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STATE HEALTH BENEFITS PROGRAM and
SCHOOL EMPLOYEES' HEALTH BENEFITS PROGRAM


Optum Rx MEDICARE PRESCRIPTION DRUG PLAN
SHBP/SEHBP RETIREE PRESCRIPTION DRUG COVERAGE

Retirees and/or covered spouses/partners who are eligible for Medicare will be enrolled through Optum Rx in Medicare Part D prescription drug coverage.  Optum Rx is the prescription drug plan administrator for these retirees and coverage in the Optum Rx Medicare Prescription Drug Plan is similar to the Optum Rx plan for non-Medicare eligible members — i.e. members pay the appropriate copayment for either a retail or mail order prescription drug order.

QUESTIONS AND ANSWERS

1. Q. Do I need to do anything to enroll in the Optum Rx Medicare Prescription Drug Plan?

A. No. The SHBP/SEHBP and Optum Rx will automatically enroll eligible retirees into Medicare Part D and the Optum Rx Medicare Prescription Drug Plan. Retirees should not actively enroll separately into Medicare Part D or into a privately offered Medicare Part D plan.

As with all SHBP/SEHBP coverage, retirees who are eligible for Medicare must enroll in and maintain both Medicare Part A (Hospital) and Part B (Medical) coverage.

Note: Retirees should carefully review plan options if comparing Medicare D plans. Retired members, and/or dependents, who enroll in privately offered Medicare Part D plans will lose their SHBP or SEHBP prescription drug coverage. In addition, the SHBP and SEHBP will not cover the costs of any drugs that are not covered by the Medicare Part D plan.

2. Q. Will I have to pay more for my medications because of the Medicare Part D “donut hole”?

A. No. The Optum Rx Medicare Prescription Drug Plan provides “wrap-around” coverage that eliminates the “donut hole” (the “donut hole” is a part of some Medicare Part D plans where members pay the full cost of prescription drug orders). Because of the “wrap-around” coverage, SHBP/SEHBP members only pay the appropriate copayment for prescription drug orders, up to any annual maximum out-of-pocket amounts.

3. Q. Are there any other costs associated with this coverage?

A. Because you are being enrolled into Medicare Part D, some members will have the monthly premium for Part D coverage deducted from their Social Security benefit. Members who earn more than $85,000 per year ($170,000 if married and filing jointly) will have a deduction as follows:

If your filling status and yearly income in 2016 was:  

File individual tax return

File joint tax return

File married &
separate tax return

You pay each month
(in 2018)

$85,000 or less
$170,000 or less
$85,000 or less
your plan premium
above $85,000 up to $107,000
above $170,000 up to $214,000
not applicable
$13.00 + your plan premium
above $107,000 up to $133,500
above $214,000 up to $267,000
not applicable
$33.60 + your plan premium
above $133,500 up to $160,000
above $267,000 up to $320,000
not applicable
$54.20 + your plan premium
above $160,000
above $320,000
above $85,000
$74.80 + your plan premium

 

*If you do not currently pay a premium for your SHBP/SEHBP coverage, you will continue to not pay a premium under this plan.

State or Local Education retirees who qualify for reimbursement of their Medicare Part B premiums will also be eligible for reimbursement by the State for Part D premiums. The Part D reimbursements will be paid in the same manner as the income-related Medicare B premiums: once a year, upon receipt of proof of the premiums paid.

Local Government retirees may qualify for reimbursement of Medicare Part D premiums if the employer participates in the SHBP and provides reimbursement under the provisions of Chapter 88, P.L. 1974 or Chapter 48, P.L. 1999.  Reimbursement of Local Government retirees is coordinated and paid through the former employer.

4. Q. Can I continue to use my current pharmacy?

A. Enrollees have access to over 63,000 network pharmacies nationally, including mail-order services through the optum Rx Pharmacy.  If your pharmacy currently accepts your commercial Optum Rx plan from the SHBP/SEHBP, you will be able to continue using that pharmacy with the Optum Rx Medicare Prescription Drug Plan. However, if your pharmacy is one of the few that do not accept Medicare Part D plans, you will be required to use a participating pharmacy in order to use the SHBP/SEHBP prescription drug benefits through the Optum Rx Medicare Prescription Drug Plan. Veteran Administration pharmacies do not participate in this plan.

5. Q. Where can I get more information?

A. Specific questions can be directed to the Optum Rx Medicare Prescription Plan — 24 hours a day, 7 days a week — at
1-866-544-9703.
  TTY/TDD users can call 1-800-716-3231.

 
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