1. health and fitness
2. drugs

2 01 5 Be ne f i t s Wor k b ook
for retired carnegie M e l lo n facult y an d staf f
For more information about 2015 benefits, go online to http://www.cmu.edu/hr/benefits.
Benefits Workbook
Read This Workbook
You should read this workbook thoroughly
and select the medical benefit that best
meets your needs. Please note the new
contribution amounts. If you require
more information, contact the HR
Benefits Office at 412-268-2047.
Carnegie Mellon reserves the right to
modify, amend, or terminate any or all
of the provisions of these benefits at any
time for any reason upon appropriate
action by the university. Notwithstanding
any of the prior statements, in all cases,
university policies will govern.
Table of Contents
Carnegie Mellon Retiree Benefits...............................................................page 3
Open Enrollment........................................................................................ page 3
Medical Options for Carnegie Mellon Retirees.........................................page 4
HealthAmerica Advantra Coverage Summary...................................page 5
Highmark Security Blue Coverage Summary.....................................page 7
UPMC for Life Coverage Summary.....................................................page 10
Prescription Drug Coverage...................................................................... page 12
Generic Drugs....................................................................................... page 13
Formulary.............................................................................................. page 13
Mail Order Prescriptions: Convenience and Affordability.............. page 13
Life and Family Status Changes................................................................page 14
Denial of Coverage Appeals.......................................................................page 14
Contact Information....................................................................................page 15
Creditable Coverage Notice (Medicare HMOs)........................................page 16
Non-Creditable Coverage Notice (Major Medical/Supp. Rx).................page 18
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For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Carnegie Mellon Retiree Benefits
We are pleased to offer retired Carnegie Mellon University faculty and staff
medical and prescription drug benefits. You may participate in one of our
Medicare HMO or Retiree Major Medical health plans. Our Major Medical
and Supplemental Prescription plan is available only for those with a
Medigap or private (not through Carnegie Mellon) plan and primary Part D
coverage.
Who is Eligible for Retiree Medical Benefits?
To participate in the Retiree Medical Benefits plan, you must:
• Be eligible for full-time health benefits at the time of retirement
Retirees Outside of
Pennsylvania
Out-of-town retirees are eligible for
the Major Medical and Supplemental
Prescription benefits through Carnegie
Mellon.
The HMO plans do NOT provide coverage
outside of Pennsylvania. If you are not
living in the area and want to participate
in a Carnegie Mellon retiree health plan,
you can NOT select a Medicare HMO plan.
• Be at least 60 years of age
• Have at least 5 years of service with the University
You may also cover your dependents. Eligible dependents include:
• Your spouse/registered domestic partner,
• Your unmarried children of any age who are incapable of self-support
due to total disability.
For further details about your eligibility for benefits, contact the HR Benefits
Office at 412-268-2047 or [email protected].
Open Enrollment
Each year, Open Enrollment (OE) provides you the opportunity to review
your benefits coverage and make new elections for the upcoming calendar
year. Elections made during OE will become effective the following January
1. Unless you experience a life or family status change, OE is the only
time during the year when you may change your benefits. All information
contained in this booklet is also available online at http://www.cmu.edu/hr/
benefits/benefit_programs/retiree-medical.html.
You must complete the university’s enrollment/change form and
return it to the Benefits Office.
Changing Coverage
You may move from our HMO coverage to
our Retiree Major Medical coverage, or
vice versa. Carnegie Mellon allows you to
enroll in the Retiree Major Medical and
Supplemental Prescription plan if you
discontinue Medicare HMO coverage.
Whenever you change plans, you must
notify the HR Benefits Office and also
notify the carriers.
Open Enrollment is your ONLY opportunity
during the year to make changes to
your health care election, unless you
experience a qualified life or family
status change (see page 14). Therefore,
evaluate your options carefully and make
new elections if necessary.
• If you are newly enrolling in/changing HMO plans, you must also complete the
•
carrier’s enrollment form and return it directly to the carrier.
