Empire Plan RETIREE At A Glance - Human Resources

Empire Plan Medicare Rx Prescription Drug ProgramThis section ONLY applies to Medicare-primary enrollees and dependents enrolled in EmpirePlan Medicare Rx.Effective January 1, 2014, the administration of the Empire Plan Medicare Rx prescription drugplan will change from UnitedHealthcare to SilverScript Insurance Company, an affiliate of CVSCaremark ® . Empire Plan Medicare Rx is a Medicare Part D plan with expanded coverage designedspecifically for Medicare-primary Empire Plan enrollees and dependents. Eligible individuals areenrolled automatically in Empire Plan Medicare Rx. Prior to enrollment, affected enrollees anddependents receive important information from SilverScript. For example, each Medicare-primaryenrollee and Medicare-primary dependent receives a unique Empire Plan Medicare Rx Card fromSilverScript to use at network pharmacies. No action is required by you to enroll in Empire PlanMedicare Rx and keep your Empire Plan Coverage.If you have questions, call 1-877-7-NYSHIP (1-877-769-7447), press 4 for the Empire PlanMedicare Rx Program, 24 hours a day, seven days a week. Plan benefit information is alsoavailable online at http://www.EmpirePlanRxProgram.com.You pay the following copayments for drugs purchased from a Network Pharmacy or through theMail Service Pharmacy.CopaymentsYou have the following copayments for drugs purchased from a Network Pharmacy or through theMail Service Pharmacy or designated Specialty Pharmacy.Up to a 31-day (one month)supply of a covered drug froma Network Pharmacy orthrough the Mail ServicePharmacy, or designatedSpecialty PharmacyTier 1 Drugs. Includes mostGeneric Drugs...................$5Tier 2. Includes PreferredBrand Drugs ...................$25Tier 3. Includes Non-preferredBrand Name Drugs.......... $4532- to 90-day supply of acovered drug from aNetwork PharmacyTier 1 Drugs. Includes mostGeneric Drugs.................$10Tier 2. Includes PreferredBrand Drugs ...................$50Tier 3. Includes Non-preferredBrand Name Drugs.......... $9032- to 90-day supply of acovered drug through theMail Service Pharmacy ordesignated Specialty PharmacyTier 1 Drugs. Includes mostGeneric Drugs...................$5Tier 2. Includes PreferredBrand Drugs....................$50Tier 3. Includes Non-preferredBrand Name Drugs.......... $90Note: Oral chemotherapy drugs for the treatment of cancer do not require a copayment. Inaddition, generic oral contraceptive drugs and devices or brand-name drugs/devices without ageneric equivalent (single source brand-name drugs/devices) do not require a copayment.You have coverage for prescriptions of up to a 90-day supply at all network, non-network and mailservice pharmacies. Prescriptions may be refilled for up to one year.AAG-NY/PE-RET-1/14-REV 19