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Medicare Part D prescription drug plan (PDP)

Effective January 1, 2024, Express Scripts Medicare® provides prescription drug benefits to participants in the MPO of the EMRMP. Your prescription drug benefit is considered a Medicare Part D prescription drug plan (PDP), which complements your medical benefits provided through Aetna Medicare Advantage (Medicare Part C).

The MPO covers outpatient prescription drugs. The MPO's prescription drug benefits offer cost-saving ways to buy outpatient prescription drugs:

  • A network of local participating retail pharmacies for short-term prescriptions.
  • Express Scripts Pharmacy, the home delivery pharmacy, and participating pharmacies for long-term or maintenance prescriptions.
  • Express Scripts Specialty Pharmacy, Accredo, for prescriptions requiring special handling.

A vaccine program is available at participating network pharmacies through Express Scripts (www.expressscripts.com), in addition to current coverage available through physician/medical facilities:

  • Members may conveniently receive common vaccinations at their retail pharmacy at no cost. Coverage includes vaccines such as Flu, Hepatitis A, B and A&B, Pneumonia, Shingles/Zoster, Meningitis, Tetanus/Diptheria/Pertussis, Human papillomavirus (HPV), etc. COVID-19 vaccine is covered through your Aetna MA plan of the MPO.
  • Shingles Vaccine: Zostavax and Shingrix are both covered under your prescription drug plan. For more information contact Express Scripts 1-866-557-8211. You can also visit www.express-scripts.com. For vaccines where there is a member cost share, the copay structure is the same as it is for other branded medications: Retail Brand 30% max $125.
  • Members are not required to provide a prescription to receive vaccines.
  • Members will need to present their prescription ID card to ensure that the vaccine is processed under the pharmacy benefit.

Note: Prescription medications, including injections, billed by and provided in a hospital or a doctor's office are typically not covered under the prescription drug program but may be covered medical expenses under the medical benefit of the MPO. For more information please refer to the Schedule of Cost Sharing (SOC) in the ExxonMobil Aetna Medicare website. Medications billed to you by Express Scripts are not covered under the medical portion of the MPO.

For certain prescription drugs:

You must call Express Scripts for prior authorization of certain prescription drugs

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another drug.

Additionally, as part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-authorized by Express Scripts, based on medical evidence submitted by your physician.

Non-targeted drugs are covered without prior authorization. Refer to the Prescription drug program section for more details.

You must identify yourself as a member of Express Scripts Medicare to receive the benefit.

Call Express Scripts at 866-557-8211 or check the Express Scripts web site at www.express-scripts.com to locate a participating retail pharmacy near you.  

Short-term prescriptions

A short-term prescription is written for a drug taken for a limited period of time, such as an antibiotic for a specific illness or if your doctor wants you to try the prescription before having a long-term prescription filled. Short-term prescriptions are provided for up to a 34-day supply. See Covered prescriptions for limitations.

You have the choice of filling your prescriptions at:

  • A local participating retail pharmacy (part of Express Script's extensive network of retail pharmacies), where you will pay your share — copayment — of the discounted cost, after the prescription drug deductible has been satisfied. There are no claims to file.
  • In emergency circumstances, a non-participating pharmacy may be used, where you will pay the full retail price and file a claim for possible partial reimbursement of the cost, after the prescription drug deductible has been satisfied.

To receive the discounted price:

  • Present your prescription and your prescription drug identification card at a participating network pharmacy.
  • The pharmacist enters the prescription and your identification number into the pharmacy's computer system to confirm:
    • That you are a participant.
    • That it is a covered prescription.
    • Your share of the prescription's cost.

Refills

You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts’ website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.

Copayments

Initial Coverage Stage: After you pay your annual prescription drug deductible of $300, you will pay the following until you reach the prescription drug out-of-pocket maximum of $2,000, or your total annual drug costs (what you and the plan pay) reach $5,030:

Initial Coverage Stage

Retail Pharmacy

Co-Pay* **

Express Scripts Pharmacy Home Delivery, or Participating Retail Pharmacies

Tier

One-month (up to 34-day) Supply

Maximum Per Prescription

Three-Month (up to 90-day) Supply

Maximum Per Prescription

Tier 1: Generic Drugs

30%

$50

25%

$100

Tier 2: Preferred (Formulary) Brand Drugs

30%

$125

25%

$250

Tier 3: Non-Preferred (Non-Formulary) Drugs

50%

$200

45%

$400

* For emergency circumstances only and if using a non-participating pharmacy, you pay 100% of the retail price and submit claim form for possible partial reimbursement of costs.

