2015 Medicare Part D coverage gap and catastrophic coverage
Depending on your income, some Medicare prescription drug plans have a coverage gap stage, a point when you may be responsible for most of your drug costs. The Coverage Gap Stage begins after you have paid $320 for drugs and you and the plan together have paid $2,960 in total yearly drug costs. At Coverage Gap Stage you pay 45% of the price for brand name drugs and no more than 65% of the price for generic drugs. You stay in this Coverage Gap Stage until your total out-of-pocket costs reach $4,700. The amount of out-of-pocket costs and rules for counting costs toward this amount have been set by Medicare. The out-of-pocket drug costs include deductibles, if applicable, co-pays, co-insurance and the amounts you pay in the Coverage Gap. It does not include monthly premiums.
If you have very high drug costs, your catastrophic coverage will begin after you have paid $4,700 out-of-pocket for one year. After that, you'll pay the greater of:
- 5% coinsurance, or
- $2.65 for a generic or preferred multiple source drug, and $6.60 for other drugs.
If you qualify for Extra Help, you'll pay:
For generic drugs (including drugs treated as generic) either:
For all other drugs:
Prescription drug list
Thousands of prescription drugs are covered, including most of the brand name and generic drugs used by people with Medicare. You can look up prescription drugs.
Some drugs have additional requirements or limits, indicated by abbreviations next to the drug names in the plan Prescription Drug List. You may request an exception to your plan coverage (often called a "clinical coverage determination") or appeal a decision about your plan coverage.
The UnitedHealthcare Medicare prescription drug benefit covers both brand name and generic drugs. A generic drug has the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less and are approved by the Food and Drug Administration (FDA). Consult with your doctor to determine whether you can lower your prescription drug costs by using generic drugs.
Questions about premiums or co-pays:
- UnitedHealthcare customer service, toll-free: 1-877-596-3258 (TTY 711) 8 a.m. - 8 p.m. local time, 7 days a week
Questions about qualifying for Extra Help:
- Medicare, toll-free: 1-800-MEDICARE (1-800-633-4227) or TTY/TDD 1-877-486-2048, 24 hours a day, seven days a week
- Social Security, toll-free: 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday, or TTY/TDD 1-800-325-0778
You may also call your state's Medicaid office
Conditions and limitations
Beginning January 1, 2006, there were limits set to when and how often you can change your Medicare plan options.
To take advantage of a Medicare Advantage plan with prescription drug coverage, you must be eligible for Medicare Part A and Part B. You must also maintain your Medicare Part A and Part B coverage by paying Part B premiums, and if applicable, Part A premiums, if not otherwise paid for under Medicaid or another third party. Benefits may vary by county and plan. Limitations, co-payments and co-insurance may apply.
Drug requirements/limits – You can find out if your drug has any additional requirements or limits by looking for the abbreviations next to the drug names on the drug listings in the Prescription Drug List. These requirements and limits may include:
- Prior Authorization (PA): Before it will cover this drug, the plan needs more information from your doctor to make sure the drug is being used correctly for a medical condition covered by Medicare. You may be required to try a different drug before the plan will cover this drug.
- Step Therapy (ST): There are effective, lower-cost drugs that treat the same medical condition as this drug. You may be required to try one or more of these other drugs before the plan will cover your drug. If you have already tried other drugs or your doctor thinks they are not right for you, you and your doctor can ask the plan to cover this drug.
- Quantity Level Review (QL): The plan will cover only a certain amount of this drug for one co-pay or over a certain number of days. These limits may be in place to ensure safe and effective use of the drug. If your doctor prescribes more than this amount or thinks the limit is not right for your situation, you and your doctor can ask the plan to cover the additional quantity.
- Medicare Part B or Part D (B/D): Depending on how this drug is used, it is covered by either Medicare Part B (doctor and outpatient health care) or Medicare Part D (prescription drugs). Your doctor may need to provide the plan with more information about how this drug will be used to make sure its correctly covered by Medicare.
Off-prescription drug list exceptions process You may ask that we make an exception to have an off-prescription drug list brand-name drug paid for by this plan. If an exception were allowed, you would get the off-prescription drug list prescription drug at the Tier 3 co-pay. Your doctor must provide us with a statement that says an exception is medically necessary for you because the drug in the prescription drug list: would not work as well as the prescription drug the doctor wants you to use; would have unwanted effects; or both.
Tier exception process You may ask that we cover a Tier 3 prescription drug at the Tier 2 co-pay level. This request must be made in writing by your doctor. The written request must include which Tier 1 or Tier 2 drugs you have tried and why no other Tier 1 or Tier 2 drug is right for your unique medical condition. The tier exception process does not apply to the Specialty Tier or Tier 2 drugs.