If you are newly enrolling in or changing to the Major Medical and Supplemental
Prescription plan, you must also complete the Highmark Major Medical
enrollment form and return it to the HR Benefits Office.
Carrier enrollment forms can be obtained by contacting the HR Benefits
Office at 412-268-2047 or [email protected].
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
Medical Options for Carnegie Mellon Retirees
Medicare HMOs
Major Medical/Supplemental Rx Coverage
Carnegie Mellon offers Pittsburgh-area retirees the
opportunity to elect a Medicare HMO. The HMO option
is available as an alternative to the Medigap/Medicare
Part D/Major Medical coverage. Prescription drug
coverage is included in the HMO plans.
Carnegie Mellon offers a Retiree Major Medical and
Supplemental Prescription Drug plan to supplement
the coverage for retirees 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:
Our Medicare HMO plans provide extensive coverage and
do not require you to purchase supplemental coverage
on your own. (You must still enroll in Medicare A and
B, however.) The out-of-pocket costs are very low and
there are NO prescription annual limits or coverage gap.
However, the plan will only cover expenses when you use
in-network providers. In addition, the HMO coordinates
all care and claims payment with one card. You
cannot enroll in our Major Medical and Supplemental
Prescription if you enroll in one of our HMO plans.
Our Major Medical coverage protects against the cost
of catastrophic illness. Durable medical equipment
coverage is also included. There is no annual deductible
and a $100,000 lifetime maximum. Major Medical
covers 80% of eligible expenses.
The three Carnegie Mellon Medicare HMOs are:
•
•
HealthAmerica Advantra
Highmark Blue Cross/Blue Shield Security Blue
•
UPMC for Life
•
•
•
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)
Caremark provides supplemental prescription coverage
for participants in the Major Medical plan (see page 12).
The member is responsible for 100% of cost prior to
meeting the $250 deductible. Once the $250 deductible
is met, Caremark will cover 80% of the remaining cost
associated with generic and preferred medications.
Medigap Plans
A Medigap plan bridges the gap between where
Medicare Part A & B stops paying and Retiree Major
Medical begins paying. Carnegie Mellon does not
offer a Medigap plan. Retirees elect this coverage
outside of the university plan on their own.
Monthly Retiree Contributions
Less than 15 Years of Service
For Each Individual Covered
15 or More Years of Service
For Each Individual Covered
HealthAmerica Advantra
$360
$340
Highmark Blue Cross/Blue
Shield Security Blue
$421
$401
UPMC for Life
$470
$450
$37.64*
$0*
Retiree Major Medical and
Supplemental Prescription*
* Participants in the Major Medical/Supplemental Prescription Drug coverage must also purchase, on their own, a Medigap or Medicare
Advantage policy and Medicare Part D coverage, if not included in the Medigap/Advantage plan. The costs for these plans vary; contact
insurance carriers for rates. Our Medicare HMO participants do not need to purchase either of these policies.
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For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Advantra HMO – Carnegie Mellon University
2015 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 INFORMATION
Your Annual Deductible
Out-of-Pocket Maximum
BENEFITS
Physician Office Visits
Specialist Office Visits
Inpatient Hospital Care
Inpatient Mental Health
Skilled Nursing Care (100 days)
Home Health Care
Outpatient Mental Health & Substance
Abuse
Outpatient Surgery Services
Ambulance
Emergency Care & Urgent Care
Outpatient Rehabilitation Services
Durable Medical Equipment
Prosthetic Devices
Diabetes Self-Monitoring Training and
Supplies
Diagnostic Tests, x-rays, and lab
services
PREVENTIVE SERVICES
Bone Mass Measurement
Colorectal Screening Exams
Immunizations
Prostate Cancer Screening Exam
Pap Smears and Pelvic Exams
Mammograms
$0
$6,700
$10 copayment
$10 copayment
Covered 100%
Covered 100%
Covered 100%
Covered 100%
$10 copayment
Covered 100%
Covered 100%
$50 copayment
Waived if admitted as an inpatient.