** You must present your Express Scripts Prescription Card or benefits will be paid at the non-network level.

Coverage Gap Stage: If you have not met the prescription drug out-of-pocket maximum of $2,000, but your total annual drug costs reach $5,030, you will generally pay the same cost-sharing amount as in the Initial Coverage stage until your annual out-of-pocket drug costs reach $8,000.

Catastrophic Coverage Stage: If you reach the Catastrophic Coverage stage, you pay nothing for covered Part D drugs for the remainder of the plan year. You may have cost sharing for excluded drugs that may be covered under our enhanced benefit, if the plan covers additional drugs not normally covered by Medicare Part D.

Prescription drugs — Annual out-of-pocket (OOP) maximums for prescription drugs--$2,000/individual (out-of-network prescription claims filled on an emergency basis only may not go towards your OOP maximum).

For short-term prescription drugs purchased at a participating retail pharmacy, you pay a percentage of the discounted cost of the drugs.

Examples (assuming you have already met the annual prescription drug deductible):

Generic short-term drug purchased at a retail network pharmacy — discounted cost of medication is $24.

You pay 30% copayment ($24 x 0.30) = $7.20

Preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $42.

You pay 30% copayment ($42 x 0.30) = $12.60

Non-preferred brand name short-term drug purchased at a retail network pharmacy (if no generic is available) — cost of medication is $64.

You pay 50% copayment ($64 x 0.50) = $32

Using a non-participating pharmacy or not identifying yourself as an Express Scripts participant

You are not eligible for a discounted price if you:

  • Have your prescription filled at a non-participating pharmacy, or
  • Do not identify yourself as an Express Scripts participant at a network pharmacy.

In either case:

  • You pay the full non-discounted price of the prescription at the time of purchase.
  • You must submit a completed Direct Reimbursement Claim Form to Express Scripts. You may obtain a claim form by calling Express Scripts at the number shown in the front of this SPD.

This example shows how you would save money when you use a network pharmacy and show your prescription ID card. In this case, you would save $10.

 

Without Express Scripts Discount*

With Express Script Discount

Full retail cost of preferred brand name prescription (non-discounted)
Discounted cost
Ineligible cost

$ 50.00

- $ 40.00
$ 10.00

N/A

$ 40.00
0.00

Ineligible cost
30% copayment ($40 x .30)

$ 10.00
$ 12.00

$ 0.00
$ 12.00

Your cost

$ 22.00

$ 12.00

*Non-Participating pharmacies are only covered in emergency circumstances

Long-term prescriptions

A long-term or maintenance drug is one you take for an extended period of time, such as for ongoing treatment of diabetes, arthritis, heart condition, or high blood pressure. The MPO generally provides benefits for up to a 90-day supply through a participating retail pharmacy or Express Scripts home delivery pharmacy. See Covered prescriptions for limitations.

If you need maintenance medication immediately, ask your doctor for two prescriptions — one for an immediate supply to be filled at a local pharmacy and a second for an extended supply to be ordered by mail or at a retail pharmacy. 

Express scripts pharmacy — home delivery pharmacy

With Express Scripts Pharmacy, the home delivery pharmacy, you save money and have the convenience of home delivery. Ask the doctor to write a prescription for up to a 90-day supply with appropriate refills. Enclose your original prescription(s) and payment of your percentage copayment in an envelope, or your doctor may send the prescription electronically directly to Express Scripts. If you are paying via check or money order, you may obtain a calculation of your percentage copayment from the Express Scripts web site or by calling Express Scripts directly. If you are paying via credit card, Express Scripts will deduct the appropriate percentage copayment, and you will receive notification of the deduction with your medication.

