This is benefit information for coverage beginning January 1, 2009.
 
Asuris Medicare Script plans are Medicare Part D prescription drug plans (PDPs). With both Asuris Medicare Script plans, you'll have:

• Over 50,000 pharmacies nationwide, plus convenient mail order service

• All Medicare-approved Part D drugs covered

• Virtually no paperwork

• Monthly explanation of benefits to help track use of your deductible and out-of-pocket costs
   

This plan is available in all Oregon and Washington counties.

Type of Plan:	Medicare Part D prescription drug plan
Deductible:	$295 for Asuris Medicare Script or $0 for Asuris Medicare Script Enhanced
Copay:	as low as $4 per prescription for Tier 1 generic medications

 

Copay and Premium Overview
	Asuris Medicare Script	Asuris Medicare Script Enhanced
Monthly premium	$64.50	$81
Deductible for prescription drugs	$295	$0
Tier 1 copay for generic drugs	$4	$4
Tier 2 copay for preferred brand-name drugs	$20	$25
Tier 3 copay for non-preferred brand-name drugs	$40	$50
Tier 4* coinsurance for miscellaneous injectables	25%	25%
Tier 5* coinsurance for specialty medications	25%	25%
Coverage during the "coverage gap" (The coverage gap begins when total yearly drug costs – paid by you and your plan – reach $2,700.)	You pay 100% of discounted drug costs until the total out-of-pocket costs for the year reach $4,350.	You pay $4 copay for Tier 1 generics, or 100% of discounted drug costs for all other Medicare-covered drugs, until the total out-of-pocket costs for the year reach $4,350.
Catastrophic coverage	You pay the greater of 5% coinsurance or $2.40/$6.00 copay, depending on the tier.

*Tiers 4 and 5 products are limited to a 30-day supply and may contain generic products.

Deductible, copays and coinsurance are based on a 30-day supply of medications (31-day supply for long-term care) and are effective January 1, 2009 through December 31, 2009.

You must go to a network pharmacy to receive coverage.

(486k PDF) Information Brochure
The brochure provides an overview of Medicare, the plan, benefits at-a-glance, advantages, and more.

(284k PDF) Summary of Benefits
This brochure provides a detailed description of the plan, benefits at-a-glance, advantages and more.

 

(379k PDF) 2009 Evidence of Coverage

This booklet is sent to members after they enroll. It explains the plan coverage including:

• Service area

• Applicable conditions and limitations

• Premiums

• Cost sharing (e.g., copayments, coinsurance and deductibles), including a description of how an individual may obtain additional information on the plan's tiered or copayment level applicable to each drug

• Any conditions associated with receipt or use of benefits

• 60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug

• Out-of-network coverage

• Quality assurance policies and procedures, including medication therapy management, and drug and/or utilization management

• Potential for contract termination

• How to obtain an aggregate number of grievances, appeals and exceptions

Network Pharmacies

Search listings of our network pharmacies:

(297k PDF) Pharmacy Directory
We have contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

(97k PDF) 90-Day Pharmacy Listing
Listing of pharmacies that are able to dispense up to a 90-day supply of most medications.

Formulary

Search a list of prescription medications to determine your copay/coinsurance amounts.

(390k PDF) Abridged Formulary

(556k PDF) Comprehensive Formulary

(101k PDF) Our Transition Policy
Information for new enrollees on our Part D prescription drug plans.

(124k PDF) Prior Authorization Requirements
Listing of Prior Authorization requirements for consideration of coverage for specific drugs.

Members have several options for expressing dissatisfaction with our services or with those of a pharmacy or other provider.

Contact:

Government Programs MS S6D Attention:  Appeal/Grievance Coordinator PO Box 12625 Salem, OR 97309-0625 Fax number for written appeals and grievances:  (503) 588-4350

Grievances

A grievance is any complaint you make about us or one of our plan providers.  This does not involve payment or coverage disputes.

Examples of grievances include:

• Dissatisfaction with the customer service you receive.
• Dissatisfaction with the length of time spent waiting on the phone or in the pharmacy.
• Dissatisfaction with the length of time required to fill a prescription or the accuracy of filling a prescription.
   

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling customer service at 1 (800) 541-8981, 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. You may also fill out a Complaint form and return it to us. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your complaint form.

