2018 BENEFITS WORKBOOK · PDF fileGeneric Drugs ... Carrier enrollment forms can be obtained...

2018 B E N E F I T S W O R K B O O KF O R R E T I R E D C A R N E G I E M E L L O N FA C U LT Y A N D S TA F F

For more informa on about 2018 benefi ts, visit h p://www.cmu.edu/hr/benefi ts.

B E N E F I T S W O R K B O O K

F o r m o r e i n fo r m a t i o n , v i s i t h t t p : / / w w w. c m u . e d u / h r / b e n e f i t s / b e n e f i t _ p r o g ra m s / r e t i r e e - m e d i c a l . h t m l .2

Table of ContentsCarnegie Mellon Re ree Benefi ts ........................................................................ 3

Open Enrollment ................................................................................................. 3

Medical Op ons for Carnegie Mellon Re rees ................................................... 4HealthAmerica Advantra Coverage Summary ............................................... 5Highmark Security Blue Coverage Summary ................................................. 8UPMC for Life Coverage Summary .............................................................. 11

Prescrip on Drug Coverage ............................................................................... 14Generic Drugs ............................................................................................. 15Formulary .................................................................................................... 15Mail Order Prescrip ons: Convenience and Aff ordability ........................... 15

Life and Family Status Changes ......................................................................... 16

Denial of Coverage Appeals ............................................................................... 16

Contact Informa on .......................................................................................... 17

Creditable Coverage No ce (Medicare HMOs) ................................................. 18

Non-Creditable Coverage No ce (Major Medical/Supp. Rx) ............................. 20

Read This Workbook

You should read this workbook thoroughly and select the medical benefi t that best meets your needs. Please note the new contribu on amounts. If you require more informa on, contact the HR Benefi ts Offi ce at 412-268-2047.

Carnegie Mellon reserves the right to modify, amend, or terminate any or all of the provisions of these benefi ts at any me for any reason upon appropriate ac on by the university. Notwithstanding any of the prior statements, in all cases, university policies will govern.

F o r m o r e i n fo r m a t i o n , v i s i t h t t p : / / w w w. c m u . e d u / h r / b e n e f i t s / b e n e f i t _ p r o g ra m s / r e t i r e e - m e d i c a l . h t m l . 3

F O R R E T I R E D C A R N E G I E M E L L O N F A C U L T Y A N D S T A F F

Carnegie Mellon Re ree Benefi tsWe are pleased to off er re red Carnegie Mellon University faculty and staff medical and prescrip on drug benefi ts. Post-65 re rees may par cipate in one of our Medicare HMO or Re ree Major Medical health plans. Pre-65 re rees are off ered coverage under COBRA un l they reach age 65 (see box to the right).

Who is Eligible for Re ree Medical Benefi ts?To par cipate in the Re ree Medical Benefi ts plan, you must:• Be eligible for full- me health benefi ts at the me of re rement• Be at least 60 years of age• Have at least fi ve years of service with the university

You may also cover your dependents. Eligible dependents include:

• Your spouse/registered domes c partner• Your unmarried children up to their 26th birthday• Your unmarried children of any age who were covered under the par cular benefi t

and were disabled as defi ned in the informa on provided by the third party administrator or insurance company

Note: If you are reemployed a er your re rement from CMU, your eligibility for Re ree Medical Benefi ts may be impacted.

For further details about your eligibility for benefi ts, contact the HR Benefi ts Offi ce at 412-268-2047 or visit h p://www.cmu.edu/hr/benefi ts/benefi t_programs/re ree-medical.html.

Open EnrollmentEach year, Open Enrollment (OE) provides you the opportunity to review your benefi ts coverage and make new elec ons for the upcoming calendar year. Elec ons made during OE will become eff ec ve the following January 1. Unless you experience a life or family status change, OE is the only me during the year when you may change your benefi ts. All informa on contained in this booklet is also available online at h p://www.cmu.edu/hr/benefi ts/benefi t_programs/re ree-medical.html.

If you want to change your elec ons during OE, you must complete the university’s enrollment/change form and return it to the HR Benefi ts Offi ce. If you do not want to make changes, you do not need to take further ac on.

• If you are newly enrolling in/changing HMO plans, you must also complete the carrier’s enrollment form and return it to the HR Benefi ts Offi ce.

• If you are newly enrolling in or changing to the Major Medical and Supplemental Prescrip on plan, you must also complete the Highmark Major Medical enrollment form and return it to the HR Benefi ts Offi ce.

Carrier enrollment forms can be obtained by contac ng the HR Benefi ts Offi ce at 412-268-2047.

Re rees Outside of PennsylvaniaOut-of-town re rees are eligible for the Major Medical and Supplemental Prescrip on benefi ts through Carnegie Mellon.

The HMO plans do NOT provide coverage outside of Pennsylvania. If you are not living in the area and want to par cipate in a Carnegie Mellon re ree health plan, you can NOT select a Medicare HMO plan.

Pre-65 Coverage under COBRARe rees (and their eligible spouses/registered domes c partners) who are age 60–64 are off ered re ree medical coverage through COBRA. Re ree medical coverage through COBRA can con nue un l age 65.