For each prescription filled, you pay:

Type of Drug

Express Scripts Pharmacy Percentage Copayment

Generic drugs

25%, maximum $100

Preferred brand name drugs

25%, maximum $250

Non-preferred brand name drugs

45%, maximum $400

Your prescription will be delivered to the address on your order form within 14 working days. By law, prescriptions may not be sent outside the U.S.

Refills

You may order refills by calling Express Scripts or sending in the refill label provided with your previous order. You may also order refills through Express Scripts website. You should order a refill about three weeks before your current supply will be exhausted, but remember that you must have used about three quarters of the previous prescription based on the prescribed dosage.

You can also fill or refill a long-term prescription at participating retail pharmacies.

Comparing retail pharmacy with Express Scripts Pharmacy

This example shows how you can save money by purchasing long-term medications through either the Express Scripts home delivery or a participating retail pharmacy.

Assume you purchase a 90-day supply of a preferred brand name drug AND you have already met your annual prescription drug deductible:

At a Participating Network Retail Pharmacy:

Through a home delivery through the Express Scripts® Pharmacy, Or a participating Network Retail Pharmacy that offers up to a 90-day’s supply:

$ 108

Cost of preferred brand name drug (up to 34-day supply)

$ 324

Cost of preferred brand name drug
(up to a 90-day supply)

x 30%

($125 max)

30% coinsurance and maximum $125 out of pocket

X 25%

($250 max)

25% coinsurance and maximum $250 out of pocket

$32.40

Your coinsurance for a 34-day supply or $97.20 for three fills (90-day)

$ 81

Your coinsurance for a 90-day supply

After your $300 prescription drug deductible is met, you pay$97.20 for a 90-day supply

After your $300 prescription drug deductible is met, you pay$81.00 for a 90-day supply

Note: This only applies until you reach the $2,000 maximum out of pocket (MOOP) at which point you would pay $0.

Except for emergency circumstances, no coverage is provided for any prescription drug filled at a non-participating network pharmacy.


By purchasing a 90-day supply of this prescription through Express Scripts home delivery or at a participating retail pharmacy, you would save $16.20. That is $64.80 a year for one prescription.

Assume you purchase a 90-day supply of a preferred brand name drug AND you have not met your annual prescription drug deductible:

At a Participating Network Retail Pharmacy:

Through a home delivery through the Express Scripts® Pharmacy, Or a participating Network Retail Pharmacy that offers up to a 90-day’s supply:

$ 108

Cost of preferred brand name drug (up to 34-day supply)

$ 324

Cost of preferred brand name drug
(up to a 90-day supply)

$300

 

 

x 30%

($125 max)

$300 prescription drug deductible

 

30% coinsurance and maximum $125 out of pocket (once deductible is met)

$300

 

 

X 25%

($250 max)

$300 prescription drug deductible

 

 

25% coinsurance and maximum $250 out of pocket (once deductible is met)

$108

Your coinsurance for a 34-day supply or $307.20 for three fills (90-day) ($108 x 3 = $324, where deductible is $300 plus 30% coinsurance on $24)

Important: after you meet your $300 deductible, on subsequent pharmacy expenses, the most you will pay is 30% coinsurance with a max $125 out of pocket.

$ 306

You pay $306 for a 90-day supply (where deductible is $300 plus 25% coinsurance on $24=$6)

Important: after you meet your $300 deductible, on subsequent pharmacy expenses, the most you will pay is 25% coinsurance with a max $250 out of pocket

Note: You must meet all your deductible and then applicable coinsurance applies on remaining amount with max out of pocket.

Except for emergency circumstances, no coverage is provided for any prescription drug filled at a non-participating network pharmacy.


Whether you fill prescriptions through Express Scripts Pharmacy, at a local pharmacy or through Express Scripts Specialty Pharmacy:

  • Your payments and copayments under the outpatient prescription drug benefits do not apply toward your deductible for other benefits under the MPO.
  • Your prescription drug payments and copayments do not apply toward your annual medical out-of-pocket limit.
  • Your prescription drug annual out-of-pocket maximum is $2,000 for each individualr.

