2017

PLAN
INFORMATION

You have entered the 2017 plan year website. Benefits, formulary, pharmacy network, premium, deductible and/or copayments/coinsurance may change on January 1, 2018. Visit our 2018 website for details.

Contract Renewal

Medicare must approve our plan each year
The Centers for Medicare & Medicaid Services (CMS) must approve Express Scripts Medicare each year. A beneficiary can continue to get Medicare coverage as a member of our plan as long as we choose to continue to offer the plan and CMS renews its approval of the plan.

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Contract Termination Notice

All Medicare prescription drug plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare prescription drug plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare prescription drug coverage in your area.

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Contracting Statement

Express Scripts Medicare® (PDP) is a prescription drug plan with a Medicare contract. Enrollment in Express Scripts Medicare depends on contract renewal.

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Eligibility Requirements

A Part D eligible beneficiary is defined as:

  • Being entitled to Medicare benefits under Part A and/or enrolled in Part B
  • Having Part D eligibility in the CMS systems
  • Being a permanent resident in the geographic service area of the Part D plan

Additional Enrollment Information

  • You may be enrolled in only one Medicare Part D plan at a time.

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Enrollment/Disenrollment Options

Initial Enrollment Period
When you reach age 65, you have a 7-month period to enroll in a Medicare Part D plan:

  • 3 months before the month you turn 65
  • The month you turn 65
  • 3 months after the month you turn 65

If you join during the 3 months before you turn 65, your coverage will start on the first day of your birthday month. If you join during or after your birthday month, your coverage will begin on the first day of the next month.

If you are eligible for Medicare due to a disability, you can enroll in a Medicare Part D plan during the 7-month period that begins:

  • 3 months before the 25th month of your disability
  • The 25th month of your disability
  • 3 months after your 25th month of disability
  • During your Initial Enrollment Period when you turn 65

For more information, call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

Annual Enrollment Period
The Annual Enrollment Period runs from October 15 through December 7 each year. In general, enrollment is allowed only during the Annual Enrollment Period unless you recently became eligible for Medicare or qualify for a Special Enrollment Period. For more information, call Customer Service toll free at 1.866.477.5703, 8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

Special Enrollment Period
A Special Enrollment Period is when a person, under certain circumstances, may enroll in, or disenroll from, a Medicare prescription drug plan at times other than during the Annual Enrollment Period. Examples of such circumstances may include receiving benefits from both Medicare and Medicaid; changing living situations (such as moving out of state or into a long-term care facility); losing creditable prescription drug coverage from an employer or other plan sponsor; or losing coverage because a plan no longer offers Medicare prescription drug coverage. For more information, call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

Late Enrollment Penalty
The late enrollment penalty is 1% of the national average premium for every month you were without Medicare Part D prescription drug coverage or other creditable prescription drug coverage following your Initial Enrollment Period. Or, the penalty can be charged if you had a break in creditable prescription drug coverage of 63 or more consecutive days. Creditable prescription drug coverage (for example, from an employer or union) means that it is expected to pay, on average, as much as Medicare's standard prescription drug coverage. You will pay this late enrollment penalty for as long as you have Medicare Part D coverage.

Voluntary Disenrollment
Members may disenroll from a prescription drug plan during one of the election periods by following these guidelines:

  • You can end your membership during the Annual Enrollment Period. This is the time when you should review your health and drug coverage and make a decision about your coverage for the upcoming year.
  • You can end your membership by enrolling in another plan.
  • In certain situations, you can end your membership during a Special Enrollment Period.

For more information about Voluntary Disenrollment, please call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231. Or contact Medicare at 1.800.MEDICARE (1.800.633.4227). TTY users should call 1.877.486.2048, 24 hours a day, 7 days a week.

Required Involuntary Disenrollment
A prescription drug plan organization must end your membership in the plan if any of the following situations occur:

  • If you do not stay continuously enrolled in Medicare Part A or Part B (or both).
  • If you move out of our service area for more than 12 months.
  • If you become incarcerated (go to prison).
  • If you lie about or withhold information about other insurance you have that provides prescription drug coverage.
  • If you intentionally give us incorrect information when you are enrolling in our plan and that information affects your eligibility for our plan.
  • If you continuously behave in a way that is disruptive and makes it difficult for us to provide care for you and other members of our plan.
  • If you let someone else use your membership card to get prescription drugs.
  • If you do not pay the plan premiums for 2 consecutive calendar months.

For more information about Involuntary Disenrollment, please call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

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Exceptions, Appeals and Transition Process

If you would like to request a coverage determination (such as an exception to the rules or restrictions on our plan's coverage of a drug) or if you would like to make an appeal for us to reconsider a coverage decision, you may:

Initial Clinical Coverage Reviews

Use this contact information if you need a coverage decision for a medication that is not on the formulary.

Administrative Coverage
Reviews and Appeals

Use this contact information if you need a coverage decision about a restriction on a specific medication and want to request a lower cost-sharing amount.

Clinical Appeals

Use this contact information if you need to file an appeal if your coverage review is denied.

