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Overview of Medicare Prescription Drug coverage
Medicare Prescription Drug coverage is insurance that helps pay for your prescription drugs, vaccines, biologicals, and some supplies not covered by Medicare Part B. We will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a preferred Plan pharmacy, Medicare Part D covers it, and other coverage rules are followed. We do not pay for drugs under Medicare Part D that are covered by Medicare Part B. As a member, all you have to do is continue to pay your monthly premium and copayments. The amount of the monthly premium is not affected by your health status or how many prescriptions you need. If you have limited income and resources, you may get extra help from Medicare to pay your premium, and copayments so that you get your prescription drugs for little or no cost. Please see Section 2 or call Customer Services to learn more.
- The UPREHS Prime Medicare Plan covers some prescription drugs that are not a Medicare benefit. Our Formulary Book identifies those drugs for you. Those drugs must be obtained through the UPREHS Depot Drug Mail Order Pharmacy when used as a maintenance prescription. If you need your prescription filled urgently, you may have a one-time-only fill at a nonpreferred network retail pharmacy. Any additional refills must go through the UPREHS Depot Drug Mail Order Pharmacy. If you must use a nonpreferred network retail pharmacy, ask your physician to write 2 prescriptions, a one-month supply to be filled at your local pharmacy and a long-term prescription to be filled through the UPREHS Depot Drug Mail Order Pharmacy per the instructions in this section. When using a UPREHS Depot Drug Walk-In Pharmacy, give the original to the pharmacist. They will enter the information about your prescription and you can obtain your refills from the UPREHS Depot Drug Mail Order Pharmacy.
- UPREHS has contracted with Ascend Specialty Drug Pharmacy as a preferred pharmacy. Ascend Specialty Drug Pharmacy provides your self-injectable medications (excluding insulin) that treat conditions such as Rheumatoid Arthritis, Multiple Sclerosis, Hepatitis-C, Cancer, Transplant and other conditions. Call 1-800-850-9122 and they will be happy to set up delivery of your medications. Your copayments will be the same as those from the UPREHS Depot Drug Mail Order Pharmacy.
Help us keep your membership record up-to-date
We have a file of information about you as a Plan member. Pharmacists use this membership record to know what drugs are covered for you. The membership record has information from your enrollment form, including your address and telephone number. It shows your specific Plan coverage and other information. Section 8 tells you how we protect the privacy of your personal health information.
Please help us keep your membership record up-to-date by letting Customer Services know right away if there are any changes in your name, address, or phone number, or if you go into a nursing home. Also, tell Customer Services about any changes in prescription drug coverage you have from other sources, such as from Medicaid or from a current or different former employer, or your spouse’s current or former employer. In addition, you should tell Customer Services about any changes in coverage due to claims filed under liability insurance, such as workers’ compensation claims or claims against another driver in an automobile accident.
What is the geographic service area for our Plan?
UPREHS offers Medicare Prescription Drug coverage under our Plan nationally including Alaska and Hawaii. Your UPREHS preferred pharmacies are the UPREHS Depot Drug Mail Order Pharmacy, all UPREHS Depot Drug Walk-In Pharmacies, and the Ascend Specialty Drug Pharmacy. You are limited to filling one 30-day supply (or less) per prescription from a UPREHS nonpreferred retail pharmacy. All maintenance prescriptions (medication taken longer than 30 days) must be filled through the UPREHS Depot Drug Pharmacies. We cannot pay for any prescriptions that are filled by pharmacies outside of the United States, even for a medical emergency.
Use your combined UPREHS Health Insurance and Rx ID Card for prescriptions instead of your red, white, and blue Medicare card
As a member of our Plan, you have a combined UPREHS Health Insurance and Rx ID Card. When obtaining prescriptions, use your UPREHS ID Card.