60-day prescription drug list change notice
Notice of prescription drug list changes will be posted 60 days prior to the removal or change in the preferred or tiered cost-sharing status of a Part D drug. The posting will include:
- The name of the affected covered Part D drug.
- Information on whether the covered Part D drug is being removed from the Prescription Drug List, or changing its preferred or tiered cost-sharing status.
- The reason why the covered Part D drug is being removed from the Prescription Drug List, or changing its preferred or tiered cost-sharing status.
- Alternative drugs in the same therapeutic category, class or cost-sharing tier, and the expected cost-sharing for that drug.
- The means by which members may obtain an updated coverage determination or an exception to a coverage determination.
How the Plan meets access requirements
UnitedHealthcare has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. The pharmacy network includes more than 65,000 standard network pharmacies nationwide including retail, mail order, long-term care, home infusion and I/T/U (Indian Health Service, Tribal or Urban Indian) pharmacy services.
If you need to have your prescription filled at a pharmacy that is not in our network, there are some exceptions allowed. But these are limited to emergencies when you are traveling and run out of your medicine, or if you become ill and cannot get to a network pharmacy. If that happens, you will need to fill out a claim form and you may not get the same negotiated prices as you would through a network pharmacy.
Remember, you will receive the lowest prices when you have your prescriptions filled at a network pharmacy. But take comfort in knowing that even in an emergency, you can still get your prescriptions filled at any pharmacy.
How to file a grievance about your prescription drug coverage
A grievance is a type of complaint that expresses your dissatisfaction with the plan or pharmacy's operations, activities or behavior.
To file a grievance, you can contact the Customer Service Center toll-free at the number listed on your identification card. You can also write a letter describing your grievance. Tell us your name, your member identification number, and your date of birth. Send it to the Part D Appeals and Grievance Department, PO Box 6106, MS CA124-0197, Cypress, CA 90630-9948. Grievances may also be faxed toll-free to 1-866-308-6294.
We will respond to or resolve your case within 30 calendar days of receiving your grievance. If your grievance was filed verbally, you will receive a verbal response, unless your grievance is related to quality of care or you have specifically requested a written response from us. All written grievances will receive written response.
If you would like to inquire about the status of a grievance please call the Customer Service Center toll-free at the number listed on your identification card.
See your plan's Evidence of Coverage for more information.
How to request an exception to your plan coverage determination
There are four types of coverage determinations that may be used by your plan:
- Prior Authorization Programs: Prior authorization refers to meeting certain criteria in order to receive benefits for certain prescribed medication. Medications require prior authorization due to coverage, benefit, clinical, or possible efficacy or safety considerations.
- Step Care Therapy Programs: Step Therapy requires plan participants to use cheaper effective alternative medications prior to receiving approval for more expensive drugs. When patients have tried the alternatives without a successful outcome, the more expensive medication may be approved for coverage.
- Quantity Limits with or without Prior Authorization: Quantity limits restrict the quantity of a drug a plan participant can receive. Most people would not need to take these drugs more often than what is allowed. Certain drugs may be approved for higher quantity limits if proven to be medically necessary.
- Tier Exceptions: Allows the member to receive a Tier 3 medication at a Tier 2 coverage level if no Tier 1 or Tier 2 drugs have proven effective for the member.
Under certain circumstances, your plan may agree to provide you with an exception to one of these coverage determinations.
A coverage determination may be requested by:
- A member
- An appointed representative
- A prescriber (the individual who prescribed the medication to the member)
Upon receipt of information needed to review a coverage request, the coverage determination is typically made within 72 hours. Expedited coverage determinations can be determined within 24 hours.
To initiate a coverage determination request, please call the Customer Service Center toll-free at the number listed on your identification card.
You will need the following information ready when you call:
- Member name
- Member date of birth
- Member ID number
- Name of the medication
- Physician's phone number
- Physician fax number (if available)
Your prescriber may also submit your request via fax or mail to:
OptumRx Mail Service Pharmacy
3515 Harbor Blvd.
Costa Mesa, CA 92626
Toll-Free Phone #: 1-800-711-4555
Toll-Free Fax #: 1-800-527-0531
Mail Stop: LC07-286
Download and print the Medicare Part D Clinical Prior Authorization Fax Form (PDF) (41.1 KB).
The results of the coverage determination will be sent to the member by mail, and the initiator of the request will be contacted by telephone. If you would like to inquire about the status of a coverage determination please call the Customer Service Center toll-free at the number listed on your identification card.
See your plan's Evidence of Coverage for more information.