$10 copayment
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
Covered 100%
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
ADDITIONAL BENEFITS
Routine Annual Hearing Exam
Hearing Aids
Routine Annual Eye Exam
Eyeglasses/Contacts (Every 2 years)
Immunosuppressive drugs
Routine Physical Exams
Health/Wellness Education
PRESCRIPTION DRUGS
Deductible
Initial Coverage Limit
Coverage Gap
RETAIL/30-DAY SUPPLY
Tier 1 - Preferred Generic
Tier 2 - Preferred Brand
Tier 3 - Non-Preferred Brand
Tier 4 - Specialty Drugs
MAIL-ORDER/90-DAY SUPPLY
Tier 1 - Preferred Generic
Tier 2 - Preferred Brand
Tier 3 - Non-Preferred Brand
Tier 4 - Specialty Drugs
Catastrophic Coverage
$0 copayment
$500 allowance for the 1st hearing aid
$500 allowance for the 2nd hearing aid
$0 copayment
$150 allowance
20% coinsurance
$10 office visit copayment
Covered 100% including health club membership and fitness
classes.
None
Up to $2,960
Continuous coverage at tier copays as listed below.
(No donut hole)
$10 copayment
$10 copayment
$10 copayment
25% coinsurance
$20 copayment
$20 copayment
$20 copayment
NOT AVAILABLE
After your yearly out-of-pocket drug costs reach $4,700, you
pay 5% coinsurance for all generic and brand drugs if the
5% coinsurance is greater than:
•
•
$2.65 copayment for generic (including brand drugs
treated as generic)
$6.60 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
1-800-470-4272, M – F, 8AM – 5PM (TDD USERS CALL 1-800-207-1262).
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For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
2015 Benefit Summary
FACILITY SERVICES
PHYSICIAN
SERVICES
PREVENTIVE CARE (OFFICE
VISIT COST SHARING
MAY APPLY)
BASIC
PLAN
COSTS
CMU
Security Blue HMO
Deductible
$0
Coinsurance
0%
Out-of-Pocket Maximum
$3,400
Annual Physical Exam
$0 cost sharing
Screenings & Exams
(Preventative PAP/Pelvic,
Mammograms, Colorectal,
Prostate & Bone Mass
Measurement)
$0 cost sharing
Doctor Office Visit
$10 copayment
Specialist Office Visit
$20 copayment
X-ray or Radiology
$0 cost sharing
Diagnostic Testing
$0 cost sharing
Outpatient Surgery
$0 cost sharing
Emergency Room Services
(Worldwide Coverage)
$50 copayment
Urgently Needed Care (this
is NOT emergency care)
$40 copayment
Inpatient Hospital Stay
$0 cost sharing
Skilled Nursing Facility Care
(100 days per Medicare
benefit period)
$0 cost sharing
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
CMU
Annual Routine Vision
Exam (Includes refraction)
ADDITIONAL BENEFITS
Eyeglasses or Contact
Lenses
(Covered every year)
Standard eyeglass lenses and frames or contact
lenses are covered in full. A $100 benefit
maximum applies to non-standard frames and a
$100 benefit maximum for specialty contact
lenses.
$20 copayment
Hearing Aids
(covered every three years)
$500 coverage
Chiropractic Office Visits
$20 copayment
Home Health
$0 cost sharing
Physical, Speech and
Occupational Therapy
(per visit/per day/per
provider)
$20 copayment
Ambulance (Emergent
Services per one way trip)
Durable Medical Equipment
(Prosthetics/Orthotics,
Diabetic Testing Supplies,
Oxygen/Oxygen Supplies)
MENTAL HEALTH
SERVICES
$0 cost sharing
Annual Routine Hearing
Exam
Part B Drugs
8
Security Blue HMO
10% coinsurance/$300 quarterly max.