During the time you are a Plan member and using Plan services, you must use this card. This ID card protects your privacy by using a UPREHS unique ID number that we use to identify you. Your UPREHS number is NOT your Social Security number or your Medicare Part A & B number. You must use your number on your card to identify yourself when obtaining prescriptions through the UPREHS Depot Drug Mail Order Pharmacy, UPREHS Depot Drug Walk-In Pharmacies, Ascend Specialty Drug Pharmacy and nonpreferred retail network pharmacies, when contacting UPREHS Customer Services and when obtaining your personal information from the UPREHS Website. Please carry your Plan membership card with you at all times. If your membership card is ever damaged, lost, or stolen, call UPREHS Customer Services right away and we will send you a new card.
Using plan pharmacies to get your prescription drugs covered by us
What are network pharmacies? With few exceptions, you must use the UPREHS Depot Drug Pharmacies to get your prescription drugs covered.
- What is a preferred pharmacy? Our preferred pharmacies are the UPREHS Depot Drug Mail Order Pharmacy, the UPREHS Depot Drug Walk-In Pharmacies and the Ascend Specialty Drug Pharmacy. UPREHS owns the Depot Drug Pharmacies that were established solely to serve our members. You must use the UPREHS Depot Drug Pharmacies for all maintenance prescriptions. Maintenance prescriptions are those taken longer than 30 days. We have negotiated a lower price from the drug manufacturers for covered prescription drugs than the price we pay for your drugs obtained at a nonpreferred network retail pharmacy. These savings are returned to you in the form of lower copayments and expanded Plan pharmacy benefits.
- What is Ascend Specialty Drug Pharmacy – a preferred pharmacy? UPREHS has added a valuable benefit for you that can change, for the better, the way you receive self-injectable and other medications (excluding insulin) that treat conditions such as Rheumatoid Arthritis, Multiple Sclerosis, and Hepatitis-C, and Cancer, Transplant and other conditions. Your copayments are the same as those from the UPREHS Depot Drug Mail Order Pharmacy. Ascend experts will provide you with specialized care including educational materials and pharmacy counseling to help you understand your medication therapy.
Effective immediately, you have the option to enroll in this additional benefit at no cost and have specialty medications delivered directly to you by Ascend. You will always be advised when to expect your shipment and most medications are shipped overnight via priority mail. In addition, you will be provided with unlimited access to expert skilled specialty pharmacy consultation.
If you currently take any of the above types of medications, this valuable benefit is yours and we hope you will take advantage of it right away. Call 1-800-850-9122 for more information.
- What is a nonpreferred network retail pharmacy? This is a pharmacy at which you can get your first 30-day prescription drug supply (or less) and emergency prescriptions using your Plan drug benefits. We call them nonpreferred network retail pharmacies because they contract with our Plan. In most cases, your prescriptions are covered only if they are filled at one of the UPREHS Depot Drug Pharmacies. A nonpreferred network retail pharmacy is still a network pharmacy, but you have to pay more for your prescriptions. Nonpreferred network retail pharmacies are retail pharmacies in the UPREHS network and their price for covered prescription drugs is more than UPREHS pays. That is the reason that your copayments are higher if you use a nonpreferred network retail pharmacy.
- What are covered drugs? A covered drug is the general term we use to mean all of the outpatient prescription drugs that are covered by our Plan. All Medicare Part D covered drugs are included in our formulary.
How do I fill a prescription at a nonpreferred network retail pharmacy?
To fill your prescription at a nonpreferred network retail pharmacy, you must show your UPREHS ID Card. If you do not have your ID card with you when you fill your prescription, you may have to pay the full cost of the prescription (rather than paying just your copayment). If this happens, you can ask us to reimburse you for our share of the cost by submitting your prescription receipt to us along with a completed UPREHS Prescription Claim Form found in the UPREHS Forms section of this book. To learn how to submit a paper claim, please refer to the paper claims process described at the end of this section.
- The UPREHS Prime Medicare Plan covers some prescription drugs that are not a Medicare benefit. Our Formulary Book identifies those drugs for you. When used as a maintenance prescription, those drugs must be obtained through the UPREHS Depot Drug Mail Order Pharmacy or a UPREHS Depot Drug Walk-In Pharmacy. If you need your prescription filled urgently, you may have a one-time-only fill at a nonpreferred network retail pharmacy. Any additional refills must go through a UPREHS Depot Drug Pharmacy.