Coverage for eligible dependent children is also off ered through COBRA. Dependent children under the age of 26 can con nue coverage up to their 26th birthday, or for a period of 36 months, whichever is greater. Disabled dependents can con nue coverage so long as they remain disabled.

For informa on on COBRA coverage, including premiums, please reference the 2018 Benefi ts Guide for Domes c Faculty and Staff , which can be found online at http://www.cmu.edu/hr/benefits/index.html.



Op on 1: Medicare HMOsCarnegie Mellon off ers Pi sburgh-area re rees the opportunity to elect a Medicare HMO. Prescrip on drug coverage is included in the HMO plans.

Our Medicare HMO plans provide extensive coverage and do not require you to purchase addi onal coverage on your own. (You must s ll enroll in Medicare A and B, however.) The out-of-pocket costs are very low, and there are NO prescrip on annual limits or coverage gap. However, the plan will only cover expenses when you use in-network providers. In addi on, the HMO coordinates all care and claims payment with one card. You cannot enroll in our Major Medical/Supplemental Rx Coverage (see op on 2 to the right) if you enroll in one of our HMO plans.

The three Carnegie Mellon Medicare HMOs are:

• HealthAmerica Advantra

• Highmark Blue Cross/Blue Shield Security Blue

• UPMC for Life

Op on 2: Major Medical/Supplemental Rx CoverageCarnegie Mellon off ers a Re ree Major Medical and Supplemental Prescrip on Drug plan to supplement the coverage for re rees who have enrolled in coverage outside the university. In order to be eligible, you must enroll, on your own and at your own expense, in:

• Medicare Part A and Part B

• A Medicare-approved Medigap* or private (not Carnegie Mellon) Medicare Advantage plan

• A Medicare Part D plan (if drug coverage is not included in your Medigap/Advantage plan)

Our Major Medical coverage, through Highmark, protects against the cost of catastrophic illness. There is no annual deduc ble and a $100,000 life me maximum. Major Medical covers 80% of eligible expenses.

Caremark provides supplemental prescrip on coverage for par cipants in the Major Medical plan (see page 14). The member is responsible for 100% of cost prior to mee ng the $250 deduc ble. Once the $250 deduc ble is met, Caremark will cover 80% of the remaining cost associated with generic and preferred medica ons.

*A Medigap plan bridges the gap between where Medicare Part A & B stops paying and Re ree Major Medical begins paying. Carnegie Mellon does not off er a Medigap plan. Re rees elect this coverage outside of the university plan on their own.

Medical Op ons for Carnegie Mellon Re rees

Monthly Re ree Contribu onsLess than 15 Years of ServiceFor Each Individual Covered

15 or More Years of ServiceFor Each Individual Covered

HealthAmerica Advantra $410.20 $390.20

Highmark Blue Cross/Blue Shield Security Blue $359 $339

UPMC for Life $470 $450

Re ree Major Medical and Supplemental Prescrip on* $38.73* $0*

* Par cipants in the Major Medical/Supplemental Prescrip on Drug coverage must also purchase, on their own, a Medigap or Medicare Advantage policy and Medicare Part D coverage (if not included in the plan). To enroll in this plan, you must include your Medigap/Medicare Advantage policy informa on on the Major Medical enrollment form. This informa on is required to ensure the benefi ts are properly coordinated upon processing.



Advantra HMO – Carnegie Mellon University2018 Benefits Summary

CAN I CHOOSE MY DOCTORS? HealthAmerica Advantra has formed a network of doctors, specialists and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list. Our number is listed at the end of this document.

WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK?If you choose to go to a doctor outside our network, you must pay for these services yourself. Neither HealthAmerica Advantra nor the Original Medicare Plan will pay for these services.

GENERAL INFORMATIONYour Annual Deductible $0Out-of-Pocket Maximum $6,700 BENEFITSPhysician Office Visits $10 copayment Specialist Office Visits $10 copaymentInpatient Hospital Care Covered 100%Inpatient Mental Health Covered 100%Skilled Nursing Care (100 days) Covered 100%Home Health Care Covered 100%Outpatient Mental Health & Substance Abuse

$10 copayment

Outpatient Surgery Services Covered 100%Ambulance Covered 100%Emergency Care & Urgent Care $50 copayment

Waived if admitted as an inpatient. Outpatient Rehabilitation Services $10 copayment

Durable Medical Equipment Covered 100%Prosthetic Devices Covered 100%Diabetes Self-Monitoring Training and Supplies Covered 100%

Diagnostic Tests, x-rays, and lab services Covered 100%



PREVENTIVE SERVICES Bone Mass Measurement Covered 100%

Colorectal Screening Exams Covered 100%

Immunizations Covered 100%

Prostate Cancer Screening Exam Covered 100%

Pap Smears and Pelvic Exams Covered 100%

Mammograms Covered 100%

ADDITIONAL BENEFITS Routine Annual Hearing Exam $0 copayment

Hearing Aids $500 allowance for the 1st hearing aid $500 allowance for the 2nd hearing aid

Routine Annual Eye Exam $0 copayment

Eyeglasses/Contacts (Every 2 years)

$150 allowance

Part B drugs Covered 100%

Routine Physical Exams $10 office visit copayment

Health/Wellness Education Covered 100% including health club membership and fitness classes.