How to appoint a representative to help you with a coverage determination
Someone you have named as an authorized representative can also make a coverage determination request. The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the coverage determination case. Download and print the Appointment of Representative form. Both you and the person you have named as an authorized representative will need to sign the representative form, unless your representative is a lawyer. In that case, only your signature is needed. If your prescribing doctor calls on your behalf no representative form will be required.
How to appeal a decision about your prescription drug coverage
If your coverage determination request is denied, you will receive a letter that provides you with the reason the coverage was denied. The second page of the letter has complete, detailed information telling you how to file an appeal of the denial. You must file your appeal within 60 calendar days from the date on the letter you receive. We've described the process below as well.
How do I file an appeal of the denial regarding the decision about my prescription drug coverage?
Write a letter describing your appeal, and include any paperwork that may help us look over your case. Tell us your name, your member identification number, your date of birth, and the drug you need.
Send it to the Part D Appeals and Grievance Department, PO Box 6106, MS CA124-0197, Cypress, CA 90630-9948. You need to mail your letter within 60 calendar days of the date you found out that you were not getting the prescription, or the date you learned that the payment was not made. If you missed the 60 day deadline, you may still be able to file your appeal with us, if you can give a good reason why you missed the deadline.
The Part D Appeals and Grievance Department will look into your case and respond to you in a letter within 7 calendar days of receiving your request. You'll receive a letter giving you detailed information about the coverage denial.
If you would like to inquire about the status of an appeal please call the Customer Service Center toll-free at the number listed on your identification card.
What if I need my medicine right away? Or what if my health will be harmed by waiting 7 days?
You or your doctor can file a request for an expedited appeal (sometimes called a "fast appeal") either in writing, or over the phone by calling toll-free 1-800-595-9532 (TTY users should call 711), 24 hours a day / 7 days a week. Requests may also be faxed toll-free to 1-866-308-6294. If your doctor files or supports your fast appeal, we must review it in 72 hours.
We'll give you an answer within 72 hours. If we decide in your favor, we will tell you what to do to get your prescription filled. You'll receive a detailed letter later on.
Do I have to handle all this myself, or can someone help me?
Someone you have named as an authorized representative can make an appeal. The representative can be a permanent one, such as a Power of Attorney, or it can be someone you name to help you only during the appeal case. Download and print the Appointment of Representative form. Both you and the person you have named as an authorized representative will need to sign it, unless your representative is a lawyer. In that case, only your signature is needed. Keep in mind that we can't accept an appeal case without this authorization. There's an exception in the case of expedited appeals if your doctor calls on your behalf. In that case, no representative form will be required.
What are my next steps if the plan says "No"?
If we say "no" to your request, you can request another review with the Qualified Independent Contractor (QIC) hired by the Centers for Medicare & Medicaid Services. The address to request this review will be included in our response letter. You must file your appeal within 60 calendar days from the date on the letter you receive.
See your plan's Evidence of Coverage for more information.
How to obtain an aggregate number of the Plan's grievances, appeals and exceptions
To obtain more information about the Plan's grievances, appeals and exceptions please contact UnitedHealthcare Customer Service. Customer Service is available, 8a.m. 8 p.m. local time, 7 days a week.
By phone –
If you are a UnitedHealthcare health plan member, please call customer service at the number printed on the back of your member ID card.
If you are not a UnitedHealthcare health plan member, please call toll-free 1-877-596-3258 (TTY 711), 8 a.m. 8 p.m. local time, 7 days a week for additional information.
Correspondence address –
P.O. Box 459018, Sunrise, FL 33345-9018
The following information about your Medicare prescription drug benefit is available upon request:
- Additional information from us on the procedures used to control utilization of services and expenditures.
- Additional information on the number and disposition in the aggregate of appeals and quality of care grievances filed by those enrolled in the plan.
- A summary description of the method of compensation used for physicians and other providers.
A description of our financial condition, including a summary of the most recently audited statement.
Quality assurance policies and procedures
To make sure you get medically appropriate, safe and cost-effective medications, we work with doctors and pharmacists to maximize the benefit of your drug therapy. The Medicare Modernization Act requires this service, especially for people with complex medication needs and expensive drugs. This process has two goals. One is to get you the prescriptions you need, even if they are not on the list of drugs the plan covers. The second is to protect you from drug interactions that might harm you.
Potential for contract termination
If your prescription drug coverage is provided under a contract with Medicare, your coverage is not guaranteed beyond the end of the current contract year. In the event that Medicare or we terminate or non-renew the contract between United Healthcare Insurance Company and Medicare, as allowed by law, this may end your coverage. If this occurs, you will be able to choose another plan without incurring a late enrollment penalty, as long as you do so within the time period required by Medicare.