 

Short-Term Per Prescription Out-of-Pocket Maximum (34-day or less supply)

Long-Term Per Prescription Out-of-Pocket Maximum (Generally 90-day or less supply)

Generic

30% with a $50.00 max

25% with a $100.00 max

Preferred brand name drugs

30% with a $125.00 max

25% with a $250.00 max

Non-preferred brand name drugs

50% with a $200.00 max

45% with a $400.00 max

Covered prescriptions

The MPO covers drugs, medicines and supplies that are:

Generic drugs

The program encourages consideration of generic alternatives, which are less expensive to you and the MPO. The majority of brand name medications have a generic equivalent available. By law, the brand name and generic medications must meet the same standards for safety, purity, strength, and effectiveness. The pharmacist will only dispense generics which receive FDA approval and only if authorized by your doctor.

Available alternatives

Sometimes, a generic drug or a less expensive brand name drug which provides the same therapeutic effect, but at a lower cost to you, may be available. If so, the network system will inform the pharmacist that a less expensive alternative medication is available to fill your prescription. A pharmacist from the network or Express Scripts Pharmacy may contact your doctor to discuss the generic or less expensive brand name alternative. If the doctor authorizes a substitution, the pharmacist will dispense it based solely on your doctor's agreement. If Express Scripts Pharmacy fills a prescription with a generic or an alternative brand name drug, your order will include an explanation of the doctor's change.  

The formulary program

A formulary is a list of commonly prescribed medications within particular therapeutic categories. The drugs on the list have been selected based on their effectiveness and cost. To be included in the formulary list, a drug must meet rigorous standards of approval by the Express Scripts Pharmacy and Therapeutic Committee - a group of nationally recognized medical professionals.

It is always up to your doctor to decide which medications to prescribe. If you have questions about the Express Scripts formulary, you should contact Express Scripts directly.

Drug monitoring service

All prescriptions, both home delivery and retail, are screened by the network's computerized drug monitoring service.

This service analyzes all of your prescriptions in the system for potential problems such as adverse drug interactions, drug duplications, and unusually high or low dosages. This service will also detect if a refill is requested too soon. If a potential problem is detected, the drug monitoring service transmits a message to the pharmacist. The pharmacist will contact your doctor about the potential problem or otherwise resolve the issue before dispensing the prescription. Of course, your doctor makes the final decision about any change in your prescription or course of treatment.

Limitations

In most cases, the pharmacist will fill the prescription according to the doctor's written orders. However, there are some limitations:

  • If the prescription is written for an amount that is greater than the MPO covers, the pharmacist will fill the prescription up to the MPO limit. You have the option to buy the additional amount at that time if purchasing at a retail pharmacy, but there is no MPO benefit.
  • If the medicine is a controlled substance or if there is a manufacturer's or prescription benefit manager's directive, a smaller amount may be provided.
  • For most prescriptions, you must use about three quarters of the previous prescription, based on the dosage prescribed, before you can obtain a refill and receive MPO benefits.
  • During natural disasters, you may be able to replace lost or damaged medications without having used 75% of the previous prescription.

The following items are not covered under the Medicare Part D prescription drug plan (PDP):

  • Over-the-counter (OTC) drugs, with the exception of preventive care OTC drugs, which will continue to be covered in accordance with the Affordable Care Act (ACA) provisions (note that you may have the option to obtain certain supplies under the Aetna Medicare Advantage medical benefits)
  • Medications for the management of cough/cold symptoms
  • Vitamin and mineral products, including vitamin D3 and folic acid
  • Sexual dysfunction medications
  • Part B supplies, such as diabetic test strips and lancets, which will now be covered under the medical benefit provided through Aetna Medicare Advantage (Aetna MA)
  • Part B usage of medications with both Part B and Part D designations (Part B usage will be covered under the medical benefit provided through Aetna Medicare Advantage; non-Part D usage will not be permitted)
  • Part B vaccinations such as flu, pneumonia, and COVID-19, which will be covered under the medical benefit provided through Aetna MA. ACA preventive care vaccinations will continue to be covered at $0 copay.
  • Repackaged drugs (drugs which are removed from the original manufacturer’s container and placed in a repackaged container and are sold at a higher retail cost)
  • Unit-dose packaged medications (except at long-term care facilities)

 

Special rules for coordinating benefits for prescriptions

If you or your family members are covered under any other prescription drug plan, the MPO coordinates benefits with that plan, as described in the Coordination of benefits section of this SPD. In addition, information about the other coverage is provided to the outpatient prescription drug network.