PRESCRIPTION DRUGS Deductible None Initial Coverage Limit Up to $3,750

Coverage Gap Continuous coverage at tier copays as listed below. (No donut hole)

RETAIL/30-DAY SUPPLY Tier 1 - Preferred Generic $10 copayment Tier 2 - Preferred Brand $10 copayment

Tier 3 - Non-Preferred Brand $10 copayment

Tier 4 - Specialty Drugs 25% coinsurance MAIL-ORDER/90-DAY SUPPLY Tier 1 - Preferred Generic $20 copayment

Tier 2 - Preferred Brand $20 copayment

Tier 3 - Non-Preferred Brand $20 copayment

Tier 4 - Specialty Drugs NOT AVAILABLE

Catastrophic Coverage

After your yearly out-of-pocket drug costs reach $5,000 you pay 5% coinsurance for all generic and brand drugs if the 5% coinsurance is greater than:

$3.35 copayment for generic (including brand drugs treated as generic)

$8.35 copayment for all other drugs

Advantra is a Medicare-approved Medicare Advantage Plan offered through HealthAmerica; who contracts with the Center for Medicare and Medicaid Services (CMS), a federal agency that administers Medicare.

If you have any questions regarding these benefits or how to enroll, please call 1.855.275.5888, M – F, 8AM – 5PM (TDD USERS CALL 1-800-207-1262).



This is only a summary of your plan’s benefits. See your Evidence of Coverage for more detailed information.

Carnegie Mellon University584266 & 584267 Security Blue HMO

Deductible $0

Coinsurance 0%

In Network Member Out-of-Pocket Maximum $3,400

Annual Physical Exam Covered in Full

Screenings & Exams (Preventative PAP/Pelvic, Mammograms, Colorectal, Prostate & Bone Mass Measurement)

Covered in Full

Doctor Office Visit $10 cost sharing

Specialist Office Visit $20 cost sharing

X-ray or Radiology 0%

Diagnostic Testing 0%

Outpatient Surgery 0%

Emergency Room Services (Worldwide Coverage) $50 cost sharing

Urgently Needed Care $40 cost sharing

Inpatient Hospital or Long-Term Acute Care Facility Stay 0%

Skilled Nursing Facility Care (100 days per Medicare benefit period) $0

Annual Routine Vision Exam (includes refraction) $0 cost sharing

HEA

LTH

Eyeglasses or Contact Lenses(Covered every year)

Standard eyeglass lenses and frames or contact lenses are covered in full. $100 benefit maximum applies to non-standard frames and $100 benefit

maximum for specialty contact lenses.

1 You must continue to pay your Medicare Part B premium.

2018 Benefit Summary



Carnegie Mellon University584266 & 584267 Security Blue HMO

Annual Routine Hearing Exam $20 cost sharing

Hearing Aids(up to two per year)

Limited to Enhanced and Premium hearing aids available exclusively through TruHearing providers

Home Health 0% cost sharing for Medicare-covered home health services

Physical, Speech and Occupational Therapy(per visit/per day/per provider) $20 cost sharing

Part B Drugs 10% coinsurance, $300 quarterly member out-of-pocket maximum

Ambulance (Emergent Services per one way trip) $25 cost sharing

Durable Medical Equipment (Prosthetics/Orthotics, Diabetic Testing Supplies)

15% coinsurance

Oxygen/Oxygen Supplies 15% coinsurance

Inpatient Psychiatric Hospital Care (Limited to 190 days per lifetime) 0%

Outpatient Mental Health/Psychiatric Services or Chemical Dependency Substance Abuse Treatment (per individual or group session)

$20 cost sharing



PART D DRUGSYou pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the

total drug costs paid by both you and your Part D Plan.

Initial Coverage

Retail Cost Sharing

Tier Up to 31 Day SupplyTier 1 (Preferred Generic) $15 copayTier 2 (Non-Preferred Generic) $15 copayTier 3 (Preferred Brand) $30 copayTier 4 (Non-Preferred Brand) $60 copayTier 5 (Specialty) $60 copay

Mail Order Cost Sharing

Tier Up to 90 Day SupplyTier 1 (Preferred Generic) $37.50 copayTier 2 (Non-Preferred Generic) $37.50 copayTier 3 (Preferred Brand) $75 copayTier 4 (Non-Preferred Brand) $150 copayTier 5 (Specialty) Not Available

Catastrophic Coverage Description: After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reaches $5,000.01, you pay the greater of: 5% of the cost, or a $3.35 copay for generics and a $8.35 copay for all other drugs.

Catastrophic Coverage Greater of: 5% or $3.35 Generic/Preferred Multi-Source or $8.35 for all others.

The coverage gap begins after the yearly drug cost (including what our plan has paid and what youhave paid) reaches $3,750.01 until your costs total $5,000, which is the end of the coverage gap. Not

everyone will enter the coverage gap.