$25 copayment
15% coinsurance
Inpatient Psychiatric
Hospital Care (Limited to
190 days per lifetime)
$0 cost sharing
Outpatient Mental
Health/Psychiatric Services
or Chemical Dependency
Substance Abuse
Treatment (per individual or
group session)
$20 copayment
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
PART D DRUGS
(UP TO 31 DAY RETAIL SUPPLY)
DRUGS
CMU
Security Blue HMO
Initial Coverage Period (up
to $2,960 in total drug
costs)
Coverage Gap Period
(from $2,960.01 in total
drug costs to $4,700 in
yearly out-of-pocket drug
costs)
Catastrophic Coverage
Period (after $4,700.01 in
total out-of-pocket drug
costs)
Mail Order (up to 90-day
supply)
$15 Preferred Generic
$15 Non Preferred Generic
$30 Preferred Brand
$60 Non Preferred Brand
$60 Specialty Drug
$15 Preferred Generic
$15 Non Preferred Generic
$30 Preferred Brand
$60 Non Preferred Brand
$60 Specialty Drug
The greater of 5% or $2.65 for generic or multisource drugs or $6.60 for all other drugs
$37.50 Preferred Generic
$37.50 Non Preferred Generic
$75 Preferred Brand
$150 Non Preferred Brand
$150 Specialty Drug
• Diagnostic or outpatient surgery cost sharing may apply for non-screening preventive services.
• Physician office visit cost sharing may apply if a separately billable physician service is rendered.
• Certain categories of Medicare Part B drugs have been excluded from member cost sharing. They
include certain vaccines and toxoids, certain miscellaneous drugs and solutions, certain
miscellaneous pathology and laboratory drugs, and certain contrast materials. Prior authorization is
necessary for coverage of certain medications. Medicare Part B drugs are not available via retail
pharmacy network.
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, provider network, premium and/or co-payments/co-insurance may
change on January 1 of each year. You must continue to pay your Medicare Part B premium.
Highmark Inc., Keystone Health Plan West, Inc. and Highmark Health Insurance Company are
Medicare Advantage plans with a Medicare contract. HM Health Insurance Company is a PDP plan
with a Medicare contract. Enrollment in Highmark Inc., Keystone Health Plan West, Inc., Highmark
Health Insurance Company and HM Health Insurance Company depends on contract renewal.
Questions on Security Blue HMO benefits? Call 1-800-227-8195 (TTY users call 711)
Reference Code (Please have this number ready when you call): 15SB4266
For more information,
EGHP_14_0499
go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
UPMC for Life
2015 Carnegie Mellon University HMO Plan
Benefits
Custom HMO
Annual Out-of-Pocket Limit1
INPATIENT CARE
Inpatient Hospital2
Inpatient Mental Health2
Skilled Nursing Facility2
Home Health Care2
Hospice
OUTPATIENT CARE
PCP Visits
Specialist Visits & Urgent Care Clinics
Chiropractic Services
Routine Chiropractic
Podiatry Services
Routine Podiatry Services
Outpatient Mental Health/Substance Abuse
Outpatient Surgery/ASC2
Ambulance Services
Emergency Care
Urgent Care (out-of-area)
Outpatient Rehab (PT, OT, ST)
Cardiac and Pulmonary Rehab Services
OUTPATIENT MEDICAL AND SUPPLIES
Durable Medical Equipment/ Prosthetics2
Oxygen & related equipment
Diabetes Supplies
Part B Drugs2
Diagnostic Tests, X-Rays, Labs2
PREVENTIVE SERVICES
Immunizations3 (flu, pneumonia, Hepatitis B)
Annual Wellness/Routine Physical Exam3
Preventive Screening Exams3
Includes: bone mass measurement, mammograms, Pap
& pelvic exam, colorectal screenings, prostate exam,
and other Medicare-covered preventive screenings.
