welcome
Welcome to the Blue Shield of California Medicare
Rx Plan (PDP) – an employer group/union-sponsored
Medicare Part D plan for eligible retirees. This
plan provides you access to enhanced Medicare
prescription drug coverage. Keep this guide
handy for quick reference about your prescription
drug benefits.
S2468_13_346B 10232013
University of California Medicare PPO with Prescription Drug
blueshieldca.com/med_formulary
Blue Shield of California
Medicare Rx Plan
employer group/union
prescription drug benefit
quick reference guide
What’s inside
1. How your Blue Shield of California Medicare Rx Plan works
2.Which ID card to use for prescription drugs
3.Where to fill prescriptions via network pharmacies and mail service
4.When to get prior authorization
5.Learning about the formulary
1 Quick reference guide
Understanding your
prescription drug coverage
Your Blue Shield of California Medicare Rx Plan is a combination of the prescription
drug coverage offered through a typical employer group/union health plan, plus the
prescription drug coverage offered by Medicare. It’s a pharmacy benefit that works
much like the prescription coverage you’ve used in the past. However, the formulary
(list of drugs) is different from the formulary you’ve used in the past, so please be sure
to review your new plan formulary for the drugs you are currently taking.
A new ID card
You will receive a separate Blue Shield
of California Medicare Rx Plan ID card
to use when filling prescriptions. It looks
like this:
Member
John Doe
le
p
m
a
s
Membership No.
XEAJ1234567801
Plan Blue Shield of California
Medicare Rx Plan (PDP)
Card issued MM/DD/YY
RxBin
RxPCN
RxGrp
Issuer
012353
03510000
MRD300
80840 CMS S2468-004
Your ID card is personalized just for you.
It will have your name, your ID number,
and the date your card was issued.
Be sure to keep your new pharmacy
ID card in your wallet, and use your
Blue Shield of California Medicare Rx
Plan ID card when you fill prescriptions.
It’s particularly important for you to show
your new card the FIRST time you fill a
prescription with this new plan so that your
pharmacy can update your records and
your claims can be processed correctly.
• S how your Blue Shield medical ID card
when you go to the doctor, and for all
other healthcare services.
• U
se your Blue Shield of California
Medicare Rx Plan ID card when you
fill prescriptions.
Key facts about your Medicare
prescription drug coverage
Your former employer group/union works
with Blue Shield to determine the benefits
and cost-sharing amounts for Medicare
prescription drug coverage. The benefit
summary below lists the cost-sharing
amounts that apply to you. You can
also check the Blue Shield of California
Medicare Rx Plan Evidence of Coverage
(EOC) included in this welcome kit, or
call Member Services at the number on
the back of your ID card.
Quick reference guide 1
Benefit highlights – 2014
Pharmacy benefits
You pay:
Tier 1 Preferred Generic Drugs
30-day supply/network preferred or other network
pharmacy or select UC Medical Center pharmacy
$10 copay
90-day supply/network preferred pharmacy or select
UC Medical Center pharmacy or through mail service
$20 copay
90-day supply/other network pharmacy
$30 copay
Tier 2 Preferred Brand Drugs
30-day supply/network preferred or other network
pharmacy or select UC Medical Center pharmacy
$30 copay
90-day supply/network preferred pharmacy or select
UC Medical Center pharmacy or through mail service
$60 copay
90-day supply/other network pharmacy
$90 copay
Tier 3 Non-Preferred Brand Drugs
30-day supply/network preferred or other network
pharmacy or select UC Medical Center pharmacy
$45 copay
90-day supply/network preferred pharmacy or select
UC Medical Center pharmacy or through mail service
$90 copay
90-day supply/other network pharmacy
$135 copay
No coverage gap! With Blue Shield of California
Medicare Rx Plan, you have no gap in coverage
or “donut hole.” Instead, you simply pay the
cost-sharing amounts listed in the chart.
2 Quick reference guide
Benefit highlights
Pharmacy benefits
You pay:
Tier 4 Injectable Drugs
30-day supply/network preferred or other network
pharmacy or select UC Medical Center pharmacy
$30 copay
90-day supply/network preferred or select UC Medical
Center pharmacy or through mail service
$60 copay
90-day supply/other network pharmacy
$90 copay
Tier 5 Specialty Tier Drugs
30-day supply/network preferred or other network
pharmacy or select UC Medical Center pharmacy
$30 copay
90-day supply/preferred or select UC Medical Center
pharmacy or through mail service
$60 copay
90-day supply/other network pharmacy
$90 copay
Important: For brand drugs that have a generic equivalent, you pay the difference
in cost between the generic and brand drug plus a Tier 1 copay.