Coverage Gap

Retail Cost Sharing

Tier Up to 31 Day SupplyTier 1 (Preferred Generic) $15 copayTier 2 (Non-Preferred Generic) $15 copayTier 3 (Preferred Brand) $30 copayTier 4 (Non-Preferred Brand) $60 copay Tier 5 (Specialty) $60 copay

Mail Order Cost Sharing

Tier Up to 90 Day Supply

Tier 1 (Preferred Generic) $37.50 copayTier 2 (Non-Preferred Generic) $37.50 copayTier 3 (Preferred Brand) $75 copayTier 4 (Non-Preferred Brand) $150 copayTier 5 (Specialty) Not Available



Benefits 2018 HMO Custom

Annual Out-of-Pocket Limit1 $3,400

Inpatient Hospital2$100 copay per stay

$300 annual maximum

Inpatient Mental Health Care2 $100 copay per stay$300 annual maximum

Skilled Nursing Facility2

(100 day benefit limit)$0 copay per day for days 1-100

Blood (3 pints) $0 copay

Home Health Care2 $0 copay

Hospice Medicare-covered

Primary Care Doctor Visits $10 copay

Specialist Visits $20 copay

Chiropractic Services $20 copay Routine Chiropractic Services(6 visits every year) $20 copay

Podiatry Services $20 copayRoutine Podiatry Services(4 visits every year) $20 copay

Outpatient Mental Health 2 $20 copay

Outpatient Psychiatric Services 2 $20 copay

Outpatient Substance Abuse $20 copay

Partial Hospitalization2 $0 copay

Outpatient Surgery and Ambulatory Surgical Center2 $25 copay$75 annual limit

Observation Stay $25 copay

Ambulance Services 2

(prior auth required for non-emergency Medicare-covered services) $50 copay

per one-way trip

Emergency Care(waived if admitted within 3 days) $100 copay

Urgently Needed Care (Clinics) (out-of-area; urgent care clinics) $20 copay

Outpatient Rehab Services (PT, OT, ST)

$20 copay

Cardiac/Pulmonary Rehab $0 copay

Durable Medical Equipment/Oxygen2 $0 copay

Prosthetic Devices and Medical Supplies $0 copay

Diabetes Training and Diabetic Supplies

$0 copay - training$0 copay - supplies

Diabetic Shoes or Inserts $0 copay

Kidney Disease Training andRenal Dialysis (ESRD)

$0 copay - training $0 copay - dialysis

Part B Drugs2 10% coinsuranceall Part B drugs; chemotherapy / self-administered

Lab Services $0 copay

Diagnostic Procedures/Tests $0 copay

X-Ray Services $0 copay

Diagnostic Radiological Services (Advanced Imaging)2 $0 copay

Therapeutic Radiological Services (Radiation) $0 copay

UPMC for Life2018 HMO Custom Plan - Carnegie Mellon University

INPATIENT CARE

OUTPATIENT CARE

OUTPATIENT MEDICAL AND SUPPLIES





Immunizations3

(influenza, pneumonia, Hepatitis B)$0 copay

Annual Wellness Exam/Routine Physical Exam3

(one exam per year)$0 copay

Screening Exams3

Includes: Bone Mass Measurement, Colorectal Screening, Mammograms, Pap & Pelvic, Prostate Exams, all Medicare-covered Preventive Services

$0 copay

Medicare-covered Dental Services $20 copay

Routine Dental Oral Exam & Cleaning(once every 6 months) $20 copay

Routine Dental Bitewing X-rays not covered

Restorative Services not covered

Medicare-covered Hearing Services $20 copay

Routine Hearing Exam(once every year) $20 copay

Routine Hearing Aid Fitting(once every three years) $20 copay

Routine Hearing Aids(once every three years) $1,000 allowance

Medicare-covered Vision Services $20 copay

Medicare-covered Glaucoma Screening and Diabetic Retinal Eye Exam $0 copay

Medicare-covered EyewearCataract Glasses/Lens $0 copay

Routine Vision Exam(once every two years) $0 copay

Routine Vision Eyewear(once every two years) $250 allowance

Health & Wellness Fitness Center Benefit Silver & Fit

Remote Technologies $10 copay - eVisits$20 copay - eDerm

Smoking and Tobacco Cessation Counseling(additional visits covered - 4 visits) $0 copay

Visitor/Travel Benefit 4Covered in the State of Florida - same INN

copays depending on services renderedWorldwide Emergency Coverage Assist America Travel Benefit

PREVENTIVE SERVICES

ADDITIONAL BENEFITSDental Services

Hearing Services

Vision Services

Other Services





Preferred:$0 copay - 30 day supply (retail)$0 copay - 90 day supply (retail)

Standard:$9 copay - 30 day supply (retail)$27 copay - 90 day supply (retail)

$18 copay - 90 day supply (mail-order)

Preferred:$10 copay - 30 day supply (retail)$30 copay - 90 day supply (retail)

Standard:$16 copay - 30 day supply (retail)$48 copay - 90 day supply (retail )

$32 copay - 90 day supply (mail-order)Preferred:

$42 copay - 30 day supply (retail)$126 copay - 90 day supply (retail)

