Pharmacy and Part D Frequently Asked Questions - FAQ's
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Click here to see drugs that have quantity limits.
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What is the GEMCare Health Plan’s Medicare Part D Program?
The Part D program is a GHP and Medicare Prescription Drug Coverage insurance program designed to help you save money on prescriptions and protect you from catastrophically high drug bills. Part D Pharmacy coverage is part of the GEMCare Health Plan.
I keep hearing about coverage “phases” and the “donut hole”. Explain, please.
First, you need to understand that the cost of your medications is paid by both GEMCare Health Plan and you. As you fill prescriptions throughout the year, the amount of dollars spent to pay for your medications increases. As the total amount of dollars paid for drugs increases, the responsibility for payment will shift between you and GHP, depending on the amount of dollars expended. Throughout the year, GHP keeps track of all payments made for prescriptions by both you and GHP.
There are 3 “phases” of coverage for the Pharmacy Part D Benefit:
- Initial Coverage Phase: In this phase of coverage you are responsible for co-payments or a percentage of the cost for prescriptions while GHP picks up the balance of the costs. When the total costs paid by you and GHP for prescriptions reaches a total of $2,840 for 2011 & $2,930 for 2012, you then enter the “coverage gap” phase.
- Coverage Gap Phase (aka the “donut hole”): When the total costs reach $2,840 in 2011 & $2,930 in 2012, you are now responsible for the full cost of medications until your total out of pocket costs (what you alone have paid) reaches $4,550 in 2011 & $4,700 in 2012. At this point, you enter the “catastrophic phase”.
- Catastrophic Phase: When your total out of pocket costs have reached $4,550 in 2011 & $4,700 in 2012, your responsibility is now reduced and you pay $2.50 in 2011 & $2.60 in 2012 for generic drugs (including brand drugs treated as generic) and $6.30 in 2011 & $6.50 in 2012 or 5% (whichever is greater) for all other drugs.
When the New Year begins, the process begins again. Based upon Medicare requirements and the costs for drugs for the previous year, the benefit and payment rules may change.
What is TROOP?
“TROOP” is a term used to indicate the total amount of money a member has paid out of pocket for the current year (the total true out-of-pocket (“TROOP”) expense). It is the sum total of all co-pays, all coinsurance payments, and all expenditures made by the member in the coverage gap (“donut hole”).
Explain formulary drug tiers, please
Medications on the GHP formulary are organized into different tiers or groups. Your co-payments or coinsurance varies with the drug tier of your medication. The tiers and co-pays for each medication received while in the network are:
Tier Name of Tier In 2011 - For a 30-day Supply (or a 31-day at a LTC Facility) you will pay this amount: In 2012 - For a 30-day Supply (or a 31-day at a LTC Facility) you will pay this amount: Tier 1 Preferred Generics $4.00 $0.00 Tier 2 Non-Preferred Generics $12.00 $12.00 Tier 3 Non-Preferred Generic & Preferred Brand Drugs (2011)
Preferred Brand (2012)
$35.00 $45.00 Tier 4 Non-Preferred Brands $75.00 $90.00 Tier 5 Injectables (2011)
Specialty (2012)
33% of the cost 33% of the cost Tier 6 Specialty (2011) 33% of the cost N/A
What do I pay out of pocket if I am a member in GHP’s Part D Program?
For GHP in 2011 and 2012, there is no insurance premium or deductible for Part D for GHP members. Your out of pocket expenses include responsibility for:
- All co-payments in all coverage phases – Co-payments do vary with the Tier level and the coverage phase you are in;
- All coinsurance costs in all coverage phases for Tier 5 – Coinsurance is reduced to 5% in catastrophic phase;
- All medication costs in the coverage gap phase (“donut hole”).
What happens when my prescription is not on the formulary?