- If you must use a nonpreferred network retail pharmacy, ask your physician to write 2 prescriptions, a one-month supply to be filled at your local pharmacy and a long-term prescription to be filled through the UPREHS Depot Drug Mail Order Pharmacy per the instructions in this section. When using a UPREHS Depot Drug Walk-In Pharmacy, give the original to the pharmacist. They will enter the information about your prescription and you can obtain your refills from the UPREHS Depot Drug Mail Order Pharmacy.
Finding a nonpreferred network retail pharmacy
Most local and national chain pharmacies are in our nonpreferred pharmacy network. Because our Plan is a national plan, all pharmacies cannot be listed in a directory. The pharmacist can tell you if their pharmacy is a network pharmacy simply by showing them your ID card. You can call Customer Services if you have questions.
What if your nonpreferred network retail pharmacy is no longer in our Plan?
Very rarely a pharmacy might leave our network. If this happens, you will have to get your prescriptions filled at another nonpreferred network retail pharmacy. Please call Customer Services to find another nonpreferred network retail pharmacy in your area.
How do I fill a prescription through the UPREHS Depot Drug Pharmacies?
You get more out of your Medicare benefits by using the UPREHS Depot Drug Mail Order Pharmacy. UPREHS is able to supply Mail Order Pharmacy prescriptions to you with lower copayments because of volume discounts from the drug manufacturers. These savings are passed on to you through lower UPREHS Depot Drug Mail Order Pharmacy copayments and the enhanced benefits you receive under our Plan. Many different drug manufacturers produce medications and label the medication with their own brand name or produce a generic drug. Drugs are individually analyzed by UPREHS for quality, safety, and cost. Formulary list selections are made and a large supply of the drug is purchased from one manufacturer to stock the UPREHS Depot Drug Mail Order Pharmacy. The manufacturer gives a volume discount for the purchase of large drug quantities. Again, these savings are passed on to you through lower UPREHS Depot Drug Mail Order Pharmacy copayments and the enhanced benefits you receive under our Plan.
You need to obtain your maintenance prescriptions from the UPREHS Depot Drug Mail Order Pharmacy and the UPREHS Depot Drug Walk-In Pharmacies. Maintenance prescriptions are those that you need to take longer than 30 days. UPREHS supplies your maintenance prescriptions with lower copayments and drug prices, so you get expanded benefit coverage.
How do I fill a prescription through Ascend Specialty Drug Pharmacy?
If you require specialty medications for the treatment of conditions such as Rheumatoid Arthritis, Multiple Sclerosis, Hepatitis-C, Cancer, Transplant and other conditions requiring self-injectable and other medications (excluding insulin), UPREHS has arranged for help for you. Ascend Specialty Drug Pharmacy will provide these medications to you at the same preferred copayment rate as the UPREHS Depot Drug Mail Order Pharmacy. Your medications will be delivered directly to you by Ascend. You will always be advised when to expect your shipment and most medications are shipped overnight via priority mail. In addition, you will be provided with unlimited access to experts in skilled specialty pharmacy consultation. Ascend Care Coordinators work directly with your UPREHS Care Coordinators, UPREHS Customer Service Representatives, and UPREHS Depot Drug Pharmacies and Clinics, to make certain that you receive the specialty medications that you require. If you have a prescription to fill soon, or if you have any questions, feel free to contact Ascend first at 1-800-850-9122 (toll free). They will be happy to coordinate with UPREHS, contact your doctor to obtain new prescriptions, and set up delivery of your medications.
Getting new prescriptions from the UPREHS Depot Drug Mail Order Pharmacy
Ordering new prescriptions is easy, and you are not charged shipping costs. Follow these directions to fill new prescriptions:
- Obtain your written prescription(s) from your doctor. Make certain the number of refills the doctor wants you to have is clearly indicated on your prescription. Your prescription can remain valid for up to one (1) calendar year, but it cannot be refilled after that time. If you continue to need the medication, you must get a new prescription from your doctor.
- Use a separate sheet of paper to show your name and UPREHS ID Card number exactly as they appear on your ID card, your return address, and your doctor’s name and telephone number with the area code.