$3,400
$100 copay per admission
$300 annual maximum
$100 copay per admission
$300 annual maximum
$0 copay
(100 day benefit period limit)
$0 copay
Medicare-covered
$10 copay
$20 copay
$20 copay
$20 copay - 6 visits per year
$20 copay
$20 copay - 4 visits per year
$20 copay
$25 copay
$75 annual limit
$50 copay per one-way trip
$65 copay - copay waived if admitted
$20 copay
$20 copay
$0 copay
$0 copay
$0 copay
$10 copay per item - 30 day supply
$30 copay per item - 90 day retail & mail-order supply
10% coinsurance all Part B drugs
$0 copay
$0 copay
$0 copay - 1 exam per year
$0 copay
ADDITIONAL BENEFITS
Dental Services
Medicare-covered Dental
Routine Oral Exam & Cleaning
Restorative Services & X-rays
Hearing Services
Medicare-covered Hearing Exams
Routine Hearing Exam
Hearing Aid Fitting & Evaluation
Hearing Aid(s)
Vision Services
10
$20 copay
$20 copay - once every 6 months
Not Covered
$20 copay
$20 copay - 1 exam per year
$20 copay - 1 fitting every 3 years
$1,000 allowance - every 3 years
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
UPMC for Life
2015 Carnegie Mellon University HMO Plan
Benefits
Medicare-covered Vision Exams
Custom HMO
$20 copay
$0 copay
Glaucoma Screening/Diabetic Retinal Eye Exam
Routine Eyewear and Routine Eye Exam
Health/Wellness includes fitness benefit
Assist America®
(worldwide emergency travel benefit)
Prescription Drugs
4
Tier 1: Generic Drugs
Tier 2: Preferred Brand Drugs
Tier 3: Non-Preferred Brand Drugs
Tier 4: Specialty Drugs
Tier 5: Select Care Drugs (Select Generics)
Initial Coverage Limit
Coverage Gap Cost-Sharing
The member pays the same copays in the Coverage
Gap Stage that he/she paid in the Initial Coverage Stage
$250 allowance every two years
Silver & Fit
$0 copay
$5 copay - 30 day
$15 copay - 90 day retail & mail-order
$25 copay - 30 day
$75 copay - 90 day retail & mail-order
$50 copay - 30 day
$150 copay - 90 day retail & mail-order
$50 copay - 30 day only
$0 copay - 30 day
$0 copay - 90 day retail & mail-order
$2,960
30-day Supply
Once the member's yearly drug costs reach $2,960 and until the member's
yearly out-of-pocket costs reach $4,700, the prescription drug
copay/coinsurance amounts are:
$5 copay for Generic Drugs
$25 copay for Preferred Brand Drugs
$50 copay for Non-Preferred Brand Drugs
$50 copay for Specialty Drugs
$0 copay for Select Care Drugs
90-day Supply
Once the member's yearly drug costs reach $2,960 and until the member's
yearly out-of-pocket costs reach $4,700, the prescription drug
copay/coinsurance amounts are:
$15 copay for Generic Drugs
$75 copay for Preferred Brand Drugs
$150 copay for Non-Preferred Brand Drugs
$0 copay for Select Care Drugs
Out-of-Pocket Maximum (TrOOP)
Catastrophic Coverage Copays
$4,700
$2.65 for generic,
$6.60 for all other drugs, or 5% coinsurance
1
Member's cost-sharing accumulates toward the OOP limit (excludes Part D drugs, routine dental, routine hearing, routine vision, and fitness
benefit). Once the annual out-of-pocket maximum is met, additional covered services are paid at 100% by the plan.
2
These services require prior authorization.
3
A separate copay may apply if additional medical services are performed during the same visit as a preventive service.
4
This is a combined allowance that must be used for both an eye exam and eyewear.
NOTE: UPMC Health Plan, Inc., has determined that the prescription drug coverage offered by these employer group
plans for 2015 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.
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
Prescription Drug Coverage
Participating
Pharmacies
Caremark: For Major Medical/Supplemental Drug Plan
Caremark is the supplemental prescription 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 deductible, member
coinsurance responsibility, and a coverage gap. Once the $250 deductible is met,
the Caremark Supplemental Prescription Drug coverage pays 80% coinsurance of the
remaining cost associated with generic and preferred medications. If a medication is
non-preferred it will not be covered by the Caremark secondary coverage.
Many chain and independent
pharmacies participate in the
prescription carrier networks.