Please see Chapter 4 of your Evidence of Coverage for more information on what
you pay for diabetic supplies, sexual dysfunction drugs, and transgender drugs.
Quick reference guide 3
Catastrophic coverage stage
If your annual True Out-Of-Pocket (TrOOP)
costs reach $4,550, you qualify for
catastrophic coverage. At this point,
you will pay nothing for covered Part D
prescription drugs.
TrOOP costs are prescription drug
expenses that you must pay because
Medicare Part D does not cover them,
or they are not paid by your former
employer group/union (typically copays
and any deductibles, if applicable).
It’s important to note that any drugs
or services that are covered under
Medicare Part B, and any Part D drugs
not covered by Medicare, but covered
4 Quick reference guide
as part of additional coverage offered
by your former employer group/union,
do not count toward your TrOOP total.
Because this is a Medicare Part D plan,
Blue Shield of California Medicare Rx Plan
is required to track and notify you of your
Part D drug costs, the amount you pay
out-of-pocket, and your current coverage
level or “stage.” For each month that you
obtain prescription drugs, you will be
mailed an Explanation of Benefits (EOB)
that outlines this information. This is for
tracking purposes only. The EOB is not a bill.
Filling prescriptions
Here are how-to tips to get the most from
your Medicare prescription drug plan.
You have the choice to fill prescriptions
at a retail network pharmacy, an
other network pharmacy, at select UC
Medical Center pharmacies, or through
Blue Shield’s convenient mail service.
Network pharmacies
Blue Shield of California Medicare Rx
Plan’s pharmacy network includes
all major drugstore chains and most
independent pharmacies throughout
California. The plan has “preferred
pharmacies” and “other network
pharmacies.” Preferred pharmacies
are pharmacies where the plan has
negotiated a lower cost-sharing for our
members for covered drugs than at other
network pharmacies. For example, you
can obtain a 90-day supply of covered
drugs for the amount of only two 30-day
copays when you visit one of our
preferred pharmacies. They include:
• Albertsons, Osco, and Sav-on*
Out-of-network pharmacies
Prescription drugs are usually not
covered at out-of-network pharmacies
except in special circumstances:
• If you become ill while traveling and
there is no network pharmacy nearby
• If you are prescribed medication as a
result of urgent or emergency care
• S ome employer group/union
sponsored plans allow you to use
out-of-network pharmacies to fill your
covered prescriptions at a higher
cost-sharing to you. See the Benefits
Rider that came with your EOC to see
if this applies to your plan.
Blue Shield of California Medicare Rx Plan
does not pay for any prescriptions that
are filled by pharmacies outside of the
United States and its territories, even for a
medical emergency.
Check your Pharmacy Directory or EOC
for more detailed information about
filling prescriptions outside the network.
• CVS*
Mail service pharmacy
• Safeway/Vons*
Blue Shield of California Medicare Rx
Plan provides access to pharmacy
mail service which provides you the
convenience of receiving up to a 90-day
supply of covered maintenance drugs†
delivered to your home or office, with no
charge for shipping.
Locating a network pharmacy is easy:
• C
heck the Blue Shield online directory at
blueshieldca.com/med_pharmacy;
• C
heck the pharmacy directory that is
included in this welcome kit packet; or
• C
all the Member Services number
on your Blue Shield of California
Medicare Rx Plan ID card or on the
back of this guide.
To receive medications from PrimeMail
(our prescription drug mail service
vendor), you must first register online,
by phone, or by mail. Once you
are registered, PrimeMail will need
your prescription, which can be sent
electronically or by phone, fax, or mail.
* Accepts e-prescribing.
†
Maintenance drugs are those prescribed to treat chronic or long-term health conditions
such as asthma, diabetes, high blood pressure, or high cholesterol, and are taken on a
regular basis to maintain health.
Quick reference guide 5
For more information, go to
blueshieldca.com, click on Pharmacy,
then choose Mail service pharmacy.
Or call PrimeMail at (866) 346-7200.
[TTY: (866) 346-7197].
Please allow 10 to 14 days to receive
your covered maintenance medications
through mail service. Once your
prescription is on file with our mail service,
please allow five to eight days to receive
refills of your covered medications.
Select UC Medical Center pharmacies
You can obtain a 90-day supply of
covered drugs for the amount of only
two 30-day copays when you visit select
UC Medical Center pharmacies. Please
contact your benefits administrator for a
list of participating pharmacies.
Knowing when to get prior authorization
Some drugs require prior authorization by
Blue Shield before the prescription can
be filled. Prior authorization ensures that
the drug is covered under Blue Shield of
California Medicare Rx Plan and that it is
safe and effective for you.