- Order a 3-month (90-day) supply for each prescription if possible. Be sure to specify whether you want a 3-month (90-day), 2-month (60-day), or 1-month (30-day) supply.
- Without copayment(s), your prescription(s) cannot be filled. You can pay by check or money order payable to the UPREHS Depot Drug Mail Order Pharmacy. It is easier for you and UPREHS to pay your copayment with your credit card. That way, you will not need to guess the amount of your copayment. To use your credit card, write down the type of card (MasterCard or VISA only) and the entire credit card number and expiration date of your card. Once your card number is on file with UPREHS, you do not need to send the number each time, just request that we use your credit card on file for your copayment on future prescriptions. Allow ten (10) working days for mail delivery of your prescriptions. Credit card payment is the most convenient way to pay your prescription copayments when you don’t know how much to pay.
Mail the prescription(s), your personal information, and your applicable Tier copayment (or credit card information) for the prescription(s) to:
UPREHS Depot Drug Mail Order Pharmacy, PO Box 165090, Salt Lake City, UT 84116-5090
To order prescription refills from the UPREHS Depot Drug Mail Order Pharmacy
You must use the UPREHS Depot Drug Mail Order Pharmacy for mail order prescription service (except for medications provided by the Ascend Specialty Drug Pharmacy). Prescription drugs that you get through any other mail order service are not covered. There are three ways to obtain prescription refills from the UPREHS Depot Drug Mail Order Pharmacy.
Refills by mail
Your prescriptions are easy to refill once they are already on file with the UPREHS Depot Drug Mail Order Pharmacy. UPREHS urges you to order a 3-month (90-day) supply depending on the number of refills left on your prescription. You may re-order another 3-month supply in 60 days, or more after your last 3-month refill so that you won’t run out of your medication.
A convenient reorder form is included in each prescription sent to you. Simply indicate a one, two or three-month supply and your method of payment. If you are not using your credit card, include a check or money order for your copayment and mail the form to the address indicated on the form.
Refills by telephone
Just call the UPREHS toll-free number, 1-800-547-0421, and follow the interactive voice response instructions. You must use your credit card (MasterCard or VISA only) for copayments to order refills by telephone. To use the telephone refill service:
- Have your UPREHS ID card, your credit card (MasterCard or Visa only) and the prescription number(s) to be refilled ready before you place your call.
- Call the UPREHS Depot Drug Mail Order Pharmacy refill service telephone number toll free at 1-800-547-0421.
- Follow the instructions of the automated pharmacy service line to order your refill(s) and pay the copayment(s) using your credit card.
- You may place your telephone order any day (including weekends and holidays) between the hours of 4 am and 11 pm, Mountain Time.
Refills using our Website
UPREHS offers you the convenience of ordering your prescription refills using our Website at www.uphealth.com. You must use your credit card (MasterCard or Visa only) for Website ordering. There are two sets of passwords that you must have to access your information on the UPREHS Website. First, your UPREHS user name and password assigned by our computer and second, your HIPAA Personal Privacy Security Code and the HIPAA Password that you choose. If you have already obtained these, you do not need to do it again. New users must follow the instructions below. You can call UPREHS Customer Services at 1-800-547-0421 if you need help.
Getting your UPREHS member/user name and password to use our Website
- First, go to our home page at www.uphealth.com and choose Members.
- Two separate pop-up boxes appear: one to let you know you are entering a secure connection (click Yes to proceed), and one to tell you that the information cannot be viewed or changed by others. (The information is encrypted.)
- If you are not yet registered to use our Website, choose either new user registration from the button at the top of the page, or create one now from the text paragraph.
- Fill in all of the blanks presented. When the computer matches this information to your membership file, your registration will be completed. You will receive a Congratulations notice.
- Your new password will be emailed to the email address that you used to register.
- Your new user name will be the email address that you used, and your personal password will be made up of at least six digits including both letters and numbers.