Call toll free 1.844.374.7377, 24 hours a day, 7 days a week. TTY users: call 1.800.716.3231. Call toll free 1.800.413.1328, Monday through Friday, 8 a.m. - 6 p.m. Central. TTY users: call 1.800.716.3231. Call toll free 1.844.374.7377, Monday through Friday, 8 a.m. - 8 p.m.,
Central. TTY users: call 1.800.716.3231.
Fax a Coverage Determination form to: 1.877.328.9799 Fax a Coverage Determination form to: 1.877.328.9660 Fax a Coverage Redetermination form to: 1.877.852.4070
Mail a Coverage Determination form to:

Express Scripts
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Mail a Coverage Determination form to:

Express Scripts
Attn: Medicare Administrative Department
P.O. Box 66587
St. Louis, MO 63166-6587
Mail a Coverage Redetermination form to:

Express Scripts
Attn: Medicare Clinical Appeals
P.O. Box 66588
St. Louis, MO 63166-6588

Download a Coverage Determination Request Form. Click here if you would like to submit a Medicare Part D coverage determination request form online.

Coverage Redetermination Request Form
The request for Medicare Prescription Drug Denial Form should be used to initiate an appeal to a previously declined coverage review request. Once complete, the form should be faxed to us (without a cover sheet) at 1.877.852.4070. Click here if you would like to submit a Medicare Part D coverage redetermination request form online.

If you would like to appoint a person to file a grievance, request a coverage determination or exception or make an appeal on your behalf, you and the person accepting the appointment must fill out an Appointment of Representative Form (or a written equivalent) and submit it with the request. Click here for further instructions on how to appoint a Medicare Part D representative.

Express Scripts Medicare Transition Process
As a new or continuing member in our plan, you may be taking drugs that are not on our formulary. Or, you may be taking a drug that is on our formulary, but your ability to get it is limited. You should talk to your doctor to decide if you should switch to an appropriate drug that we cover or request a formulary exception so that we will cover the drug you take. For each of your drugs that is not on our formulary, or if your ability to get your drugs is limited, we will cover a temporary supply up to at least 30 days at retail (unless you have a prescription written for fewer days) when you go to a network pharmacy within the first 90 days of the calendar year (or the first 90 days of your effective date if your coverage begins after the first of the year). After your first 30-day supply, we will not pay for these drugs. For additional information on our transition policy or if you are a resident of a long-term care facility, please refer to the plan's Evidence of Coverage.

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Extra Help

You may be able to get Medicare Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Medicare 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.
  • The Social Security Office at 1.800.772.1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1.800.325.0778; or
  • Your State Medicaid Office

If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. However, it does not include any Medicare Part B premium you may have to pay.

Please note: If you have received assistance with your prescription drug costs from a charity and receive a refund, you should work directly with the charity to refund its portion.

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Formulary

Brand-Name & Generic Drugs
Express Scripts Medicare covers both brand-name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs.  FDA-approved generic drugs are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

Size of Formulary
The Express Scripts Medicare formulary includes more than 3,000 brand and generic drugs most commonly prescribed for seniors.

60-Day Notice for Formulary Changes
We may periodically add or remove a drug, make changes to coverage rules on certain drugs, or change how much you pay for a drug. If we make any formulary change that limits your ability to fill prescriptions, we will notify you at least 60 days before the change is made. Note that if the Food and Drug Administration finds that a drug on the formulary is unsafe or if the drug's manufacturer removes the drug from the market, we immediately remove the drug from our formulary and then notify you of the change.

Coverage
Certain drugs may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.

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How to Request Dispute History

You may request information about the total number of grievances, appeals, and exceptions that have been filed with Express Scripts Medicare, as well as about the outcomes of these disputes. Call Express Scripts Medicare Customer Service toll free at 1.800.758.4574 (New York State residents, call 1.800.758.4570), 24 hours a day, 7 days a week. This information is available for free in other languages. TTY users should call 1.800.716.3231.

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Medication Therapy Management Program

The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.

To qualify for the MTM program, you must be eligible. Please see below for those details. If you qualify, you will be automatically enrolled into the program, and the service is provided at no additional cost to you. You may choose not to participate in the program, but it is recommended that you make use of this free service.

The MTM program is offered through a partnership between Express Scripts and the Medication Management Center (MMC) at the University of Arizona. The MTM program is not considered a part of the plan’s benefit.

You may qualify for the MTM program if:

  1. You have 3 or more chronic health problems. These may include:
    • Asthma
    • Chronic Heart Failure (CHF)
    • Chronic Obstructive Pulmonary Disease (COPD)
    • Diabetes
    • End-Stage Renal Disease (ESRD)
    • High blood fat levels
    • High blood pressure
    • Osteoporosis
  2. You take 7 or more daily medicines covered by Medicare Part D.
  3. You spend $3,919 or more per year on Medicare Part D – covered medications.