Standard: $47 copay - 30 day supply (retail)$141 copay - 90 day supply (retail)

$117.50 copay - 90 day supply (mail-order)Preferred:

$95 copay - 30 day supply (retail)$285 copay - 90 day supply (retail)

Standard:$100 copay - 30 day supply (retail)$300 copay - 90 day supply (retail)

$300 copay - 90 day supply (mail-order)

Tier 5: Specialty Drugs (previously Tier 4 Specialty Drugs)

Preferred : 33% coinsurance (retail)Standard: 33% coinsurance (retail/mail-order)

30 day supply only

Initial Coverage Limit $3,750

Full coverage Wrap-around as follows:

30-day SupplyOnce the Initial Coverage Limit ($3,750) is met, the following cost-sharing

applies until the member reaches ($5,000) (TrOOP):Preferred Generic Drugs: Preferred: $0 / Standard: $9

Generic Drugs: Preferred: $10 / Standard: $16 Preferred Brand Drugs: Preferred: $42 / Standard: $47 Non-Preferred Drugs: Preferred: $95 / Standard: $100

Specialty Drugs: 33% coinsurance 90-day Supply

Once the Initial Coverage Limit ($3,750) is met, the following cost-sharing applies until the member reaches $5,000 (TrOOP):

Preferred Generic Drugs: Preferred: $0 / Standard: $27Generic Drugs: Preferred: $30 / Standard: $48

Preferred Brand Drugs: Preferred: $126 / Standard: $141 Non-Preferred Drugs: Preferred: $285 / Standard: $300

Out-of-Pocket Limit (TrOOP) $5,000

Catastrophic Coverage CopaysGreater of:

$3.35 generic/brand treated as generic$8.35 or 5% all others

Tier 1: Preferred Generic Drugs(previously Tier 5 Select Care Drugs)

PART D PRESCRIPTION DRUGS

3 A separate copay may apply if additional medical services are performed during the same visit as a preventive service.4 The visitor/travel benefit is available outside of UPMC for Life HMOs’ service area in the state of Florida. Members must contact UPMC for Life Member Services to activate the travel benefit. Member Services will assist the member in locating a participating provider. Claims for non-emergent and non-urgent care may be denied if member did not contact Member Services prior to seeking medical care in Florida. Members are responsible for paying the applicable copayments for services rendered which are noted on the benefit chart.

NOTE: UPMC Health Plan has determined that the prescription drug coverage offered by this employer group plan for 2018 is creditable coverage.

This grid is not intended to provide a full description of benefits. Please refer to the Evidence of Coverage for complete benefit information.

Tier 2: Generic Drugs(previously Tier 1 Preferred Generic Drugs)

Tier 3: Preferred Brand Drugs(previously Tier 2 Preferred Brand Drugs)

Tier 4: Non-Preferred Drugs(previously Tier 3 Non-Preferred Drugs )

Coverage Gap Cost-SharingDuring the Coverage Gap Stage, the member will continue to pay the same copays as in the Initial Coverage stage.

1 Member's cost-sharing for Medicare-covered benefits accumulates toward the OOP limit (excludes Part D drugs, routine dental, routine hearing, 2 These services require prior authorization.



Prescrip on Drug CoverageCaremark: For Major Medical/Supplemental Drug PlanCaremark is the supplemental prescrip on administrator for our Major Medical coverage. It must be paired with a primary Medicare Part D plan. Medicare Part D plans vary, but have a minimum level of coverage that may include a deduc ble, member coinsurance responsibility, and a coverage gap. Once the $250 deduc ble is met, the Caremark Supplemental Prescrip on Drug coverage pays 80% coinsurance of the remaining cost associated with generic and preferred medica ons. If a medica on is non-preferred, it will not be covered by the Caremark secondary coverage.

When you need a prescrip on (re)fi lled at a par cipa ng pharmacy:

You will be required to pay for the drug in full and then fi le for reimbursement. Reimbursement of your prescrip on could take up to several weeks to be processed. In order to receive reimbursement, you will need to obtain a Caremark claim form and provide your receipts along with your explana on of benefi ts. The claim form is available online at the Caremark website, www.caremark.com, or by calling 877-347-7444. The form is also available on the CMU website, www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.

Medicare HMO Prescrip on CoveragePar cipants in Carnegie Mellon’s re ree HMOs have prescrip on coverage through their medical plan. To fi ll a prescrip on, you must go to a par cipa ng pharmacy. Present your HMO member card along with your prescrip on. You’ll pay the designated copay, based on the drug’s generic or formulary status. If you do not present your medical card at the me of your fi rst purchase, you will have to pay for the medica on in full and later fi le a request for reimbursement. Please refer to the plan-specifi c summary grids in this workbook for details on the prescrip on drug copay and coinsurance totals.