Getting your Personal HIPAA Security Code and HIPAA Password
UPREHS is required by Federal law to guard the security of your individual Personal Protected Information. To access your Personal Protected Information you must enter and use a HIPAA Security Code and a HIPAA Password. Your HIPAA Security Code is your member identification number, exactly as shown on your UPREHS ID Card. Your HIPAA Password is a password chosen by you, and can be any combination of letters and/or numbers, up to 25 characters.
26 UPREHS PRIME MEDICARE PLAN BENEFIT GUIDE 2008 If you do not have these, please register by clicking on the message below when you see it on the member Website: Need a HIPAA Security Code and Password? Click here to Register.
When you click to register, the following information is requested:
- Your HIPAA Security Code is your member ID number as it appears on your UPREHS ID Card. You will choose and register your own HIPAA Password (up to 25 characters.) You will need to type your password selection twice for confirmation.
- The computer will verify that you now have a valid HIPAA Security Code, and HIPAA Password.
- You will need to have the HIPAA Security Code handy, and remember your HIPAA Password (or have your computer browser remember it) for you to see your Personal Protected Information in the future.
Back to ordering your prescription refills on the UPREHS Website:
Log in, now that you have your passwords.
- Choose Members from the home page. Member Services and Information will appear. First, enter your UPREHS user name and password. A screen will appear showing a Table of Contents. Click on Order Rx refill then Begin.
- When you see Rx Refill Processing, a HIPAA security screen will appear. You will use your HIPAA Security code and HIPAA Password to proceed with your Personal Protected Information. The computer will recognize your HIPAA Security Code and Password as valid. Click the Continue button.
- Begin by selecting the prescription you want to refill; choose the number of months you want to refill and click on Add to Rx shopping cart.
- hen you have entered all the prescriptions you want to order, click on Begin checkout process. You will be asked to enter your daytime telephone number and then to verify the last 4 digits of your credit card and the expiration date. You may update or change your credit card information, or if a credit card is not on file, you may enter your card number and expiration date (only MasterCard or Visa are accepted).
- You will be asked to verify the prescriptions you have ordered, how many months supply, and the amount to be charged to your credit card and the address to which the prescriptions will be shipped.
- At any time up to this point you can go back to edit your entries or cancel the entire order.
- You can then click on Submit order for processing, and the message at the top of the box will verify that you are Finished.
Filling prescriptions outside the network
Before you fill your prescription in any of these situations, call UPREHS Customer Services to see if there is a nonpreferred network retail pharmacy in your area where you can fill your prescription. Failure to do so may cause your payment request to be denied. Generally, UPREHS also limits the quantity of drugs covered out of network when approved. We will cover your prescription at an out of network pharmacy if at least one of the following applies:
- If you are trying to fill a prescription drug that is not regularly stocked at the UPREHS Depot Drug Mail Order Pharmacy, or an accessible nonpreferred network retail pharmacy (including high cost and unique drugs).
- If you are unable to obtain a covered drug in a timely manner because there is no nonpreferred network retail pharmacy within a reasonable driving distance that provides 24-hour service.
- If you are getting a covered vaccine that is medically necessary but not covered by Medicare Part B and/or some covered drugs that are administered in your doctor’s office.
If you do go to an out of network pharmacy for the reasons listed above, you will have to pay the full cost (rather than paying just your copayment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a paper claim completed by the pharmacy and your receipt for the medication with a letter explaining your situation to UPREHS at the address listed on the UPREHS Prescription Drug Claim Form. If you go to an out of network pharmacy, you are responsible for paying the applicable copayment and the difference between what we would pay for the medication and what the out of network pharmacy charged for your medication. You should submit a claim to us if you fill a prescription at an out of network pharmacy as any amount you pay will help you qualify for catastrophic coverage (see Section 4). To learn how to submit a paper claim, please refer to the paper claims process described next.
How do I submit a paper claim to UPREHS?
