZIN: Diné (Navajo) bizaad bee yániłti'go, saad bee áka'anída'awo'ígíí, t'áá jíík'eh, bee ná'ahóót'i'. T'áá shǫǫdí ninaaltsoos nitł'izí bee nééhozinígíí bine'dęę' t'áá jíík'ehgo béésh bee hane'í biká'ígíí bee hodíilnih.

OGOW: Haddii aad ku hadasho Soomaali (Somali), adeegyada taageerada luqadda, oo bilaash ah, ayaad heli kartaa. Fadlan wac lambarka telefonka khadka bilaashka ee ku yaalla kaarkaaga aqoonsiga.