The webinar is now online. The following materials are available to - - PowerPoint PPT Presentation

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The webinar is now online.

The following materials are available to reference during the presentation, please print them if desired. The presentation will begin at 4:00 pm EST

• 1. Handout version of this presentation – for taking notes

and jotting down questions as we proceed To download: www.adventistretirement.org, Retiree, Retiree Webinars, SHARP 2014 Changes & Rx Option Webinar

SHARP Changes for 2014

Lisa Turpen RN Assistant Administrator/SHARP Manager 2

IRS status of the SHARP plan

• In 2013 the IRS made changes relating to group health plans

and the SHARP plan is no longer considered a retirement only plan.

• The impact of this change is found in two areas for SHARP

The ACA (Affordable Care Act) HIPAA (Health Insurance Portability and Accountability) The non-Medicare eligible dependents are the group impacted by these Acts.

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Changes for the Medicare eligible retiree

The ACA (Affordable Card Act – 2010) has added some benefits for the Medicare eligible retiree.

• Medicare eligible retirees enrolled in the SHARP Base or MCx

Options are impacted in the following way.

• Preventive Care Services list: Medicare and SHARP payment

equals 100% for these covered services

• Physical Exam every year
• Blood Cholesterol test every year
• Complete Blood Count every year
• Fecal Occult Blood test every year
• Flexible Sigmoidoscopy every 3 years
• Prostate Specific Antigen (PSA) every year
• Routine Colonoscopy every 10 years
• Thyroid Function test every year

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Preventive Care (continued)

• Urinalysis every year
• Fasting Blood Glucose Test every 3 years
• Abdominal Aortic Aneurysm screening 1 between 65 and 75 years of

age

• Routine GYN Exam , Pap Smear
• Mammogram
• Bone Density testing every 2 years beginning at age 65
• The complete list will be noted in the 2014 SHARP document.
• You may also review the preventive care list for Medicare at

www.medicare.gov

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HIPAA Portability Rules

The HIPAA (Health Insurance Portability And Accountability- 1996) group health plan portability rules have now brought a few changes to the SHARP benefits.

• No lifetime limit on essential health benefits
• SHARP removed lifetime limits to benefits in 2011
• No pre-existing clause (Pre-Medicare/Non-Medicare)if member has

not had lapse in healthcare coverage of more than 63 days.

• Medicare eligible retiree/spouse have not had the pre-existing clause

ever applied

• No limit on medical necessary genetic testing (as defined by the

ACA)

• SHARP has included this in the plan since 2013
• Mental Health Parity
• Coverage of services that are part of a clinical trial
• External Appeal Process
• Healthcare claim processing now includes a third party appeal

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Dependent Eligibility change -2014

SHARP must comply with a portion of the Affordable Care Act(ACA) effective January 1, 2014.

• The dependent child age 19-26 may enroll in SHARP.
• The SHARP committee has a vote on the 2014 costs Nov. 21,

2013.

• No lifetime limits on essential medical benefits.

SHARP must also comply with ACA rules for the spouse of a retiree.

• The Non-Joint & Survivor spouse (married after retirement)

may enroll in SHARP benefits.

• Spouse employer benefits are required to be primary
• The Earned Credit Does Not apply to the Non-Joint & Survivor

spouse enrollment.

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SHARP Rx Option - 2014

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SHARP Drug Spend 2012

• In 2012 the SHARP Rx Option had a drug spend of $17,611,529
• SHARP accessed additional federal retiree drug subsidies of

$3.6 million to help offset the total drug spend.

• Total drug spend of a little over $13 million
• 93% of enrollees utilize the Rx benefit
• There was a 3.4% increase in the Specialty Drug classification

in 2012.

• Drugs for high cost disease processes

In 2012 for the SHARP Rx Option the generic fill rate was 78.9%. The home delivery utilization was 82.2%. The formulary compliance rate was 96.5%

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Plan change for 2014

• The Adventist Retirement Board has approved a change

in the SHARP Rx Option for the Medicare eligible retiree and/or spouse.

• The SHARP Rx Option enrolled retiree/spouse will be

moved to a new prescription drug program effective 1-1- 2014.

• This is not an open enrollment to join the SHARP Rx Option.

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Plan Change for 2014

• Effective 1-1-2014 the SHARP Rx Option will

become a two part benefit.

• 1. Express Scripts Medicare (PDP): all age 65 members
• Required enrollment in Medicare Part A and Part B
• 2. Express Scripts: Pre-Medicare/Non-Medicare

member and age 65 new retiree/spouse while awaiting approval for enrollment in Express Scripts Medicare (PDP).

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Express Scripts Medicare (PDP) + Wrap- a Medicare D plan

• All age 65 retirees/spouses will be required to have Medicare

Part A and Medicare Part B to participate in the SHARP Rx Option.

• The retiree/spouse currently enrolled in the SHARP Rx Option

does not need to complete a new enrollment form for 2014.

• SHARP will automatically move you to the new plan.
• The retiree will not enroll in Medicare D on their own.
• The retiree will not pay a base Medicare D premium to Social

Security.

• SHARP pays the base Medicare D premium for the approved member
• The retiree will pay CMS (Centers for Medicare and Medicaid Services)

any High Income penalty

• Tax return of single $85,000/year or family $170,000/year

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New Retiree Enrollment

At retirement the retiree/spouse will decide whether or not to enroll in the SHARP Rx Option.

• The retiree/spouse must be enrolled in Medicare Part A and

Medicare Part B.