When there is other prescription drug coverage that is primary to your Medicare Part D coverage, a code will indicate  that you have other coverage that should pay benefits first for your prescription drug costs. In these cases, your prescription must first be adjudicated  according to your primary plan provisions and then any remaining amount will be sent to Medicare. In order to use Express Scripts Home Delivery prescription service, your primary coverage must also use Express Scripts. In other cases, after the primary plan has paid, you may file a claim with the MPO for reimbursement of any remaining amount; the procedure is the same as when a non-participating pharmacy is used. The MPO will pay the lesser of what would have been paid if the claim was not filed with the primary plan or the amount not paid by the primary plan. Depending on the scenario, Medicare Part D coverage may be primary (it pays your health care provider first) and your other health coverage may be secondary (paying after primary payer pays), or viceversa. To understand more, please review this document.

Medicare Part D and the Prescription Drug Plan

Participants who choose to enroll in another Medicare Part D prescription drug plan will no longer be eligible for coverage under the MPO and they will be automatically dropped. . 

Specialty medications

Specialty medications, including injectable and infusions for rheumatoid arthritis and other inflammatory conditions, require special handling and may be administered in a hospital, clinic, doctor’s office, or in your home. Some specialty medications, like most oncology drugs administered in a hospital setting, are covered under the medical benefit administered by Aetna. Other specialty medications are covered under the prescription drug program administered by Express Scripts. If you have questions about starting a specialty medication, call Aetna member services and ask to speak to a Health Advocate nurse.

Specialty medications administered by Express Scripts are filled through their specialty pharmacy Accredo and can be delivered to hospitals, clinics, doctor’s offices, or to a home health care provider.

Advanced utilization management program

In some cases, you may be required to try one or more specified drugs to treat a particular medical condition before the MPO will cover another drug. Prior authorization and preferred drug step therapy rules are designed to encourage the use of effective, lower-cost drugs.

As part of Express Scripts’ Advanced Utilization Management (AUM) program, certain targeted drugs will not be covered unless pre-authorized by Express Scripts, based on medical evidence submitted by your physician. In addition, some therapies will be monitored for appropriate pharmacogenomics parameters, and oral oncology medications will be limited to ensure appropriate use. Please visit www.express-scripts.com for more information about your medications and if they require a coverage review.  If you have a question regarding a drug on the AUM program list, contact Express Scripts at the number listed in the Information Sources section of this SPD.

Prior authorization: preferred drug step therapy rules

You must call Express Scripts for prior authorization of certain prescription drugs described below:

Preferred drug step therapy rules are used for certain therapeutic chapters of drugs, to encourage the use of effective, lower-cost drugs by excluding some targeted medications from coverage. In the therapeutic chapters including: proton pump inhibitors, sleep agents, depression, osteoporosis, respiratory, cardiovascular, migraine growth hormone, stimulants for Attention Deficit Hyperactivity Disorder, prostate therapy drugs, topical steroids, and stroke prevention, there will be targeted drugs determined by Express Scripts which will not be covered unless pre-certified by Express Scripts. Non-targeted drugs will be covered without such authorization and will continue to be dispensed with no further action by either you or the prescribing physician. If you have a question regarding a drug in any of these therapeutic chapters, contact Express Scripts to determine whether your drug is covered. You will be notified directly by Express Scripts if you are affected by these rules.