If you qualify for the MTM program, you will be contacted and have the chance to speak with a highly trained pharmacist or a pharmacist intern who works under the direct guidance of a pharmacist. During that call, the pharmacist or pharmacy intern will complete a comprehensive review of your medicines and talk with you about:

  • Any questions or concerns about your prescription or over-the-counter medicines, such as drug safety and cost
  • Better understanding of your medicines and how to take them
  • How to get the most benefit from your medicines

If you qualify for the MTM program, you will receive:

  • A welcome letter that tells you how to get started.
  • A full medication review
    • You will have the chance to review your medicines each year with a highly trained pharmacist or a pharmacist intern working under the direct guidance of a pharmacist. This review will take about 20 to 30 minutes. During this call, any issues with your medicines will be discussed. The call can be scheduled at a convenient time for you.
    • After you complete the full medication review, a summary is mailed to you. The summary includes a medication action plan with space for you to make notes or write down any follow-up questions.
    • You also will be mailed a personal medication list that includes all of the medicines that you take and the reasons why you take them.
    • Click here to see a blank copy of a Personal Medication List.
  • Ongoing targeted medication reviews
    • At least once every 3 months, your medicines will be reviewed, and you or your doctor will be contacted. Please inform us of any changes in your list of medicines. You may get a letter or a phone call for this review.

For information about the MTM program or to see if you qualify, you can call 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

Note: The Medication Therapy Management Program is not considered a benefit.

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Medigap

If you have a Medigap (Medicare Supplement Insurance) policy that includes prescription drug coverage, you must contact your Medigap issuer to let them know that you have enrolled in a Medicare prescription drug plan. If you decide to keep your current Medigap policy, your Medigap issuer will remove the prescription drug coverage portion of your policy and lower your premium. Call your Medigap issuer for details.

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Pharmacy Access

Pharmacy Network
As an Express Scripts Medicare member, you have access to over 67,000 network pharmacies nationally, including convenient home delivery service through the Express Scripts PharmacySM.

Out-of-Network Coverage
In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. Covered Medicare Part D drugs are available at out-of-network pharmacies under certain circumstances, such as illness while traveling outside the plan's service area where there is no retail network pharmacy. You may incur an additional cost for prescriptions filled at an out-of-network pharmacy. Please note that the pharmacies in our network now may change. For the most up-to-date information, visit our Medicare Part D pharmacy locator tool or call Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231.

Pharmacy Access & Participation
This plan has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. In most cases, your prescriptions are covered under this plan only if they are filled at a retail network pharmacy or through our home delivery pharmacy. We will fill prescriptions at out-of-network pharmacies under certain circumstances. Quantity limitations and restrictions may apply.

Long-term care and home infusion pharmacies may service a broad area. Therefore, you may need to look outside your immediate area for these types of providers.

Pharmacy List
To get current information about Express Scripts Medicare network pharmacies in your area, visit our Medicare Part D pharmacy locator tool. Inclusion in this list does not guarantee that a pharmacy continues to participate in our plan.

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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). You may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area. You can also download the plan ratings for this plan. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

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Premiums

As a member of our plan, you pay a monthly plan premium. In addition, you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party, even if the Medicare Part D premium is $0. Click here to view a listing of Medicare Part D premiums by state.

If you are assessed a Medicare Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premimum.

If you would like to change your premium payment method, please contact Customer Service toll free at 1.866.477.5703, 24 hours a day, 7 days a week, except Thanksgiving and Christmas. TTY users should call 1.800.716.3231. Please note: If you do choose to change your method of payment, it may take up to 3 months for this change to take effect, and you may continue to be billed via the original method until your change takes effect.

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Privacy

This website is designed to provide access to online information regarding the Express Scripts Medicare Part D product offering. In connection with providing this information, there are times when we will ask for, or collect, personal information from you. As part of our commitment to honoring your privacy, this policy will explain the approach we take in protecting and using the information that we gather from you on this website. For your ease and convenience, we make this notice available from every page of the website, identified as "Privacy," with a link to this notice.

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Service Area

The service area for the Value and Choice Medicare Part D plans includes all 50 states, the District of Columbia, and Puerto Rico.

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Service Complaint

  • If you would like to make a complaint or for process or status questions regarding a complaint related to issues such as quality of care, waiting time, or the Customer Service you receive, you may: Call us toll free at 1.800.758.4574 (New York State residents should call 1.800.758.4570). Customer Service is available 24 hours a day, 7 days a week. TTY users should call 1.800.716.3231.

    OR
  • You may write to us and send by mail to:

    Express Scripts Medicare
    Attn: Grievance Resolution Team
    P.O. Box 3610
    Dublin, OH 43016-0307

If you need assistance or more information on filing a complaint, please call Customer Service toll free at the number listed above.

If you would like to submit feedback about your Medicare Part D prescription drug plan directly to Medicare, please complete their online form at:
https://www.medicare.gov/
MedicareComplaintForm/home.aspx
*

You may also contact them by phone at 1.800.MEDICARE (1.800.633.4227), 24 hours a day, 7 days a week. TTY users can call 1.877.486.2048.

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Need help?

Call 1.866.477.5703 TTY users: 1.800.716.3231
8 a.m. to 8 p.m., 7 days a week, except Thanksgiving and Christmas

*By selecting this link, you will be opening a new browser window to another site. We assume no responsibility for any material or information you may encounter on this or any other non-Express Scripts site.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.