If your prescription is not on the formulary, you should do the following:
- Contact Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312) to confirm that your prescription is not on the formulary;
- If Member Services confirms that your medication is not covered on the formulary, you should call your doctor to see if you can safely switch to another drug that is on the formulary;
- If you or your physician feels that your requested medication has no alternatives, then you or your physician can request that GHP grant an “exception” or make a “coverage determination” to allow you to have the medication covered. The request is reviewed and the request can either be granted or denied.
How do you fill a prescription through the mail-order pharmacy service?
The GHP mail-order service is available to fill prescriptions for any drug on the formulary. The process is as follows:
For First Time Users: For your first order, Integrated HMO Pharmacy (IHMO) requires that you fill out the order form and include the original prescriptions from your doctor. This initial order form must include information about you, including the current medications, any known drug allergies, and chronic medical conditions. If you have any questions, contact IHMO at 1-800-633-7928.
For Ordering Refills: You should order refills when you have 14-21 days supply left. To reorder medications, you have options:
- You can call 1-800-633-7928;
- You can fill out the order form enclosed with each order you receive, or,
- You can order your refills online at the IHMO web site:
Note: Remember to include your payment with your refill order to avoid possible delays in processing your prescription order.
When you order prescription drugs by mail-order you must order at least a 60-day supply, and no more than 90-day supply of the drug. Please allow 14-21 days to process and ship your order. If mail order is delayed, you can always obtain a prescription from a local network pharmacy. Please call Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312) for more information.
You can also get an extended supply of medication through all retail network pharmacies. Please call Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312) to find out which retail pharmacies off an extended supply.
Do I qualify for financial assistance with medications?
People with limited income and resources may qualify for extra help. The amount of assistance depends on your financial circumstances. There are 2 situations where you can obtain assistance:
- You automatically qualify for assistance if:
- You have full coverage from a state Medicaid (Medi-Cal) program;
- You are receiving assistance from Medicaid in paying your Medicare premiums (Medicare Savings Program); or,
- You are receiving Medicare Supplemental Security Income benefits.
- You may apply to qualify for extra help if:
- You believe you have a low yearly income; and,
- You believe you do not have enough financial resources
If you think you may qualify and wish to apply for assistance, call Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778), visit your local Social Security Office, or visit the web site www.socialsecurity.gov. You may also apply at your State Medical Assistance (Medi-Cal) office.
If you believe you have a low income subsidy, but you are currently paying regular co-pays for your Part D prescription drugs, you should contact GEMCare Health Plan Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312) who can assist you with this issue.
For more detailed information, you can go to this Medicare Website http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_best_available_evidence_policy.asp.
What do I need to know if I qualify for extra help (the low-income subsidy, or LIS) from Medicare to pay for my prescription drugs?
If you continue to qualify for the same amount of extra help next year, the table below tells you how your prescription costs will change. If you don’t know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
If you pay this much this year
(2011)
You will pay this much next year
(2012)
$0 deductible
$1.10 for generics and brands that are treated as generics
$3.30 for brand name drugs
$1.10 for generics and brands that are treated as generics
$3.30 for brand name drugs
$2.50 for generics and brands that are treated as generics
$6.30 for brand name drugs
$2.60 for generics and brands that are treated as generics
$6.50 for brand name drugs
15% coinsurance for all drugs
15% coinsurance for all drugs
If you qualify for extra help, you pay $0 or a reduced monthly premium (for both medical services and prescription drug benefits).
What is the LEP or Late Enrollment Penalty?
The LEP is applied to members who did not join a Medicare drug plan when they were first eligible, or for some reason were without prescription drug coverage for a continuous period of 63 days or more.
If an LEP applies to you, the GHP drug plan will inform you as to the amount. The LEP is added to the monthly premium you pay. The penalty amount is adjusted each plan year and must be paid as long as you have Medicare prescription drug coverage. If you qualify for financial assistance, you may not be required to pay the LEP.
For more questions, call Member Services at 1-877-697-2464, (TTY users should call 1-888-833-9312).