Par cipa ng Pharmacies

Many chain and independent pharmacies par cipate in the prescrip on carrier networks. A par al list of par cipa ng pharmacies includes:▪ Costco ▪ CVS ▪ Giant Eagle ▪ K-Mart ▪ Medicine Shoppe ▪ RiteAid ▪ Target ▪ Walgreens ▪ Wal-Mart

Major Medical Par cipants: Enroll in Medicare Part D

In order to receive Carnegie Mellon’s supplemental prescrip on coverage (which provides benefi ts for the Medicare Part D coverage gaps), you must enroll in a Medicare Part D plan or a Medigap/Advantage plan with drug coverage through a par cipa ng carrier of your choice.

Par cipants in one of our Medicare HMOs need not enroll in Medicare Part D, as these plans include creditable coverage.



Generic Drugs The Medicare HMO plans require that generic drugs be subs tuted automa cally for brand-name medica ons when available, unless a medical necessity waiver has been submi ed by your physician and approved in advance. Generic drugs have been tested by the FDA to ensure that they contain equivalent ac ve ingredients. U lizing a brand-name drug when a generic subs tu on can be made will result in addi onal costs to you.

FormularyOur re ree HMO plans and most Medicare Advantage and Part D plans u lize a formulary. A formulary is a list of preferred medica ons that have been selected for trea ng various condi ons. The medica ons on the formulary are based on eff ec veness, cost, and demand.

You should consider trying a formulary medica on before a non-formulary op on in order to maximize your cost savings. It is wise to bring the formulary list with you to the doctor’s offi ce to ensure that a formulary medica on has been selected before having the prescrip on fi lled.

See your Medicare D carrier or HMO carrier website for a complete list of the drugs on its formulary. The formulary can be modifi ed at any me by the carrier, so refer to the website for the most up-to-date informa on.

Mail Order Prescrip ons: Convenience and Aff ordability CMU Re ree HMOs all provide mail order services for medica ons prescribed more than two months. When you order long-term use or maintenance medica ons through mail order:

• Your nearest pharmacy is as close as your phone, computer or mailbox.

• You only need to order refi lls every few months, instead of going to the pharmacy every few weeks.

• You generally save money with lower copays or coinsurance based on bulk prices.

The forms and instruc ons for using the mail order services can be found on the carriers’ websites.

Wri ng Prescrip ons for Mail Order

For the quickest service and best prices, submit mail order prescrip ons correctly:

• Your doctor should write the prescrip on for a 90-days supply (not 30-days) with the appropriate number of refi lls.

• Be sure the prescrip on is signed and wri en legibly.

• New prescrip ons take up to two weeks to fi ll. (Refi lls generally take less me.) If you need the drug immediately, ask for samples or a script for a short-term supply that can be fi lled at your pharmacy.

Caremark Reimbursement with Mail Order

• Send the prescrip on to your Part D carrier’s mail order service.

• Pay the amount billed and keep your receipts.

• Complete the Caremark Prescrip on Claim form in its en rety. (Complete all ques ons, even if the receipt contains some of the informa on requested.)

• Send a copy of the receipt and the completed claim form to Caremark.

• Caremark will reimburse you for 80% of your costs (a er the $250 deduc ble is met). See page 14 for more details.



Denial of Coverage AppealsMost ques ons or concerns about your coverage, fi ling claims, or eligible expenses should be directed to the carrier of the plan you selected. Contact informa on for each of our carriers is found on the next page. You should have your group and ID numbers available when you contact the carrier so they can see the specifi c provisions of the Carnegie Mellon plan. If a claim that you submi ed to one of our benefi t plans is denied by the carrier, you should follow these procedures:

For Medical Appeals:Appeals concerning a medical treatment plan or medical assessment can only be appealed through the carrier. Please follow the procedures outlined in your plan booklet to appeal a medical decision. To obtain a plan booklet, contact the HR Benefi ts Offi ce at 412-268-2047 or visit the CMU website at www.cmu.edu/hr/benefi ts/benefi t_programs/re ree-medical.html.

For Other (Administra ve) Appeals:If you believe the denial was made in error, contact the carrier directly to begin the appeals process. (See Contact Informa on on the next page.) If you are unable to resolve the situa on with the carrier, please contact the HR Benefi ts Offi ce at 412-268-2047 for assistance in working with the carrier. The HR Benefi ts Offi ce can also provide informa on about fi ling a formal appeal with the carrier to challenge the denial.

Life and Family Status Changes The elec ons you make will remain in eff ect for the en re calendar year, unless you experience a life or family status change. The events listed in the chart below are changes that permit you to modify your coverage outside of the Open Enrollment period. All life or family status changes must be requested within 30 days of the event. You must also provide suppor ng documenta on, such as a marriage cer fi cate or proof of new coverage, within 30 days of the life or family status change.

Qualifying Life or Family Status Changes Under the Re ree Benefi ts Program

Marital/Domes c Partnership Status Changes • Marriage/registra on of domes c partnership • Death of spouse/domes c partner • Divorce/termina on of domes c partnership

Number of Covered Dependent Children Changes

Spouse/Domes c Partner Gains or Loses Coverage from Another Source

Signifi cant Change in Cost of Plan

Signifi cant Change in Coverage of Plan • New or improved plan is off ered • Signifi cant reduc on in overall coverage of current plan

Signifi cant Change in Loca on (if have an HMO)



Contact Informa onDo you need more informa on about a specifi c benefi t op on? Contact the carrier directly to request details about levels of coverage, provider networks, directories, and claims issues. Website addresses, telephone numbers, and group numbers are provided below. For issues related to eligibility, enrollment or unresolved issues, contact Human Resources.