A partial list of participating
pharmacies includes:
▪ Costco ▪ CVS ▪ Giant Eagle
▪ K-Mart ▪ Medicine Shoppe
▪ RiteAid ▪ Target ▪ Walgreens
▪ Wal-Mart When you need a prescription (re)filled at a participating pharmacy:
• You must present and identify your Primary Part D coverage card and your
Caremark card as secondary when you visit your pharmacist.
• If you do not present your Caremark and Primary Part D cards, or you use an outof-network pharmacy, you will be required to pay for the drug in full and then file
for reimbursement. Reimbursement of your prescription 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
explanation of benefits. 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 Prescription Coverage
Participants in Carnegie Mellon’s retiree HMOs have prescription coverage through their
medical plan. To fill a prescription, you must go to a participating pharmacy. Present
your HMO member card along with your prescription. 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 time of your first purchase, you will have to pay for the medication in full and later
file a request for reimbursement.
Major Medical
Participants: Enroll in
Medicare Part D
In order to receive Carnegie Mellon’s
supplemental prescription coverage
(which provides benefits 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 participating
carrier of your choice.
Participants in one of our Medicare
HMOs need not enroll in Medicare
Part D, as these plans include
creditable coverage.
Prescription Drug Participant Copays/Coinsurance
Medicare HMO Copays
HealthAmerica
Advantra
Highmark Security
Blue
UPMC for Life
Medicare Part D plus
Caremark
Retail
(30-day supply)
(31-day supply)
(30-day supply)
Generic (automatic substitution)
$10.00
$15.00
$5.00
Preferred Brand
$10.00
$30.00
$25.00
Non-preferred Brand
$10.00
$60.00
$50.00
25% coinsurance
$60.00
$50.00
Generic (automatic substitution)
$20.00
$37.50
$15.00
Member is responsible
for 100% of cost prior
to meeting the $250
deductible. Once the
$250 deductible is met,
Caremark will cover
80% of the remaining
cost associated with
generic and preferred
medications.
Preferred Brand
$20.00
$75.00
$75.00
Non-preferred Brand
$20.00
$150.00
$150.00
not available
$150.00
not available
Specialty
Mail Order (Up to 90-day supply)
Specialty
If a medication is nonpreferred it will not
be covered by the
Caremark secondary
coverage.
Part D must be
purchased on your own.
12
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Caremark Reimbursement
with Mail Order
• Send the prescription to your Part D
carrier’s mail order service.
• Pay the amount billed and keep
your receipts.
• Complete the Caremark
Prescription Claim form in its
entirety. (Complete all questions,
even if the receipt contains some of
the information requested.)
• Send a copy of the receipt and the
completed claim form to Caremark.
• Caremark will reimburse you for
80% of your costs (after the $250
deductible is met). See page 12 for
more details.
Writing Prescriptions
for Mail Order
For the quickest service and best prices,
submit mail order prescriptions correctly:
Generic Drugs
The Medicare HMO plans require that generic drugs be substituted
automatically for brand-name medications when available, unless a medical
necessity waiver has been submitted by your physician and approved in
advance. Generic drugs have been tested by the FDA to ensure that they
contain equivalent active ingredients. Utilizing a brand-name drug when a
generic substitution can be made will result in additional costs to you.
Formulary
Our retiree HMO plans and most Medicare Advantage and Part D plans
utilize a formulary. A formulary is a list of preferred medications that have
been selected for treating various conditions. The medications on the
formulary are based on effectiveness, cost, and demand.
You should consider trying a formulary medication before a non-formulary
option in order to maximize your cost savings. It is wise to bring the formulary
list with you to the doctor’s office to ensure that a formulary medication has
been selected before going to get the prescription filled.
See your Medicare D carrier or HMO carrier website for a complete list of
the drugs on its formulary. The formulary can be modified at any time by the
carrier, so refer to the website for the most up-to-date information.
Mail Order Prescriptions: Convenience and Affordability
Caremark and the retiree HMOs all provide mail order services for
medications prescribed more than two months. When you order long-term
use or maintenance medications through mail order:
• Your doctor should write the
prescription for a 90-days supply,
(not 30-days) with the appropriate
number of refills.
