Part D benefits, formulary, pharmacy network, premiums and/or copayments may change on January 1, 2009. Please Contact UPREHS Customer Services for details at 1-800-547-0421 Monday through Friday, 7:30 AM to 3:30 PM Mountain Time.
You must continue to obtain your prescription drugs through the preferred UPREHS Depot Drug Mail Order Pharmacy and UPREHS Depot Drug Walk-In Pharmacies during all stages of your Medicare Part D benefit year.
| Benefit Description |
UPREHS Prime Medicare
Plan Benefits |
MEDICARE PART D |
| UPREHS EXPANDS YOUR BENEFITS |
AN ENHANCED PLAN |
BASIC BENEFITS |
Combined Monthly Premium for Medicare Part D, Medicare HCPP & Medicare Secondary Plan Members
|
Payment is included in your $210 combined premium—again for 2008—no increase in your premium. |
Varies depending on the plan and location. |
| Part D Deductible for All Members |
UPREHS pays your $275 deductible! No first-dollar costs to you except for drug copayments. |
$275 |
| Part D Initial Coverage Limit (ICL) for All Members |
$3,000 – UPREHS extends your ICL at our cost! This is your enhanced benefit! |
$2,510 |
| Out of Pocket Maximum for All Members for Medicare Part D Drugs |
$4,050 – Drugs during your out-of-pocket coverage gap are supplied to you through the UPREHS Depot Drug Mail Order Pharmacy at cost plus a small dispensing fee. |
$4,050 |
| Catastrophic Part D Drug Coverage for All Members |
After $4,050 out-of-pocket costs to you, UPREHS pays for all Medicare Part D drugs and your copays are the greater of 5% of drug costs or $2.25 for generic or $5.60 name brand. |
All Medicare Part D drugs after $4,050 out-of-pocket with copays at the greatest of 5% of drug costs or $2.25 for generic or $5.60 name brand. |
| Quantity of Part D Drug Supply for All Members |
30, 60 or 90-day supply through the preferred UPREHS Depot Drug Mail Order Pharmacy ONLY. 30-day supplies available through non-preferred network retail pharmacies. |
30, 60 or 90-day supply available through preferred network pharmacies. 30-day supplies through non-preferred pharmacies. |
| Drugs Requiring Pre-authorization, Cost-utilization Limits, and Step Therapy Requirements for All Members |
We have made using your benefits simple. There are only approximately 15 drugs that have limitations. Out-of-pocket costs are your decision through our tiered formulary and preferred Mail Order Pharmacy option. |
Many plans have cost utilization limits, preauthorization, and step therapy requirements to transition you to their chosen formulary drugs. |
| Part D Formulary for All Members |
Yes! UPREHS includes all Part D drugs in our formulary! And…some drugs not covered by Medicare! |
Yes. All Medicare plans are required to use a formulary, and many plans restrict or limit access to certain brands. |
| Mental Health Part D Drugs for All Members |
Yes! UPREHS covers all Part D covered drugs - AND UPREHS pays for some drugs using your Extended Benefit amount not covered by Medicare with applicable copayment. Examples: Diazepam, Alprazolam, Temazepam, Lorazepam, Phenobarbitol, etc. |
Limited. Many Mental and Behavioral Health drugs are not a Medicare Part D covered benefit and therefore, many plans do not include them. |
| Part D Diabetic Supplies that are Not Covered Under Part B for All Members |
Yes! The UPREHS Depot Drug Mail Order Pharmacy provides excellent benefits. For example, they will send you three boxes of alcohol swabs for only one $5 copay (your doctor’s prescription is required). |
Yes! |
| Home Infusion Therapy Part D Drugs for All Members |
Yes! Contact UPREHS Customer Services for coordination. |
Yes! |
| Long Term Care Part D Drugs for All Members |
Yes! The UPREHS Depot Drug Mail Order Pharmacy offers Long Term Care maintenance drugs so that you can obtain your medications – at our special low prices – no matter where your facility is located! |
Yes! |
| Smoking Cessation Part D Drugs for All Members |
Yes! Medicare limitations apply. |
Yes. Medicare limitations apply. |
| 30, 60 or 90-Day Supply Part D Drugs for All Members |
Yes! Up to 90-day supplies are available through our preferred UPREHS Depot Drug Mail Order Pharmacy. 30-day-only supplies are available through non-preferred retail pharmacies. |
Yes. 30, 60 or 90-day supply available through preferred network pharmacies. |
| Prescription Copayment for Part D Drugs for All Members |
Copay depends on your selection of the drug tier AND your use of the UPREHS Mail Order preferred pharmacy. See the chart below. |
25% to 33 % of drug cost depending on plan. |
| 2008 30-DAY COINSURANCE/COPAYMENT AMOUNTS FOR PART D DRUGS |
Tier 1
30-Day |
Tier 2
30-Day |
Tier 3
30-Day |
Tier 4
30-Day |
| UPREHS Depot Drug Mail Order Pharmacy Preferred Pharmacy 30, 60, or 90-Day Supply Available |
$5 |
$10 |
$40 |
Higher of $50 or 33% of drug cost |
Ascend Specialty Drug Pharmacy (Mail Order Pharmacy for self-injectable medications (excluding insulin) or medications for oncology (cancer) or transplant) Preferred Pharmacy 30, 60, or 90-Day Supply Available
|
$5 |
$10 |
$40 |
Higher of $50 or 33% of drug cost |
| UPREHS Depot Drug Walk-In Pharmacies Preferred Pharmacies |
$10 |
$20 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
| National Retail Pharmacy Network Non-Preferred Pharmacies 30-day or less Supply Available Only |
$15 |
$30 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
| Out-of-Network Pharmacy – Emergency Only We pay you the UPREHS cost for the Part D drug minus your tier copay amount. You pay any charges above UPREHS cost. Non-Part D drugs are not covered. |
$15 |
$30 |
Higher of $50 or 33% of drug cost |
Higher of $100 or 33% of drug cost |
UPREHS. Plan for Life.™ 
