Annual Medicare D Creditable Coverage Notice

Important NoticefromJefferson Science Associates About

YourPrescriptionDrug CoverageandMedicare

Pleaseread thisnoticecarefullyand keep itwhereyou can find it. Thisnoticehas information aboutyour currentprescription drug coveragewith Jefferson Science Associates andaboutyour optionsunderMedicare’sprescription drug coverage. This information canhelpyou decidewhether or notyouwanttojoin aMedicaredrug plan. If you are considering joining,you should compareyourcurrentcoverage, includingwhich drugs arecovered atwhatcost,with thecoverage and costs of the plansoffering Medicareprescription drugcoverageinyour area. Informationabout whereyou can get help to makedecisionsaboutyour prescription drug coverageis at the end ofthisnotice.

There aretwo importantthingsyou need to knowaboutyourcurrent coverage andMedicare’sprescription drug coverage:

1. Medicareprescription drug coveragebecameavailablein 2006to everyone with Medicare.You can get this coverageifyoujoin aMedicarePrescriptionDrug Plan or join aMedicareAdvantage Plan(likeanHMOor PPO)that offersprescription drug coverage.AllMedicaredrug plansprovide at least astandard levelof coverage set byMedicare.Someplansmayalso offer more coverageforahigher monthlypremium.

2. Jefferson Science Associateshasdetermined that theprescription drugcoverageoffered by Anthem or Optima is, on averagefor allplan participants,expected topay outasmuchas standardMedicareprescription drug coveragepaysand is, thereforeconsideredCreditableCoverage.Becauseyour existing coverageis CreditableCoverage,you can keep thiscoverage and notpayahigher premium (a penalty) ifyou laterdecideto join aMedicaredrug plan.

When Can You JoinAMedicare Drug Plan?

YoucanjoinaMedicare drugplanwhenyoufirst becomeeligible for Medicare andeach year fromOctober15thtoDecember 7th.

However, ifyouloseyour current creditableprescriptiondrugcoverage,through nofault of your own,youwill alsobeeligible for atwo(2) monthSpecialEnrollmentPeriod(SEP)tojoin aMedicaredrug plan.

WhatHappensTo YourCurrentCoverageIfYou Decideto JoinA Medicare Drug Plan?

Ifyou decidetojoina Medicare drugplan,your currentJefferson Sciencecoveragewill be affected. Individuals whoelectPart D coverage under Jefferson Science Associates plan. Coveragewill endfor theindividual andallcovered dependent.

Anthem plan

Effective April 1, 2017

Tier 1

Copay

/

Tier 2

Copay

/

Tier 3

Copay

/

Tier 4

Co-Pay*

Up to a 30-day medication supply at participating retail pharmacies / $10 / $20 / $35 / 20% up to $200
Up to a 90-day medication supply delivered to your home / $25 / $50 / $88 / Not Available
Only available through specialty mail order pharmacy

*A Tier 4 prescription category has been added to the prescription co-pay structure. All Tier 4 medications will be subject to a 20% coinsurance payment up to $200 per prescription (or $400 for mail order).

There will be a $2,500 per member and $5,000 per family per benefit year out-of-pocket maximum included with this benefit ( Includes Medical and Pharmacy Benefits)

Optima Plan

Effective April 1, 2017

Tier 1

Copay

/

Tier 2

Copay

/

Tier 3

Copay

/

Tier 4

Co-Pay*

Up to a 30-day medication supply at participating retail pharmacies / $10 / $30 / $50 / 20% up to $250
Up to a 90-day medication supply delivered to your home / $25 / $75 / $150 / Not Available
Only available through specialty mail order pharmacy

*A Tier 4 prescription category has been added to the prescription co-pay structure. All Tier 4 medications will be subject to a 20% coinsurance payment up to $250 per prescription (or $250 for mail order).

The following information will be provided to you by the search feature:

  • Alternatives
  • If there are any special requirements (pre-authorization, step-edit)
  • Genericavailability

*Note:Ifthereisagenericavailableforyourcovereddrug,thenthe genericiscoveredundertheplan.Therewillbeabrandbuy-upcharge ifyouchoosebrandwhengenericisavailable.

Ifyou dodecidetojoinaMedicaredrugplananddropyourcurrentJefferson Science Associates coverage, be aware thatyouandyour dependents may not be able to get this coverage back without a qualifying life event.

