Microsoft word - pa medicare d prescription plan.doc
Information About The Port Authority of NY & NJ
Retiree Prescription Drug Plan – Express Scripts
For Customer Service Call (800) 557-3949
An identification card will be provided to each Medicare-enrolled individual. Bring the card each time with you each time you need to fill a prescription at your participating pharmacy. In the event you forget the card or misplace it, the pharmacy can still identify you as an Express Scripts member if you provide your social security number and the Port Authority/PATH Rx Group - PANN. Lost cards can be replaced by calling the number above.
Your program covers all medications that require a prescription by either State or Federal law and are prescribed by a licensed medical practitioner. All refills will be dispensed according to your physician’s directions. The co-pay is 20% with no annual deductible and an annual out-of-pocket maximum of $500 per covered individual per year. See Section XII for cost comparison with a standard Medicare Part D plan. Insulin is covered by prescription only. Insulin syringes and needles are covered by prescription only. Prescriptions will be dispensed as written by the physician. Contraceptives are available through mail order only. Maintenance drugs used on a long-term basis that are filled through mail order will save you money. Prescription vitamins can also be filled through mail order to save money. There is no limit to the number of prescriptions allowable through your prescription drug program. To find out if any dosage limitations, restrictions or other requirements apply to a drug that may be or has been prescribed, please contact Express Scripts.
Medications lawfully obtainable without a prescription; devices or appliances - support garments or other non-medicinal substances; administration charges for drugs or insulin; investigative or experimental drugs; unauthorized refills/prescriptions covered without charge under Federal, State or local programs including Workers’ Compensation; medications provided to eligible participants confined to a rest home, nursing home, sanitarium, extended care facility, hospital or similar entity where drugs are covered under either Medicare Part A or B; medication used for cosmetic purposes (e.g., Rogaine/Monoxidil for hair restoration and Retin-A for individuals over 25 years old).
To fill a prescription, present your identification card to one of the participating pharmacies. Express Scripts can help you locate the name of a participating pharmacy. At the pharmacy, you will be asked to sign for the prescription and pay 20% for each prescription or refill. If you are using a maintenance medication on a long-
term basis for chronic ailments such as high blood pressure, heart conditions, diabetes, asthma, arthritis, etc., you will save money by using the Mail Order Program to fill your prescription. For individuals with Veteran Administration (VA) pharmacy benefits, Medicare law does not permit coordination of benefits. For individuals with TRICARE pharmacy benefits, by law, TRICARE only pays after all other health plans have paid - if you want TRICARE as your primary coverage, you must disenroll from the Port Authority’s prescription drug plan.
The Mail Order Program allows members to receive up to a 90-day supply of maintenance medications delivered directly to their residence or other specified location. The cost is 20% for each mail order prescription or refill that is dispensed, up to a 90-day supply. There is no charge for postage. _________________________________________________________________________________________
If you are traveling or experience an emergency which necessitates the use of a pharmacy that is not part of the network, you can get reimbursed for up to a 30-day supply by paying the full cost of the prescription to the pharmacy and submitting a claim form to Express Scripts. Claim forms can be obtained by calling the above customer service number or from the Express Scripts website. Please bear in mind that your use of pharmacies within the network helps keep plan costs in line and, thereby, helps to preserve current benefit levels.
Dependent children are covered until the end of the calendar year in which they turn age 19. This coverage may be extended through the end of the month in which the child graduates from college, or through the end of the calendar year the child turns age 26, if he or she is single, attending an accredited educational institution full time and dependent on the employee/retiree for support.
Pharmacists are willing to assist you or your physician with pharmaceutical advice. If you have questions about your medication, you may wish to contact your physician and/or your pharmacist.
If coverage is denied, you can contact Express Scripts at 1-800-557-3949. Express Scripts will send you a written decision explaining the reason for the denial. Getting Information To Support Your Appeal Express Scripts must gather all the information needed to make a decision about your appeal. If Express Scripts needs your assistance in gathering this information, it will contact you. You have the right to get and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information. You can give Express Scripts your additional information in any of the following ways:
• In writing: Express Scripts, Inc. Attention: Pharmacy Appeals – Part D, Mail Route: BL0390,
6625 West 78th Street, Bloomington, MN 55439.
• By telephone -- if it is a fast appeal -- at 1-800-344-3405 extension 2373022. (A doctor’s supporting
• In person, at Express Scripts, Inc. Attention: Pharmacy Appeals – Part D, 6625 West 78th Street,
A standard appeal is decided within 7 days and a “fast” appeal is decided within 72 hours. If the appeal decision is not completely favorable, you have additional levels of appeal that are available. If your appeal is not completely favorable, you will receive a letter describing the additional levels of appeal.
X. GRIEVANCES A grievance is a complaint other than one that involves a coverage determination. You would file a grievance if you have any type of problem with Express Scripts or one of its network pharmacies that does not relate to coverage for a prescription drug. For example, you would file a grievance if you have a problem with waiting times when filling a prescription, the way your network pharmacist or others behave, being able to reach someone by phone, getting the information you need, or the cleanliness/condition of a network pharmacy. Grievances are handled by the Express Scripts Grievance Department. The Express Scripts' Medicare Grievance Team is available, Monday - Friday, from 8:00 a.m. to 5:00 p.m. CST. During non-business hours, you may leave a message and your call will be returned on the next business day. You may submit your grievance to Express Scripts by mail, phone or fax: mail to Express Scripts, Attn: Director of Grievances, PO Box 66517, Saint Louis, MO 63166-6517; phone by calling 1-866-533-8512; or fax to 1-800-305-1686. You will be notified of the grievance ruling within 30 days of the date the grievance was filed. If your claim is denied in whole or in part, you may appeal the denial. A request for review must be received within 90 days after the claim payment date or the date of denial notification, and should state the reason you think the claim was improperly paid or denied with supporting documentation. A review of the denial will be made and a response will be provided within 60 days. If the review cannot be completed within 60 days, you will be notified of the delay within the 60-day period and provided with a final response to the request within 120 days of the date of the request for review of the denial. If the denial is upheld you will be provided with the specific reasons/plan provisions upon which the denial is based. XI. HIPAA / PRIVACY STATEMENT A federal law, the Health Insurance Portability and Accountability Act of 1996 (HIPAA), requires that health plans (Plan) protect the confidentiality of your private health information. A complete description of your rights under HIPAA can be found in the Port Authority/PATH sponsored group health plans’ privacy notice, distributed on April 14, 2003, and available upon request. This Plan will not use or further disclose information that is protected by HIPAA (“protected health information”) except as necessary for treatment, payment, health plan operations and plan administration, or as permitted or required by law. By law, the Plan has required Express Scripts to also observe HIPAA’s privacy rules. Further, the Plan will not, without authorization, use or disclose protected health information for employment-related actions and decisions or in connection with any other benefit or employee/retiree benefit plan of the Plan Sponsor. Under HIPAA, you have certain rights with respect to your protected health information, including certain rights to see and copy the information, receive an accounting of certain disclosures of the information and, under certain circumstances, amend the information. You also have the right to file a complaint with the Plan or with the Secretary of the U.S. Department of Health and Human Services if you believe your rights under HIPAA have been violated.
XII. COMPARISON OF PORT AUTHORITY PRESCRIPTION DRUG COVERAGE AND STANDARD MEDICARE PRESCRIPTION DRUG COVERAGE
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