• Your nearest pharmacy is as close as your phone, computer or
mailbox.
• Be sure the prescription is signed
and written legibly.
• You generally save money with lower copays or coinsurance based on
• New prescriptions take up to two
weeks to fill. (Refills generally take
less time.) If you need the drug
immediately, ask for samples or a
script for a short-term supply that
can be filled at your pharmacy.
• You only need to order refills every few months, instead of going to
the pharmacy every few weeks.
bulk prices.
The forms and instructions for using the mail order services can be found on
the carrier websites.
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
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Benefits Workbook
Life and Family Status Changes
The elections that you make will remain in effect for the entire calendar year, unless you experience a life or family
status change. The events listed in the chart below are considered IRS qualifying family status changes that permit
you to modify your coverage. All life or family status changes must be requested within 30 days of the event. You
must also provide supporting documentation such as a marriage certificate or proof of new coverage within 30 days
of the life or family status change.
Qualifying Life or Family Status Changes Under the Retiree Benefits Program
Marital/Domestic Partnership Status Changes
•
Marriage/registration of domestic partnership
•
Death of spouse/domestic partner
•
Divorce/termination of domestic partnership
Number of Covered Dependent Children Changes
Spouse/Domestic Partner Gains or Loses Coverage from Another Source
Significant Change in Cost of Plan
Significant Change in Coverage of Plan
•
New or improved plan is offered
•
Significant reduction in overall coverage of current plan
Significant Change in Location (if have an HMO)
Denial of Coverage Appeals
Most questions or concerns about your coverage, filing claims, or eligible expenses should be directed to the carrier
of the plan you selected. Contact information 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 specific provisions of the Carnegie
Mellon plan. If a claim that you submitted to one of our benefit 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 Benefits Office at 412-268-2047 or visit the cmu website at: www.cmu.edu/hr/benefits/benefit_
programs/retiree-medical.html.
For Other (Administrative) Appeals:
1. If you believe the denial was made in error, contact the carrier directly to begin the appeals process.
(See Contact Information on the next page.)
2. If you are unable to resolve the situation with the carrier, please contact the HR Benefits Office at
412-268-2047 for assistance in working with the carrier.
3. The HR Benefits Office can also provide you with information about filing a formal appeal with the carrier
to challenge the denial.
14
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Contact Information
Do you need more information about a specific benefit option? 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 or enrollment, or unresolved issues, contact
Human Resources.
Carnegie Mellon Benefits Office
412-268-2047
[email protected]
http://www.cmu.edu/hr
Medicare
800-633-4227
www.medicare.gov
Social Security Administration
800-772-1213
http://www.ssa.gov
Medical Options
Prescription Drug Plan
Highmark Blue Cross/Blue Shield Caremark (Retiree Major Medical Plan)
Group Number (15 or more years of service):
Carrier 5806 RET/001
Group Number (less than 15 years of service):
Carrier 5806 RET/002
877-347-7444
http://www.caremark.com
Retiree Major Medical
Group Number: 50387-02
800-472-1506
http://www.highmarkbcbs.com
Signature 65 (for Mellon Institute retirees only)
Group Number: 62387-00
800-367-6565
http://www.highmarkbcbs.com
Highmark Blue Cross/Blue Shield
Security Blue HMO/Prescription Coverage
Group Number: 58426-60 (less than 15 years service)
Group Number: 58426-70 (more than 15 years service)
800-935-2583
http://www.highmarkbcbs.com
UPMC for Life Medicare HMO/Prescription Coverage
Group Number: MC0144
877-381-3765
http://www.upmchealthplan.com
HealthAmerica Advantra Medicare HMO/Prescription
Coverage
Group Number: 2101881001
800-470-4272
http://www.pa.chcadvantra.com
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
15
Benefits Workbook
Creditable Coverage Notice (Medicare HMOs)
OMB 0938-0990
Important Notice from Carnegie Mellon University About
Your Prescription Drug Coverage and Medicare
The Carnegie Mellon University Benefit Plan
Medicare 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 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 want to join 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 make decisions 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. You can get this coverage
if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO) that offers
prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by Medicare.
