(Kaiser Permanente Plan Participants Must Use Kaiser Permanente Plan Pharmacies)
EnvisionRx Options administers the Prescription Drug Program for the Fresno Unified School District. If you fail to use the EnvisionRx Options program and its provider Pharmacies there will be NO benefit to you. For a complete list of participating pharmacies, please register online and visit www.envisionrx.com or call EnvisionRx Options Help Desk at (800) 361-4543.
Each eligible Employee, Retiree and Dependent will be charged the copayments outlined on the insert in the back of this Plan Booklet.
ENVISIONRX PLUS PLAN
If you are a Retiree currently enrolled in Medicare Parts A (hospital) and/or B (medical) coverage, or you become eligible for Parts A and/or B of Medicare at a later date, or you are awarded Medicare through Social Security Disability benefits after 24 months of being disabled, you will automatically be enrolled in the EnvisionRx Plus Plan unless you notify the District’s Benefits Office that you wish to “Opt Out’ and decline Prescription Drug coverage. You will be required to complete an Opt Out election form (available through EnvisionRx Plus or the District’s Benefit Department). Your Medicare-eligible Dependents will also automatically be enrolled in this plan; however if your Dependents are not eligible for Medicare, they will not be enrolled in EnvisionRx Plus Plan and will continue to be covered the same as for Non-Medicare Dependents.
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The EnvisionRx Plus Plan provides the same benefits as you currently receive. Note that effective April 1, 2012 copayments will apply to all Retirees and Dependents whether dual coverage exists or not.•
You are not required to be enrolled in EnvisionRx Plus Plan if you are eligible for Medicare Parts A and/or B. However if you choose to Opt Out, you will lose all prescription drug coverage under the Envision Rx Options plans (outlined herein) AND you will not be allowed to elect coverage in the future. You understand that if you leave this EnvisionRx Plus plan and do not have or obtain other Medicare prescription drug coverage that is at least as good as Medicare’s Part D coverage, you may have to pay a Medicare late enrollment penalty in addition to your premium for Medicare Part D prescription coverage in the future.Note: In January 2012, the Social Security Administration implemented specific rules on how they calculate monthly Medicare Part D (prescription drug) premiums for higher-income beneficiaries. High-higher-income beneficiaries pay an “higher-income related” monthly adjustment amount (IRMAA). Social Security uses your most recent federal tax return to determine if you will be required to pay higher Medicare premiums for an income-related monthly adjustment amount.
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EnvisionRx Plus Plan is a Medicare drug plan and is in addition to your coverage under Medicare;therefore, you will need to maintain your Medicare coverage. It is your responsibility to inform EnvisionRx Plus of any other prescription drug coverage that you have or may get in the future.
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If you have a Medigap (Medicare Supplement) policy that includes prescription drug coverage, you must contact your Medigap Issuer to let them know that you have joined the EnvisionRx Plus Plan offered through this Plan. Your Medigap Issuer will remove the prescription drug coverage portion of the policy and adjust your premium. Call your Medigap issuer for details.•
You may leave this plan only at certain times of the year by sending a request to EnvisionRx Plus or by calling 1-800-Medicare. Please notify the District’s Benefit Department if you choose to leave this plan as well.•
Additional information for Medicare-eligible Retirees and Dependents: When you enroll in this plan, you will receive an Evidence of Coverage brochure from EnvisionRx Plus which will provide additional information including your right to Claim Appeals relating to payment or services. It is your responsibility to read the EnvisionRx Plus Evidence of Coverage brochure.By joining the Plan’s EnvisionRx Plus Medicare prescription drug plan, EnvisionRx Plus is required to release your information to Medicare and other plans as is necessary for treatment, payment and health care operations, who may release it for research and other purposes which follow all applicable Federal statutes and regulations.
If you have additional questions regarding the EnvisionRx Plus Plan, please call EnvisionRx Plus at (866) 250-2005 24-hours a day, 7 days a week. TTY users should call 711.
ENVISIONRX OPTIONS RETAIL, MAIL AND SPECIALTY PLAN
The prescription program contains the following parts; in addition, there is important benefit information relating to:
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Brand and Generic drugs, (see chart on page 38)•
Quantity Limits on specified drugs (page 38)•
Over the Counter (OTC) drugs for stomach-related and allergy conditions (pages 41)•
Step Therapy requirements for Sleep Agents, Cholesterol, Antidepressants and Osteoporosis medications (pages 41 to 42)•
Clinical Prior Authorization for specified medications, (page 39)•
Prescription Drug, Adherence Program for Chronic Diseases (page 39)1. Retail Pharmacy Benefit – Choose from thousands of EnvisionRx Options participating pharmacies nationwide.
2. Retail - up to 90 Day Supply for Maintenance and Non-Maintenance Benefit – Choose from EnvisionRx Options retail pharmacies to dispense your maximum 90 day supply.
3. Orchard Mail Order – Up to 180 Days Pharmacy Benefits (an affiliate of EnvisionRx Options) – Order your long-term maintenance medications and have them delivered right to your door. Note: In order to receive more than a 90-day supply (91-180 days) the Plan requires an initial 30-day prescription be filled. Mail Order is an excellent way to receive prescriptions you will be taking for a long time with fewer worries about availability at the local retail pharmacy. Mail order services offer the convenience of home delivery or to another specified address. In order to use this program, please refer to page 40.
4. Specialty Pharmacy Program – EnvisionRx Options retains Costco Specialty Pharmacy Programs in order to provide convenient, dependable access to medications for people living with complex health conditions. The programs and services focus on injectables and medication therapies involving strict compliance requirements, special storage/handling/delivery, complex administration methods, and education/monitoring/ongoing support. Drugs that fall under this program can only be dispensed at a Costco retail pharmacy, some retail pharmacies or via a home delivery method through the mail order program. These drugs are limited to a 30-day supply regardless if dispensed at a retail pharmacy or at a mail service pharmacy. Retail copays will also apply at retail/mail.
Your Cost: Retail, Mail-Order and Specialty Pharmacy
When your covered prescriptions are filled under these pharmacy programs, you will share a portion of the cost; the Plan pays the rest. If the cost of the drug is less than the Copayments, OR if the Copayment plus the difference in cost between the Brand-name and Generic drug is less than the actual cost of the Brand-name drug, you will only be responsible for the actual cost of the drug. Your costs for the prescription program are summarized on the following page.
Exception: Preventive Services coverage for Prescription Drugs noted by an asterisk on Insert III, in the back of this Plan Booklet, are covered at 100% with no Copayment provided a physician writes a prescription, even if they can be bought over the counter. The physician’s prescription and the receipt must be submitted with the Over the Counter (OTC) Preventive Prescription Drug at an EnvisionRx Options pharmacy in order to be covered by the Plan and to receive reimbursement.