Medicare 800-633-4227

www.medicare.gov

Social Security Administra on800-772-1213

h p://www.ssa.gov

Carnegie Mellon HR Benefi ts Offi ce412-268-2047h p://www.cmu.edu/hr

Medical Op onsHighmark Blue Cross/Blue Shield Re ree Major Medical

Group Number: 50387-02800-472-1506h p://www.highmarkbcbs.com

Signature 65 (for Mellon Ins tute re rees only)Group Number: 62387-00800-367-6565h p://www.highmarkbcbs.com

Highmark Blue Cross/Blue Shield Security Blue HMO/Prescrip on Coverage

Group Number: 58426-60 (less than 15 years service)Group Number: 58426-70 (more than 15 years service) 800-935-2583h p://www.highmarkbcbs.com

UPMC for Life Medicare HMO/Prescrip on CoverageGroup Number: MC0144877-381-3765h p://www.upmchealthplan.com

HealthAmerica Advantra Medicare HMO/Prescrip on Coverage

Group Number: 2101881001800-470-4272h p://www.pa.chcadvantra.com

Prescrip on Drug PlanCaremark (Re ree Major Medical Plan)

Group Number (15 or more years of service): Carrier 5806 RET/001Group Number (less than 15 years of service): Carrier 5806 RET/002877-347-7444h p://www.caremark.com



Creditable Coverage No ce (Medicare HMOs)OMB 0938-0990

Important Notice from Carnegie Mellon University AboutYour Prescription Drug Coverage and Medicare

The Carnegie Mellon University Benefit PlanMedicare Advantage HMO

(HealthAmerica Advantra, Highmark Blue Cross Blue Shield Security Blue, UPMC For Life)

Please read this notice carefully and keep it where you can find it. This notice has information about yourcurrent prescription drug coverage with Carnegie Mellon University and about your options underMedicare’s prescription drug coverage. This information can help you decide whether or not you want tojoin a Medicare drug plan. If you are considering joining, you should compare your current coverage, including which drugs are covered at what cost, with the coverage and costs of the plans offering Medicare prescription drug coverage in your area. Information about where you can get help to makedecisions about your prescription drug coverage is at the end of this notice.

There are two important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. Youcan get this coverage if you join a Medicare Prescription Drug Plan or join a MedicareAdvantage Plan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drugplans provide at least a standard level of coverage set by Medicare. Some plans may also offermore coverage for a higher monthly premium.

2. Carnegie Mellon University has determined that the prescription drug coverage offered by theCarnegie Mellon University Benefit Plan-Medicare Advantage HMO (HealthAmerica Advantra,Highmark Blue Cross Blue Shield Security Blue, UPMC For Life) is, on average for all planparticipants, expected to pay out as much as standard Medicare prescription drug coverage paysand is therefore considered Creditable Coverage. Because your existing coverage is CreditableCoverage, you can keep this coverage and not pay a higher premium (a penalty) if you laterdecide to join a Medicare drug plan.

When Can You Join A Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you lose your current creditable prescription drug coverage, through no fault of your own, you will also be eligible for a two (2) month Special Enrollment Period (SEP) to join a Medicare drugplan.

What Happens To Your Current Coverage If You Decide to Join A Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Carnegie Mellon University coverage will not beaffected.

If you do decide to join a Medicare drug plan and drop your current Carnegie Mellon University coverage, you and your dependents will be able to get this coverage back.



Creditable Coverage No ce (Medicare HMOs)

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

You should also know that if you drop or lose your current coverage with Carnegie Mellon University anddon’t join a Medicare drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premiummay go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premiummay consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, youmay have to wait until the following October to join.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact information is provided on the last page of this document. NOTE: You’ll get this notice eachyear. You will also get it before the next period you can join a Medicare drug plan, and if this coveragethrough Carnegie Mellon University changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage:• Visit www.medicare.gov.• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help.• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web atwww.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Remember: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you may be required to provide a copy of this notice when you join to show whether or not you have maintained creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date: 10/15/2017 Name of Entity/Sender: Carnegie Mellon UniversityContact–Position/Office: Benefits OfficeAddress: 5000 Forbes Avenue, Pittsburgh, PA 15213-3815 Phone Number: 412-268-2047



Non-Creditable Coverage No ce (Major Medical & Supp. Rx)OMB 0938-0990

Important Notice From Carnegie Mellon University AboutYour Prescription Drug Coverage and Medicare

The Carnegie Mellon University Benefit PlanRetiree Major Medical and Supplemental Prescription Plan

Please read this notice carefully and keep it where you can find it. This notice has information about your current prescription drug coverage with Carnegie Mellon University and about your options under Medicare’s prescription drug coverage. This information can help you decide whether or not you wantto join a Medicare drug plan. Information about where you can get help to make decisions about yourprescription drug coverage is at the end of this notice.