Some plans may also offer more coverage for a higher monthly premium.
2. Carnegie Mellon University has determined that the prescription drug coverage offered by the Carnegie Mellon
University Benefit Plan-Medicare Advantage HMO (HealthAmerica Advantra, Highmark Blue Cross Blue Shield
Security Blue, UPMC For Life) is, on average for all plan participants, expected to pay out as much as standard
Medicare prescription drug coverage pays and is therefore considered Creditable Coverage. Because your existing
coverage is Creditable Coverage, you can keep this coverage and not pay a higher premium (a penalty) if you later
decide 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 drug plan.
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 be affected.
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.
16
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Creditable Coverage Notice (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 and don’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 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 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, you may 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 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 1-800-7721213 (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:10/9/2014
Name of Entity/Sender:
Carnegie Mellon University
Contact–Position/Office:
Benefits Office
Address:5000 Forbes Avenue, Pittsburgh, PA 15213-3815
Phone Number:412-268-2047
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
17
Benefits Workbook
Non-Creditable Coverage Notice (Major Medical & Supp. Rx)
OMB 0938-0990
Important Notice From Carnegie Mellon University About
Your Prescription Drug Coverage and Medicare
The Carnegie Mellon University Benefit Plan
Retiree 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 want to join a Medicare drug plan. Information about
where you can get help to make decisions about your prescription 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. You can get this coverage if you join a Medicare Prescription Drug Plan or join a Medicare Advantage Plan (like an HMO or PPO)
that offers prescription drug coverage. All Medicare drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. Carnegie Mellon University has determined that the prescription drug coverage offered by the Retiree Major Medical
and Supplemental Prescription Plan is, on average for all plan participants, NOT expected to pay out as much
as standard Medicare prescription drug coverage pays. Therefore, your coverage is considered Non-Creditable
Coverage. This is important because, most likely, you will get more help with your drug costs if you join a Medicare
drug plan, than if you only have prescription drug coverage from the Retiree Major Medical and Supplemental
Prescription Plan. This also is important because it may mean that you may pay a higher premium (a penalty) if you
do not join a Medicare drug plan when you first become eligible.
3. You can keep your current coverage from the Retiree Major Medical and Supplemental Prescription Plan. However,
because your coverage is non- creditable, you have decisions to make about Medicare prescription drug coverage
that may affect how much you pay for that coverage, depending on if and when you join a drug plan. When you make
your decision, you should compare your current coverage, including what drugs are covered, with the coverage and
cost of the plans offering Medicare prescription drug coverage in your area. Read this notice 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 Enrollment Period (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.
18
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
f o r r e t i r e d c a r n e g i e m e l l o n fac u lt y a n d s ta f f
Non-Creditable Coverage Notice (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 Prescription Plan is not
creditable, depending on how long you go without creditable prescription drug coverage, you may 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 without prescription 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 least 19% 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 until the 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 be affected. 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 University coverage, 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 1-800-7721213 (TTY 1-800-325-0778).
Date:10/9/2014
Name of Entity/Sender:
Carnegie Mellon University
Contact–Position/Office:
Benefits Office
Address:5000 Forbes Avenue, Pittsburgh, PA 15213-3815
Phone Number:412-268-2047
For more information, go online to http://www.cmu.edu/hr/benefits/benefit_programs/retiree-medical.html.
19
Carnegie Mellon University does not discriminate in admission, employment, or administration of its
programs or activities on the basis of race, color, national origin, sex, handicap or disability, age, sexual
orientation, gender identity, religion, creed, ancestry, belief, veteran status, or genetic information.
Furthermore, Carnegie Mellon University does not discriminate and is required not to discriminate in violation
of federal, state, or local laws or executive orders.
Inquiries concerning the application of and compliance with this statement should be directed to the vice
president for campus affairs, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213,
telephone 412-268-2056.
Obtain general information about Carnegie Mellon University by calling 412-268-2000.