We must notify you of our decision about your grievance within 30 calendar days after receiving your complaint.

 

Coverage Determinations

 

Contact:

Government Programs MS 2P Attention:  Prior Authorization 100 SW Market Street Portland, OR 97207-1271 Fax number for written coverage determinations:  1 (888) 335-3016

 
A coverage determination is made when we make a decision about the prescription drug benefits you can receive under the plan, and the amount you may pay for a drug.
 
Examples of coverage determinations include:

• Formulary exceptions*

• Copayment tiering exceptions*
   

Coverage determinations will be responded to within 72 hours for standard requests and 24 hours for expedited requests.** Coverage determinations can be submitted by you or your prescribing physician by filling out the Coverage Determination form in its entirety and returning it to us. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your Coverage Determination form.
 

*If you are asking for a formulary or tiering exception, your PRESCRIBING PHYSICIAN must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to the generic drugs.

**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician’s support, we will decide if your health condition requires a fast decision.

 
Appeals

An appeal is any complaint you make when you want us to reconsider a decision we have made about your Part D prescription drug benefits.

Examples of appeals include:

• Our decision not to cover a drug, vaccine or other Part D benefit.

• Our decision not to reimburse you for a Part D drug that you paid for.

• Our denial of a coverage determination.

Appeals must be filed within 60 days of the payment or coverage denial. You may send an appeal to us in writing or by using our appeal form. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your appeal form.

We must notify you of the outcome of your appeal within 7 calendar days after receiving your appeal.

Additional information may be found by referring to the Evidence of Coverage in the section titled "Appeals and Grievances: what to do if you have complaints."

Quality Improvement
Asuris works hard to provide quality programs for our members.  We’re here to help ensure that medication options for our members are appropriate, safe and effective.  We have concurrent drug utilization review and safety initiatives geared to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions or therapy duplications.

Our medication policies and procedures are based on careful review of scientific information and input from practicing physicians.  Our ultimate goal is to enhance health outcomes with improved medication use for our members.

Medication Therapy Management
Medication Therapy Management (MTM) is a program offered to members of our Medicare Part D prescription drug plans.  MTM is a voluntary program that is offered to our members, with limited eligibility requirements, to assist with controlling chronic disease.  The MTM program is not actually a plan benefit, it is an educational program offered to members.

The MTM program is currently available to assist members in controlling the following conditions:

• Asthma and Diabetes
• Asthma and High Cholesterol
• Diabetes and High Cholesterol
• Asthma, Diabetes and High Cholesterol
   

For additional information about the program and eligibility, members should contact us at 1 (800) 541-8981.

Your Rights and Responsibilities Upon Disenrollment

• You must continue to use network pharmacies until you are disenrolled from our plan.
• You may only disenroll or switch prescription drug plans under certain circumstances.
• You have the right to make a complaint if we ask you to leave our plan.

Our Rights and Responsibilities Upon Your Disenrollment
We will let you know, in writing, the date your coverage ends. We have the right to disenroll you for the following reasons:

• You are no longer eligible for Medicare prescription drug coverage.
• If we are no longer contracting with Medicare or we leave your service area.
• When you move out of our service area.
• You materially misrepresent third-party reimbursement.
• You fail to pay your plan premium.
• You provide fraudulent information when you enroll or abuse your enrollment card.

Notification in the Event of Medicare Contract Termination
We have a contract with the Centers for Medicare & Medicaid Services (CMS), which is the government agency that runs Medicare. This contract may be renewed each year. However, we or CMS can decide to end the contract at any time. You will generally be notified 90 days in advance if this situation occurs. However, your advance notice may be 30 days or less if CMS ends our contract in the middle of the year.

Individual Eligibility
Anyone residing in the service area and who is eligible for Medicare benefits under Part A or is enrolled in Part B or Part B only is eligible to enroll.

 

Part D Enrollment
Medicare beneficiaries may be enrolled in only one Part D prescription drug plan at a time. If a beneficiary is also enrolled on a Medicare Advantage plan that includes Part D coverage, the beneficiary may not enroll in a separate Part D plan unless they disenroll from their current Medicare Advantage plan.

 

Medicare Premium Payment
Asuris Medicare Script members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.