What are some medications that may be under the Tier 4 category?

Medications classified as Specialty Drugs under the co-pay plans for Anthem and Optima Health will be covered at the Tier 4 level beginning April 1, 2017. Specialty Drugs have unique uses and are generally prescribed for people with complex, ongoing medical conditions. These drugs typically require special dosing, administration, and additional education and support from a health care professional. Specialty Drugs include the following:

  • Medications that treat certain patient populations including those with rare diseases;
  • Medications that require close medical and pharmacy management and monitoring;
  • Medications that require special handling and/or storage;
  • Medications derived from biotechnology and/or blood derived drugs or small molecules; and
  • Medications that can be delivered via injection, infusion, inhalation, or oral administration.

Specialty Drugs are only available through the Specialty Pharmacies that serve Anthem’s and Optima’s members. Tier 4 Specialty Drug medications are NOT available at the local pharmacies (CVS, Target, Walgreen’s, etc).Accredo is the Express Scripts Specialty Pharmacy that will be used by Anthem members taking Tier 4 medications. Optima’s specialty pharmacy for Tier 4 medications is BriovaRx. More information about Specialty Pharmacies and coverage for Specialty Drugs can be found by contacting Member Services at the below numbers:

  • Anthem KeyCare members: 1-800-451-1527
  • Optima HMO Vantage Members: 1-800-741-9910

When WillYouPayAHigherPremium(Penalty)To JoinAMedicareDrug Plan?

Youshould alsoknowthatifyou dropor loseyourcurrentcoveragewith Jefferson Science Associates anddon’tjoina Medicare drug planwithin63continuousdaysafter your current coverage ends,you maypaya higher premium(apenalty)tojoinaMedicare drugplanlater.

Ifyougo63continuous days or longerwithoutcreditable prescription drugcoverage,your monthlypremium maygo upbyatleast1%oftheMedicare basebeneficiarypremiumper monthfor everymonththat youdidnothavethatcoverage.For example,ifyougo nineteen months without creditablecoverage,your premiummayconsistentlybeatleast19% higher than theMedicarebase beneficiarypremium.Youmayhave topaythis higher premium(a penalty) as longas you haveMedicareprescription drugcoverage.In addition, youmayhave towait untilthefollowing Octobertojoin.

For MoreInformationaboutthisnoticeor your currentPrescription Drug Coverage:

Contact thepersonlistedbelowforfurther informationAnthem or Optima Health Insurance at 1-800-451-1527 (Anthem); 1-800-741-9910 (Optima). NOTE:You’ll getthis noticeeachyear.Youwillalsogetitbeforethe nextperiodyoucanjoinaMedicare drug plan, andifthis coveragethroughJefferson Science Associates changes.You alsomayrequestacopyofthis noticeatanytime.

MoreInformationaboutyouroptions underMedicare Prescription Drug Coverage

More detailedinformationaboutMedicare plans thatoffer prescription drugcoverageis inthe “MedicareYou” handbook.You’ll getacopyofthehandbook inthemail every year from Medicare. Youmayalso becontacted directlyby Medicare drugplans.

For moreinformationaboutMedicareprescription drugcoverage, visit:

Call your StateHealthInsurance AssistanceProgram(seetheinside backcover of your copyofthe “Medicare &You”handbookfor their telephonenumber)for personalized help, call:

1-800-MEDICARE(1-800-633-4227).TTYusers shouldcall1-877-486-2048.

Ifyou havelimitedincomeandresources, extra help payingfor Medicare prescription drug coverageis available.For information aboutthis extra help, visitSocial Security ontheweb at or call them at1-800-772-1213(TTY1-800-325-0778).

Remember:

KeepthisCreditableCoveragenotice.Ifyoudecidetojoin oneoftheMedicaredrugplans,youmaybe required to provideacopyof thisnoticewhen you join toshowwhetheror notyouhavemaintained creditablecoverageand,therefore,whetherornotyouarerequiredtopay ahigher premium(apenalty).

Date:10/2017

Name of Entity/Sender:SURA/Jefferson Science Associates

Contact--Position/Office:Treva Ferguson, Douglas Roeder

Address:628 Hofstadter Road, Suite 2, Newport News, VA 23606

Phone Number:757-269-7291, 757-269-7576

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