When you get your prescriptions from a preferred UPREHS Depot Drug Pharmacy, your claim is automatically submitted to UPREHS. If you go to an out of network pharmacy because of the reasons listed above, the pharmacy will not be able to submit the claim directly to us and you will have to pay the full cost of your prescription. You may have the pharmacy submit your claim using the UPREHS Prescription Drug Claim Form found in the UPREHS Forms section of this book. Please submit your form, your receipt and your letter explaining your situation to the following address:
UPREHS Depot Drug Pharmacy, PO Box 165090, Salt Lake City, UT 84116-5090
Upon receipt, we will make an initial coverage determination on your request. If we determine that we should cover the prescription, and the paper claims form is completed by the pharmacy, we will mail our payment for our cost of the drug directly to you. Your receipt does not contain all of the information that Medicare requires us to have for a coverage determination. Please refer to Section 6 for more information about initial coverage determinations.
To receive our coverage determination and possible payment for vaccine and administration costs from your physician that is not covered by Medicare Part B, please have your physician copy, complete and mail the Prescription Drug Claim Form found in the UPREHS Forms section of this book. You may contact our Customer Services at 1-800-547-0421. They will supply you and/or your physician with a paper claim form that gives us the information that Medicare requires that we have in order to pay for your vaccine and administration costs.
Home Infusion Pharmacies
It is our policy to contract with any willing Home Infusion Pharmacy that meets State, Federal and UPREHS requirements to become a network HI Pharmacy. UPREHS requires that you, your representative or the Home Infusion Pharmacy immediately contact UPREHS Customer Services if you find the need for HI therapy. We will direct you to the nearest network HI Pharmacy. UPREHS usually cannot supply Home Infusion therapy drugs so you must use one of our HI network pharmacies. We will cover HI drugs that are not obtained through either of these sources on a temporary basis if the need is urgent. The UPREHS Prime Medicare Plan will cover home infusion therapy if:
- Your prescription drug is on our formulary;
- Your prescription is written by an authorized prescriber; and
- You get your home infusion services from a UPREHS Home Infusion network pharmacy.
Long-term Care Pharmacies
UPREHS provides maintenance (taken longer than 30-days) Long Term Care drugs through the UPREHS Depot Drug Mail Order Pharmacy. We have many Long Term Care network pharmacies through our network that provide drugs not available from our Mail Order Pharmacy. UPREHS requires the Long Term Care facility, you, your representative, or your doctor to call UPREHS Customer Services at 1-800-547-0421 and arrange for your Long Term Care maintenance drugs to be supplied to you through the UPREHS Depot Drug Mail Order Pharmacy, or a network pharmacy.
UPREHS has a national pharmacy network, but it is impossible for us to contract with every LTC pharmacy in the nation. Therefore, UPREHS has made maintenance LTC formulary drugs available to all members through our UPREHS Depot Drug Mail Order Pharmacy. You must obtain your maintenance LTC formulary drugs through the UPREHS Depot Drug Mail Order Pharmacy. It is our policy to contract with any willing LTC pharmacy that meets State, Federal and UPREHS requirements to become a nonpreferred network LTC Pharmacy.
to become a nonpreferred network LTC Pharmacy. UPREHS will cover Long Term Care drugs that are not obtained through either of these sources on a temporary basis if the need is urgent. For more information, please contact Customer Services.
Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Pharmacies
Only Native Americans and Alaska Natives have access to Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) Pharmacies through our network pharmacy and in limited areas.
It is our policy to contract with any willing I/T/U pharmacy that meets State, Federal and UPREHS requirements to become a network pharmacy. Please contact Customer Services for more information.
Some vaccines and drugs may be administered in your doctor’s office
We may cover vaccines and their administration by your doctor that are preventive in nature that are not already covered by Medicare Part B. In addition we cover some drugs that may be administered in your doctor’s office. (Please see Section 4, How does your enrollment in our Plan affect coverage for drugs covered under Medicare Part A or Part B? for more information.)
To receive our coverage determination and possible payment for vaccine and administration costs from your physician that is not covered by Medicare Part B, please see the UPREHS Forms section of this book. Your physician can copy the UPREHS Prescription Drug Claim Form and submit a claim for vaccine and administration directly to UPREHS. You can contact our Customer Services at 1-800-547-0421. They will supply you and/or your physician with this claim form that gives us the information that Medicare requires that we have in order to pay for your vaccine and it’s administration.
Last Updated: 04/21/2008 |
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UPREHS. Plan for Life.™ 