There are three important things you need to know about your current coverage and Medicare’s prescription drug coverage:

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare. Youcan get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare AdvantagePlan (like an HMO or PPO) that offers prescription drug coverage. All Medicare drug plansprovide at least a standard level of coverage set by Medicare. Some plans may also offer morecoverage for a higher monthly premium.

2. Carnegie Mellon University has determined that the prescription drug coverage offered by theRetiree Major Medical and Supplemental Prescription Plan is, on average for all planparticipants, NOT expected to pay out as much as standard Medicare prescription drug coveragepays. Therefore, your coverage is considered Non-Creditable Coverage. This is importantbecause, most likely, you will get more help with your drug costs if you join a Medicare drugplan, than if you only have prescription drug coverage from the Retiree Major Medical andSupplemental Prescription Plan. This also is important because it may mean that you may paya higher premium (a penalty) if you do not join a Medicare drug plan when you first becomeeligible.

3. You can keep your current coverage from the Retiree Major Medical and SupplementalPrescription Plan. However, because your coverage is non- creditable, you have decisions tomake about Medicare prescription drug coverage that may affect how much you pay for thatcoverage, depending on if and when you join a drug plan. When you make your decision, youshould compare your current coverage, including what drugs are covered, with the coverageand cost of the plans offering Medicare prescription drug coverage in your area. Read thisnotice carefully - it explains your options.

When Can You Join a Medicare Drug Plan?

You can join a Medicare drug plan when you first become eligible for Medicare and each year from October 15th to December 7th.

However, if you decide to drop your current coverage with Carnegie Mellon University, since it is employer/union sponsored group coverage, you will be eligible for a two (2) month Special EnrollmentPeriod (SEP) to join a Medicare drug plan; however you also may pay a higher premium (a penalty) because you did not have creditable coverage under the Retiree Major Medical and Supplemental Prescription Plan.



Non-Creditable Coverage No ce (Major Medical & Supp. Rx)

When Will You Pay a Higher Premium (Penalty) to Join a Medicare Drug Plan?

Since the coverage under Carnegie Mellon University Retiree Major Medical and Supplemental PrescriptionPlan is not creditable, depending on how long you go without creditable prescription drug coverage, youmay pay a penalty to join a Medicare drug plan. Starting with the end of the last month that you were first eligible to join a Medicare drug plan but didn’t join, if you go 63 continuous days or longer withoutprescription drug coverage that’s creditable, your monthly premium may go up by at least 1% of the Medicare base beneficiary premium per month for every month that you did not have that coverage. For example, if you go nineteen months without creditable coverage, your premium may consistently be at least19% higher than the Medicare base beneficiary premium. You may have to pay this higher premium (penalty) as long as you have Medicare prescription drug coverage. In addition, you may have to wait untilthe following October to join.

What Happens to Your Current Coverage if You Decide to Join a Medicare Drug Plan?

If you decide to join a Medicare drug plan, your current Carnegie Mellon University coverage will not beaffected. You can keep this coverage if you elect Part D and this plan will coordinate with Part D coverage.

If you do decide to join a Medicare drug plan and drop your current Carnegie Mellon Universitycoverage, be aware that you and your dependents will be able to get this coverage back.

For More Information About This Notice or Your Current Prescription Drug Coverage…

Contact information is provided on the last page of this document. NOTE: You’ll get this notice each year. You will also get it before the next period you can join a Medicare drug plan and if this coverage through Carnegie Mellon University changes. You also may request a copy of this notice at any time.

For More Information About Your Options Under Medicare Prescription Drug Coverage…

More detailed information about Medicare plans that offer prescription drug coverage is in the“Medicare & You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare.You may also be contacted directly by Medicare drug plans.

For more information about Medicare prescription drug coverage: • Visit www.medicare.gov.• Call your State Health Insurance Assistance Program (see the inside back cover of your copy of

the “Medicare & You” handbook for their telephone number) for personalized help.• Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you have limited income and resources, extra help paying for Medicare prescription drug coverage is available. For information about this extra help, visit Social Security on the web at www.socialsecurity.gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778).

Date: 10/15/2017Name of Entity/Sender: Carnegie Mellon UniversityContact–Position/Office: Benefits OfficeAddress: 5000 Forbes Avenue, Pittsburgh, PA 15213-3815 Phone Number: 412-268-2047

Carnegie Mellon University does not discriminate in admission, employment, or administra on of its programs or ac vi es on the basis of race, color, na onal origin, sex, handicap or disability, age, sexual orienta on, gender iden ty, religion, creed, ancestry, belief, veteran status, or gene c informa on. Furthermore, Carnegie Mellon University does not discriminate and is required not to discriminate in viola on of federal, state, or local laws or execu ve orders.

Inquiries concerning the applica on of and compliance with this statement should be directed to the university ombudsman, Carnegie Mellon University, 5000 Forbes Avenue, Pi sburgh, PA 15213, telephone 412-268-1018.

Obtain general informa on about Carnegie Mellon University by calling 412-268-2000.

2018 BENEFITS WORKBOOK · PDF fileGeneric Drugs ... Carrier enrollment forms can be obtained...

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