Prior authorization rules 

New prior authorization rules apply to certain therapeutic classes of drugs; some therapies in this section will be monitored for appropriate pharmacogenomics parameters. These classes include miscellaneous immunological agents, central nervous system/miscellaneous neurological therapy, biotechnology/adjunctive cancer therapy, central nervous system/headache therapy, central nervous system/analgesics, neurology/miscellaneous psychotherapeutic agents, and miscellaneous pulmonary agents. In addition, anabolic steroids, high cost antibiotics, anti-emetics, antivirals, narcotics, acne dermatological and topical pain medications may trigger a prior authorization. Oral oncology medications will also be limited to ensure appropriate use. Certain drugs within each chapter as determined by Express Scripts will only be covered to the extent they are authorized by Express Scripts. If you have a question regarding coverage for a drug in any of these therapeutic classes, contact Express Scripts. You will be notified directly by Express Scripts if you are affected by these rules.

Therapeutic Resource Centers

MPO participants and their physicians may receive outreach calls from Express Scripts Therapeutic Resource Center (TRC) pharmacists or healthcare specialists to offer personal over-the-phone guidance as well as other health management tools. You can also ask to speak to a TRC pharmacy specialist when you call Express Scripts.

If you are eligible for Medicare, you are eligible to enroll in a Medicare Part D plan that offers prescription drug coverage. There is a late enrollment penalty if you do not enroll in Medicare Part D coverage when you are first eligible unless you have “creditable coverage” under an employer group health plan. (You must enroll in a Medicare Part D plan within 63 days of losing creditable coverage to avoid the late enrollment penalty.) The prescription drug coverage offered under the HealthPlus and Standard options is considered to be “creditable coverage” for purposes of Medicare Part D. Therefore, you do not need to enroll in a Medicare Part D plan while you are covered under one of these options. However, the prescription drug coverage offered under the Health+Savings option is not considered to be “creditable coverage” for purposes of Medicare Part D. Each year, you will be sent a notice notifying you whether the plan’s prescription drug coverage remains “creditable” for purposes of Medicare Part D.

Creditable Coverage and Late Enrollment Penalties

If you are eligible for Medicare, you are eligible to enroll in a Medicare Part D plan that offers prescription drug coverage. There is a late enrollment penalty if you do not enroll in Medicare Part D coverage when you are first eligible unless you have “creditable coverage” under an employer group health plan. You must enroll in a Medicare Part D plan within 63 days of losing creditable coverage to avoid the late enrollment penalty. The prescription drug coverage offered under the EMMP and pre-65 options of the EMRMP are considered to be “creditable coverage” for purposes of Medicare Part D. Therefore, you do not need to enroll in a Medicare Part D plan while you are covered under one of these options. Each year, you will be sent a notice notifying you whether the plan’s prescription drug coverage remains “creditable” for purposes of Medicare Part D. The late enrollment penalty is an amount you may be charged for as long as you have Medicare prescription drug coverage if you were enrolled in other coverage after you become Medicare eligible that did not meet the creditable coverage requirements. This penalty is required by law and is designed to encourage people to enroll in a Medicare prescription drug plan when they are first eligible or to keep other prescription drug coverage that meets Medicare’s minimum standards. If we determine that you owe a late enrollment penalty or have an existing penalty that needs to be adjusted, we will notify you of the change.

Part D Income-Related Monthly Adjustment Amount (Part D-IRMAA)

Some participants of the MPO may be required to pay an extra amount for their Medicare Part D premium because of their yearly income. If you are required by law to pay an extra amount, Social Security will send a letter telling you what the extra amount will be and how to pay it. This extra amount will not be payable to MPO or Express Scripts Medicare directly, however if you fail to pay this amount to Social Security, it will result in loss of coverage.

This extra amount is called the Part D Income-Related Monthly Adjustment Amount or Part D-IRMAA. No matter how your plan premium is paid, the extra amount will be withheld from your Social Security or Office of Personnel Management benefit check. If your benefit check isn’t enough to cover the extra amount, you will get a bill from Medicare. For more information about the extra amount you may have to pay based on your income, go to
https://www.medicare.gov/part-d/costs/premiums/drug-plan-premiums.html. The extra amount must be paid separately and cannot be paid with your monthly premium.

If you have any questions about this extra amount, contact Social Security at 1.800.772.1213 between 8 a.m. and 7 p.m. local time, Monday through Friday to speak with a representative. Automated messages are available 24 hours a day. TTY users should call 1.800.325.0778.

You can search this SPD section by section or click here to create a single searchable document.