• Retiree/spouse Do Not enroll in Medicare Part D
• If the retiree opts to enroll in SHARP Rx he/she will be

automatically enrolled in the Express Scripts Medicare D program by completing the SHARP enrollment form.

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What is Medicare D with a Wrap?

• The core of the new program is the CMS (Centers for Medicare

and Medicaid Services) approved Medicare D drugs.

• In addition SHARP has provided a Wrap formulary.
• The wrap consists of drugs which are found on the national

formulary that SHARP currently uses but which are not on the Medicare D formulary.

• The wrap drugs do not apply to the Medicare D coverage stages
• There will be three levels of benefit:
• Generic drugs
• Brand drugs
• Non-preferred/non-formulary drugs
• As with all prescription drug formularies there may be some

drugs which are not covered. FDA rules do apply.

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Express Scripts Medicare (PDP) How does it works?

Catastrophic Coverage Stage: After the $4550 limit is reached for Medicare D drugs you will pay the greater of 5% coinsurance or:

A $2.55 copayment for covered generic drugs A $6.35 copayment for all other drugs

Coverage Gap Stage: You will continue to pay the copayment until your yearly out-of-pocket Medicare D drug costs (what you and the 50% manufacturer payment) reach $4550. Initial Coverage Stage: You will pay the copayment until your total yearly Medicare D drug costs (what you and the plan pay) reach $2850.

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What is the Coverage Gap Yearly Out-of- Pocket limit?

Brand drugs in the Coverage Gap of a Medicare D program include a manufacturer discount of 50%.

• The amount the retiree/spouse pays in copayment and the

amount discounted by the manufacturer count toward your true

• ut-of-pocket costs in the Coverage Gap. ($2850 -$4550)
• SHARP pays the remainder.
• SHARP’s payment does not count toward the retiree/spouse

yearly out-of-pocket limit.

Generic drugs in the Coverage Gap of a Medicare D program include a retiree/spouse copay.

• SHARP pays the remaining price of the drug.
• The amount SHARP pays for generic drugs in the Coverage Gap

does not count toward the retiree/spouse yearly out-of-pocket

• limit. ($2850 -$4550)

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Cost Containment Rules

CMS (Center for Medicare and Medicaid Service) stipulates all cost containment rules that apply under the Express Scripts Medicare (PDP) program.

• Prior Authorization
• Step Therapy
• Quantity limits
• Participating Retail Pharmacies
• Medication Therapy Management must be offered to the

member but participation is not required. In 2014 the Retail Refill Allowance rule is removed.

• CMS requires that a member be allowed up to fill a prescription

to a 90 day supply at retail.

• Walgreens will be a participating pharmacy in 2014.

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2014 SHARP RX Three Tier copay

Retail : 30 , 60 & 90 day supply

• $12 generic
• $24 brand
• $40 non-preferred/non-

formulary

• 60 day supply is 2 times

the above noted copay

• 90 day supply is 3 times

the above noted copay

Mail order: 90 day supply

• $29 generic
• $58 brand
• $90 non-preferred/non-

formulary

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Upcoming Mailings in 2013

• Express Scripts mailing to participating retirees/spouses.
• The Pre-notification letter was mailed 11-8-2013.
• Retiree/spouse have 21 days to respond if they wish to opt out.
• CMS requires the opt out opportunity.
• SHARP will not offer any other type of prescription option.
• If the retiree opts out they will need to find prescription drug

coverage on the open market.

• SHARP will not assist with open market premiums the retiree may incur.
• December of 2013 each SHARP Rx Option participating

retiree/spouse will receive the Welcome Kit from Express Scripts.

• The kit will include the evidence of coverage letter, program

formulary, drug list and ID cards.

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Yearly Rx Option Notice

• The Express Scripts Medicare (PDP) currently enrolled

retiree/spouse will receive an opt out notice yearly (annual notice of change/ANOC).

• The member is not required to make a change
• The member who wants to continue in the SHARP Rx Option is

not required to sign anything.

• If the retiree/spouse opts out of Express Scripts Medicare (PDP)

there will be no other prescription drug plan offered by SHARP.

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Express Scripts Pre-Medicare/Non-Medicare

• The Pre-Medicare/Non-Medicare eligible retiree, spouse or

eligible dependent child who enrolls in the SHARP Rx Option will remain on the current national formulary. The cost containment rules in place will continue to apply.

• The new Three Tier Copay will apply (see slide 17)
• The Retail Refill Allowance rule is removed effective 1-1-2014
• Up to a 90 day supply may be purchased as retail.
• Walgreens will be a participating pharmacy in 2014.

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New SHARP ID Cards 2014

• The retiree/spouse will now have three ID cards for

healthcare.

• Medicare Part A and Part B card (primary medical benefits) or

Pre-Medicare/Non-Medicare the Blue Cross card

• SHARP ID card (if covered by the SHARP Base, MCx or DVH

Options)

• Express Scripts card (if covered by the SHARP Rx Option)
• Each member will have their own card.
• The SHARP ID card will have: NAD logo and

Supplemental Healthcare Adventist Retirement Plan Adventist Risk Management, Inc.

• The Express Scripts ID card will have the Express Scripts and NAD

logo and prescription information only.

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SHARP Customer Service

SHARP (Eligibility) Main Phone Number: 1-301-680-5036 Monday – Thursday 8 a.m. – 5 p.m. Eastern Time SHARP@nad.adventist.org Express Scripts Medicare Customer Service: 1-866-838-3974 (opens 12-1-2013) ARM/SHARP Claims and Benefits Customer Service: 1-800-447-5002

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