Regence medicare advantage drug formulary

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Highlights

This is benefit information for coverage beginning January 1, 2014.

Regence Medicare Script is reliable, secure Part D prescription drug coverage from a company with extensive experience in providing care to Medicare beneficiaries. When you’re covered by a Regence Medicare Script plan, you can count on getting quick answers, friendly service and coverage you can trust.

With Regence Medicare Script Enhanced and Regence Medicare Script Basic, you get:

• An easy-to-use formulary that includes most Medicare Part D-covered drugs
• Benefits that are simple to use and easy to understand
• Almost 63,000 pharmacies nationwide, including large, recognized chain pharmacies and convenient mail-order service
• Tools for choosing the most effective, cost-conscious medications

Coverage Information

Here are some helpful documents to understand our coverage better:

Overview

• (PDF) Overview - Idaho residents
• (PDF) Overview - Utah residents

This booklet provides important information you need to evaluate your options and find the plan that best fits your needs.

Summary of Benefits

• (PDF) Summary of Benefits - Idaho residents
• (PDF) Summary of Benefits - Utah residents

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

• (PDF) Evidence of Coverage - Idaho residents
• (PDF) Evidence of Coverage - Utah residents
• Addendum (PDF)

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, 2014. Please contact Regence Medicare Script for details.

Plan Ratings

• (PDF) Plan Ratings - Idaho and Utah residents

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 above, or you may go to www.medicare.gov and select "Find Health and Drug Plans," and then follow the prompts to enter your information. The list of plans that appears provides plan ratings for each plan.

Plan performance Star Ratings are assessed each year and may change from one year to the next.

Pharmacies & Covered Drugs

Network Pharmacies

• (PDF) Pharmacy Directory - Idaho residents
• (PDF) Pharmacy Directory - Utah residents

We have contracts with almost 63,000 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.

For additional network pharmacy information, contact Regence Medicare Script 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 1 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.

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

• (PDF) Comprehensive Formulary - Idaho residents
• (PDF) Comprehensive Formulary - Utah residents

This is a comprehensive listing of all of the drugs on our formulary.

• (PDF) Notice of Formulary Changes - Idaho and Utah residents

Our Transition Policy

Information for new enrollees on our Part D prescription drug plans.

Prior Authorization Requirements

• (PDF) 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.gov/Medicare/Prescription-Drug-Coverage/PrescriptionDrugCovContra/Best_Available_Evidence_Policy.html

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.

• (PDF) Medication Therapy Management - Idaho residents
• (PDF) Medication Therapy Management - Utah residents

The MTM program is not actually a plan benefit, it is an educational program offered to members. The MTM program is designed to help members who meet the below criteria to get the most from their medications:

• 3 or more chronic diseases including:
  • Bone Disease which includes Osteoporosis
  • Diabetes
  • Dyslipidemia
  • Mental Health Conditions, specifically Depression
  • Chronic Respiratory Disease

  For additional information about the program and eligibility, members should contact us at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 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.

  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.
  

  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:

  • The customer service you receive.
  • The length of time spent waiting on the phone or in the pharmacy.
  • 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 1 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

  Rx Appeals
  Sixth Floor
  200 Market St
  Portland, OR 97201

  Number to call for oral coverage decision request:
  1 (800) 541-8981

  Fax number for coverage decisions:
  1 (888) 335-3016

  Number to call to request or check the status of a redetermination (appeal):
  1 (866) 749-0355

  Click here for helpful forms that will aid you in the coverage decision, appeal and grievance process.

  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 calling us or faxing your request. 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 (PDF).

  *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 seven 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 1 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.

  Contacting Medicare Directly
  You can also submit feedback about your Medicare health plan or prescription drug plan directly to Medicare. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.
  www.medicare.gov/claims-and-appeals/file-a-complaint/health-or-drug-plan/complaints-about-plans.html

  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 PDP plan with a Medicare contract. Enrollment in Regence depends on contract renewal. Medicare renews this contract annually. Your Part D 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 is a brief summary, not a complete description of benefits. For more information contact the plan. You must continue to pay your Medicare Part B premium. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.

  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.

  Note: To print a PDF document, you need Adobe® Acrobat® Reader. Adobe.com.
  

  Last updated 07/14/2014
  Y0062_2014_V6_MEDICARE Approved