Here are two ways to find out if any
prescription drugs you currently take
require prior authorization:
1.Search the Blue Shield of California
Medicare Rx Plan formulary for your
specific drug (see the “Learning
about the formulary” section).
If you see “PA” in the Requirements/
Limits column, you or your physician/
prescriber must obtain prior
authorization from Blue Shield
Pharmacy Services.
2. Call the Member Services number
listed on your Blue Shield of California
Medicare Rx Plan ID card or on the
back of this guide.
Your physician/prescriber can contact
Blue Shield Pharmacy Services at
(800) 535-9481 [TTY: (888) 239-6482]
weekdays from 8:30 a.m. to 5 p.m.,
to request a prior authorization.
6 Quick reference guide
Learning about the formulary
Your Blue Shield of California Medicare
Rx Plan includes a Medicare-approved
formulary. This is the list of covered
drugs. And it’s more extensive than
what’s usually offered through a typical
employer group/union health plan.
Depending on the type of drugs you
take, you may see some differences
between our formulary and others you’ve
seen or used. These differences reflect
Medicare requirements and/or are based
on safety concerns and effectiveness for
specific age categories.
Check the Blue Shield of California
Medicare Rx Plan Formulary online
It’s easy to review all the drugs that are
covered under your plan. To find out
which ones are available through mail
service, have quantity limits, or require a
first-line therapy or prior authorization:
• Go to blueshieldca.com/med_formulary
• C
hoose PDP Formulary (Employer
Group Only)
No Internet access? No problem. We’ve
included a copy of the formulary in
this welcome kit, or, just call us at
(888) 239-6469 [TTY: (888) 239-6482] to
request a copy of the formulary.
Additional drugs Blue Shield of California
Medicare Rx Plan covers
Blue Shield of California Medicare Rx
Plan covers more drugs than required
by Medicare.
In fact, not all Medicare Part D plans
cover the drugs we do.
With Blue Shield of California Medicare
Rx Plan, you have coverage for:
• C
ough and cold drugs – generic
prescription products are covered
• Vitamin and mineral products
When the formulary changes
We will send you a printed formulary
every year to reflect the coming year’s
changes. In addition, we update our
formularies monthly on our website. See
the “Check the Blue Shield of California
Medicare Rx Plan Formulary online”
section above for instructions. In addition,
Medicare can change the list of covered
Medicare Part D drugs at any time.
If drugs are ever removed from the
Blue Shield of California Medicare Rx
Plan Formulary, or if a prior authorization
becomes required, or if there is a change
to the quantity limits or step therapy
restrictions, you will be notified of the
change 60 days before it takes effect
if you currently take that drug.
Checking the formulary before you fill
a prescription is the best way to know
whether or not the drugs are covered.
Quick reference guide 7
You may also verify if a particular drug is
on our formulary by calling the Member
Services number on your Blue Shield of
California Medicare Rx Plan ID card or
on the back of this guide.
Financial help from Medicare
People with limited incomes may qualify
for Extra Help, a program to help pay for
their prescription drug costs. To see if you
qualify for Extra Help, call:
• 1-800-MEDICARE (1-800-633-4227).
TTY users should call (877) 486-2048,
24 hours a day, seven days a week;
• T he Social Security Office at
(800) 772-1213 between 7 a.m. and
7 p.m., Monday through Friday. TTY
users should call (877) 486-2048; or
• Your State Medicaid Office.
8 Quick reference guide
Have a question? Need help? Give us a call.
For prescription drug benefits
Our Member Services team is available 7 a.m. to 8 p.m., seven days a week from
October 1 through February 14. However, after February 14, your call will be handled
by our automated phone system on weekends and holidays. All calls to these numbers
are toll-free.
Phone: (888) 239-6469
TTY: (888) 239-6482 (This number requires special telephone equipment.)
For prior authorization requests
If you are prescribed a drug that requires prior authorization, have your physician/
prescriber contact Blue Shield Pharmacy Services at (800) 535-9481 [TTY: (888) 239-6482],
weekdays, 8:30 a.m. to 5 p.m.
For medical benefits
When you have questions or need help with your medical benefits, you can call the
number listed on your medical plan ID card.
For general questions and information about Medicare Part D, visit the Medicare
website at www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227), 24 hours
a day/7 days a week. TTY users should call (877) 486-2048.
The benefit information provided is a brief summary, not a complete description
of benefits. For more information contact the plan. 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.
Blue Shield of California is a PDP plan with a Medicare contract. Enrollment in Blue Shield
of California depends on contract renewal.
An independent member of the Blue Shield Association
Blue Shield of California Medicare Rx Plan
P.O. Box 927
Woodland Hills, CA 91365
PDP00046-UC-COB (10/13)
You can also write to us at: