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Frequently Asked Questions

About HOP - (FAQ page category)

About HOP Covered Drugs and Filling Prescriptions - (FAQ page category)

About Medicare Prescription Drug Coverage - (FAQ page category)

HOP Eligibility - (FAQ page category)

HOP Medical - (FAQ page category)

HOP Prescription Drug Coverage - (FAQ page category)

Premium Assistance - (FAQ page category)

About HOP

What is the PSERS Health Options Program?

The Pennsylvania Public School Employees' Retirement System (PSERS) sponsors the Health Options Program for the sole benefit of PSERS retirees, their spouses or surviving spouses, and their dependents. The Program is voluntary, and each retiree must decide whether or not to participate. It is funded exclusively by the premiums paid by its participants for the benefit coverage they elect. Private health care insurers and providers provide the medical coverage and services available through the Health Options Program.

Does the Health Options Program offer Medicare Prescription Drug Coverage?

Yes. The Health Options Program prescription drug coverage options offered to Medicare-eligible individuals are Medicare Prescription Drug Coverage.

Is medical and prescription drug coverage available if I move out of Pennsylvania?

Yes. The HOP Medical Plan, the Medicare Rx Options and the HOP Pre-65 Medical Plan provide coverage and benefits in all 50 states. The Medicare-eligible and pre-65 Managed Care Plans are offered across the country as well. See the Managed Care Plans for Medicare-Eligible and Non-Medicare-Eligible Members regional brochures on the "Resources" page to learn about which Managed Care Plans are are available where you live, the benefits they offer and their rates.

How do I decide which coverage Option is best for me?

Choosing health care coverage is a personal decision. When weighing your Options, consider the monthly premium amount, what you will have to pay out of pocket (deductibles, copays, and coinsurance amounts), level of prescription drug coverage provided, and flexibility to choose your provider.

How is my coverage affected if I live in different parts of the country during the year?

If you have coverage in one of the fee-for-service plans, i.e., the HOP Pre-65 Medical Plan, HOP Medical Plan, Basic or Enhanced Medicare Rx Options, there is no effect. You have the freedom of choice to see any provider you want. The pharmacy network is nationwide. If you are enrolled in a Medicare Advantage/managed care plan, you will have to consult their specific rules as there may be some limitations.

Will the same prescription drug plans (Basic and Enhanced Medicare Rx Options) be offered next year?

The Health Options Program anticipates offering these same Options next year, but cannot guarantee that these same Options will be available next year.

How do I pay my premium?

If you are a current Health Options Program member, your premiums are paid as described below. If you are a new enrollee, you will start out paying by check on a monthly basis until the PSERS benefit system deducts your premium or you are sent a payment coupon book.   

There are two ways that monthly plan premiums are paid.

Premiums are deducted from your PSERS pension check.  As long as your monthly PSERS retirement benefit is more than the monthly HOP Medical Plan and Medicare Rx Option coverage premium, the full amount will be deducted.  This option is only available to annuitants choosing a HOP Medical plan with Prescription coverage or a Health Options Program-sponsored Medicare Advantage Plan.  Please note: if you elect standalone drug coverage under the Basic or Enhanced Medicare Rx Options, PSERS is not able to deduct the premium from your pension check.

Payment coupon book. If you cannot pay for the entire HOP Medical Plan and Medicare Rx Option premium or a Medicare Advantage premium with your PSERS retirement benefit, or if you have Medicare prescription drug coverage without HOP Medical Plan coverage, you must pay your monthly plan premium directly to our plan. If you make direct payment, you will receive a coupon book prior to your coverage effective date. The monthly coupon and check must be mailed to the Health Options Program, P.O. Box 64979, Baltimore, MD, 21264- 4979, the 25th of the prior month. If you run out of coupons or lose your coupon book, call the HOP Administration Unit 1-800-773-7725 for a replacement.

Contact the HOP Administration Unit for more information or if you have any questions about your plan premiums.

How do I find out what options are available to me?

Available options differ depending on where you live. Click here for more information.

About HOP Covered Drugs and Filling Prescriptions

What prescription drugs does the Health Options Program cover?

For information about prescription drugs covered through the Basic or Enhanced Medicare Rx Option, download the abridged and/or comprehensive formulary. You can also use the online Part D Formulary Lookup Tool. Visit the Find a Drug page for details.

Where can I get my prescriptions filled?

Under the Basic and Enhanced Medicare Rx Options, you have access to pharmacies in every state. For information about participating pharmacies, call 1-888-239-1301 or click here.

How much do I have to pay when getting prescriptions filled?

Under the Basic and Enhanced Medicare Rx Options, you pay no deductibles for prescription drugs, just a copay or coinsurance, depending on the type of drug (generic, brand-name with or without a generic equivalent, or a Specialty drug).

For a side-by-side cost comparison of the Basic and Enhanced Medicare Rx Options, see the Health Options Program for Medicare-Eligible Participants brochure.

How will the pharmacist know what to charge me?

Present your prescription drug card at the pharmacy (or send the identifying information requested if you're using mail order). The pharmacist will then be able to electronically access information regarding all prescription drugs obtained after presenting your prescription drug identification card or purchased through the mail service pharmacy. This central data base will indicate what your copay should be.

Can I get a 90-day supply of my drugs?

Yes. All of the Health Options Program plan options offer a mail-order prescription drug program, which provide up to a 90-day supply of your medication. Some retail pharmacies also offer a 90-day supply. Please note: a pharmacy must have an agreement with OptumRx regarding dispensing a 90-day supply before your 90-day prescription can be filled.

How can I find out how much a drug will cost under the Basic or Enhanced Medicare Rx Options?

The amount you pay will depend on the type of drug (generic, brand or Specialty) you purchase. For a side-by-side cost comparison of the Basic and Enhanced Medicare Rx Options, see the Health Options Program for Medicare-Eligible Participants brochure.

 

If I am currently taking a non-formulary drug, what do I need to do to ensure I maximize my prescription drug benefits?

You should talk with your provider to determine if the non-formulary drug you are taking can be replaced with a formulary drug. Click here for information about the formulary for the Basic and Enhanced Medicare Rx Options. If your provider determines that there is not a formulary drug that can be substituted, your provider must call OptumRx at 1-888-239-1301 to request an exception.

What happens if I currently get my drugs from abroad?

The Health Options Program does not cover drugs bought from Canada or other countries.

What if I'm in a state pharmacy assistance program?

Your state pharmacy assistance program may coordinate with Medicare prescription drug coverage to give you greater savings. Check with your state program or contact your state health insurance counseling program. If you currently get your drugs through Medicaid, you automatically qualify for extra help.

What if I get free drugs from a drug manufacturer's patient assistance program?

You can still do so and have Medicare Prescription Drug Coverage too—as long as the manufacturer's program continues this help for people on Medicare. Check with the drug manufacturer company.

What does QLL or quantity limit mean?

Your plan's Drug Quantity Management program is designed to help you get the medicines you need when you need them, in safe, economical amounts, while taking your special needs into account. The program follows guidelines developed by the U.S. Food and Drug Administration (FDA), medical researchers and drug manufacturers. These professionals recommend the maximum quantities considered safe, especially for those drugs where it is difficult to decide on the proper dose. As a result, some drugs have quantity limits.

By making sure you only get the recommended amount of your medications when you request a refill, Drug Quantity Management not only safeguards your health, it also helps you save money. When you request a prescription, you will receive the quantity prescribed by your doctor not to exceed the recommended amount, which should last until it's time for a refill. If you regularly need refills sooner than recommended, you may be using too much of your medication and should contact your doctor. He or she may be able to suggest ways you can use your medication so you don't have to refill—and pay for—your prescriptions as often.

What is step therapy?

Step therapy is a program designed for people who take prescription drugs regularly to treat an ongoing medical condition (for example, arthritis, asthma, or high blood pressure). In step therapy, the covered drugs you take are organized in a series of "steps." Each step is a different category of drug, such as first-step treatments and second-step treatments.

The program usually starts with requiring coverage for the "first-step drug." This first step allows you to begin or continue treatment with prescription drugs that are appropriate for you, but more proven than drugs in the "second step."

If your doctor determines the first-step drug does not work for you, you can receive coverage for a second-step drug.

About Medicare Prescription Drug Coverage

If I am eligible for the Low Income Subsidy, how will it reduce my monthly premiums for Health Options Program Medicare Prescription Drug Coverage?

If you are eligible for the Low Income Subsidy and participate in the HOP Enhanced Medicare Rx Plan, your billable monthly premium for 2014 is $55.00. If you are eligible for the Low Income Subsidy and participate in the HOP Basic Medicare Rx Plan, your billable monthly premium for 2014 is $2.00. These premiums apply regardless of whether you qualify for LIS payments at the 25%, 50%, 75% or 100% level.

Who is eligible for Medicare Prescription Drug Coverage?

Medicare Prescription Drug Coverage is available to anyone with Medicare (including individuals eligible for Medicare due to being age 65 or older or due to disability or end-stage renal disease). No physical exams are required. Nobody can be denied for health reasons.

If I'm Medicare eligible, am I required to sign up for Medicare Prescription Drug Coverage?

No. It's voluntary. However, if you do not sign up when you are first eligible or do not have other creditable coverage, you may have to pay a premium penalty when you sign up later.

Is there much difference between the different Medicare Prescription Drug Plans?

Yes. There are differences in premiums and deductibles, covered drugs, copays, and participating pharmacies. The costs for plans vary. Carefully compare plans in your area.

When does the late enrollment penalty apply?

You may be subject to a penalty in the form of a higher premium rate if you go 63 days or longer without prescription drug coverage that is at least as good as standard Medicare Prescription Drug Coverage (or creditable coverage). The premium increase will be 1% per month for every month after you are eligible for but did not have Medicare coverage. You will have to pay this higher premium as long as you have Medicare Prescription Drug Coverage.

Who is eligible for the low-income subsidy for Medicare Prescription Drug Coverage?

There is extra help for people with lower income and assets who are enrolled in Part D. Depending on the level of need, premiums, deductibles, coinsurance, and/or copayment amounts may be reduced or eliminated.

Eligibility for extra help depends on your income (money you receive from retirement benefits or other money that you report for income tax purposes) and, in some cases, your assets (for example, property other than your residence). If you have both Medicare and Medicaid, you automatically qualify for this extra help. If you do not have Medicaid, you may still qualify for some assistance if your income and other assets are below certain levels.

In certain cases, the Centers for Medicare and Medicaid Services (CMS) systems do not reflect a beneficiary's correct low-income subsidy status. To address this issue, CMS created the best available evidence (BAE) policy. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary's information is not accurate. For more information about the best available evidence policy, click here.

If you think you might qualify for extra help and have not yet been contacted, you can contact the Social Security Administration. A worksheet is also available on their Web site that can help you determine whether you may qualify. Information can be found on the Social Security Web site at www.socialsecurity.gov/prescriptionhelp.

What's the "coverage gap"? Do the Enhanced and Basic Medicare Rx Options have a coverage gap?

In 2014, under the Basic Medicare Rx Option, once your total drug costs (what your plan has paid plus your deductible and copays) exceed $2,850, Medicare will not cover any more covered expenses in the year until you spend $4,550 out of pocket. This gap in coverage is called the "coverage gap." During the Coverage Gap Stage, you receive a discount on brand name drugs and pay only 72% of the cost of generic drugs. You stay in this stage until your out-of-pocket costs reach $4,550. This is the amount you must pay out-of-pocket to leave the Coverage Gap Stage and qualify for Catastrophic Coverage. When you reach the $4,550 limit, catastrophic drug coverage kicks in automatically. At that point, for generic drugs, you pay the greater of 5% or $2.55 to a maximum of $100; and for brand name drugs, you pay the greater of 5% or $6.35 to a maximum of $100.

In 2014, under the Enhanced Medicare Rx Option, once your total drug costs (what your plan has paid plus your deductible and copays) exceed $2,850, Medicare will not cover any more covered expenses in the year until you spend $4,550 out of pocket. This gap in coverage is called the "coverage gap." During the Coverage Gap Stage, you receive a discount on brand name drugs and pay $7 retail/$21 mail order for generic drugs. You stay in this stage until your out-of-pocket costs reach $4,550. When you reach the $4,550 limit, catastrophic drug coverage kicks in automatically. At that point, for generic drugs, you pay the greater of 5% or $2.55 to a maximum of $100; and for brand name drugs, you pay the greater of 5% or $6.35 to a maximum of $100.

HOP Eligibility

Who is eligible for participation in a Health Options Program medical plan?

Health Options Program medical plans are designed for PSERS members. Members of the Public School Employees' Retirement System in Pennyslvania who are already enrolled in Medicare Parts A and B are eligible to join the Health Options Program. Health Options Program members and their dependents can enroll in a Health Options Program medical plan.

I'm turning 65 in a few months, how will this affect my coverage and what will happen?

If you are not currently participating in the Health Options Program, turning age 65 is considered a Qualifying Event and gives you the right to enroll in the Program.

If you are currently enrolled in the Program, you will have some additional prescription drug coverage options available to you.

In either case, you will receive an invitation to a meeting before your 65th birthday where HOP representatives will explain the options available to you. You will also recieve a personalized statement showing your options and explaining what you need to do if you want to enroll or change your option.

If I (the PSERS retiree) die, can my spouse continue coverage?

Yes. Your surviving spouse is eligible to continue coverage through the Health Options Program, provided timely premium payments are received.

Can my Medicare-eligible spouse be covered under the Health Options Program if I'm not, even if I'm still a PSERS retiree?

Yes.

Are medical and prescription drug coverage available if I travel overseas?

Medicare does not cover medical expenses incurred outside the United States. If you are eligible for Medicare and enrolled in the HOP Medical Plan, you can submit an itemized invoice from a foreign country for consideration under Major Medical. Covered expenses are subject to the Major Medical Deductible and copay amounts. If you are not eligible for Medicare and enrolled in the HOP Pre-65 Medical Plan, you can also receive reimbursement for out-of-country medical expenses. If you are enrolled in a managed care plan, you will have to consult their specific rules.

When can I and/or my dependents enroll in the Health Options Program?

If you or your dependent(s) are not currently enrolled in the Health Options Program, your next opportunity to enroll would be if you experience a Qualifying Event, which include:

  • You retire or lose health care coverage under your school employer’s health plan. Coverage under your school employer’s health plan includes any COBRA continuation coverage you may elect under that school employer’s plan.
  • You involuntarily lose health care coverage under a non-school employer’s health plan (which includes any COBRA continuation coverage you may elect under that non-school employer’s health plan).
  • You or your spouse reach age 65 or become eligible for Medicare.
  • There is a change in your family status (including divorce, your death or death of a spouse, addition of a dependent through birth, adoption, or marriage, or a dependent loses eligibility).
  • You become eligible for Premium Assistance due to a change in legislation.
  • A plan approved for Premium Assistance terminates or you move out of a plan’s service area.

HOP Medical

Is there a network for the HOP Medical Plan?

No. If you sign up for the HOP Medical Plan, you may use the licensed provider or facility of your choice. There are no restrictions on where or when you receive care.

Why does the same HMO offer plans to individuals that are cheaper than their plan in the Health Options Program?

HMOs market different/lesser benefit plans to individuals than the group plan offered through the Health Options Program. In many instances this difference is in prescription drug coverage with individual plans offering little or no coverage.

Who selects what HMO Plan is offered through the Health Options Program?

Once an HMO is approved to participate in the Health Options Program, the HMO selects the plan they want to market to PSERS retirees and their dependents within guidelines set by PSERS. We encourage HMOs to offer a plan that matches up with the top fee-for-service plan.

How can one HMO company charge different rates for the same coverage in different counties in the Health Options Program?

HMO rates are based on the community's experience and the Health Care Financing Administration's (HCFA) reimbursement rate that is calculated for each county. HMOs make the final decision on the rates they charge. Where possible, the Health Options Program offers more than one HMO in an area to foster competition.

Can I elect HOP medical coverage on a standalone basis and elect prescription drug coverage elsewhere?

Yes. You may elect the HOP Medical Plan on a standalone basis. If you do this, you may elect prescription drug coverage from another provider.

Why don't I have an HMO/POS option in my area?

An HMO takes several factors into consideration when deciding to offer benefits in a particular geographic area:

  1. For a Medicare risk HMO, a primary consideration is the Medicare reimbursement rate that varies by county.
  2. Another factor is the local provider community. An HMO must determine if they can build a viable network based upon the providers' willingness to participate with the HMO.
  3. Finally, an HMO must obtain approval from state and federal regulators to provide HMO benefits.

HOP Prescription Drug Coverage

If I have HOP prescription drug coverage, will I need to sign up for other Medicare Prescription Drug Coverage?

If you have prescription drug coverage through the Health Options Program, you do not need to sign up for other Medicare Prescription Drug Coverage outside of the Program. Both the Enhanced and Basic Medicare Rx Options are Medicare Part D plans. If you sign up for another Medicare Part D plan, you will automatically lose your prescription drug coverage under the Health Options Program.

If I am currently enrolled in a Medicare Advantage Plan, can I enroll for HOP prescription drug coverage?

No. The federal government will not permit Medicare eligible individuals to enroll in more than one Part D plan.

If I elect the Basic or Enhanced Medicare Rx Option, can I switch my selection next year?

Yes. You will have an opportunity each fall to change your Option.

If I chose the Basic Medicare Rx Option now, will I have to pay a penalty/increased premium if I change to the Enhanced Medicare Rx Option?

No. You will not be penalized if you elected the Basic Medicare Rx Option during an Option Selection Period and decide you want coverage under the Enhanced Medicare Rx Option during the next Option Selection Period. Please note: premium rates for all Medicare Part D plans are subject to change.

How do I decide if the Basic or Enhanced Medicare Rx Option is better for me?

Please refer to the Annual Notice of Change and Evidence of Coverage for a detailed comparison of the Basic and Enhanced Medicare Rx Options.

If I don't enroll for HOP prescription drug coverage when I first become eligible, can I enroll at a later date without penalty?

If you are eligible for Medicare Prescription Drug Coverage and do not enroll for prescription drug coverage through the Health Options Program, you may be eligible to enroll for coverage under the Program at a later date. However, you may be subject to a penalty in the form of a higher premium rate if you go 63 days or longer without prescription drug coverage that is at least as good as Medicare Prescription Drug Coverage (or creditable coverage). The premium increase will be 1% per month for every month after you are eligible for but did not have Medicare coverage. For example, if you go 19 months without coverage, your monthly premium will always be 19% higher than what most other people pay. You will have to pay this higher premium as long as you have Medicare Prescription Drug Coverage.

If I enroll for the Basic or Enhanced Medicare Rx Options, will I have premiums deducted from my Social Security check?

If you are enrolled in the HOP Medical Plan and either of the Medicare Rx Options, your premiums will be deducted from your PSERS pension check provided your pension benefit is greater than the premium amount. If your pension benefit is less than the premium amount or you enroll in either of the Medicare Rx Options on a standalone basis, you will be billed for the cost of your coverage. At some point in the future, you may be given the option to have your Part D premium deducted from your Social Security benefit.

Can I elect the HOP Medical Plan on a standalone basis and elect prescription drug coverage elsewhere?

Yes.

What is creditable prescription drug coverage?

Creditable prescription drug coverage means that the coverage is at least as good as the standard Medicare drug benefit. If you are in a plan that is considered creditable coverage, you can switch to a Medicare Part D plan at a later date without penalty.

Is the PFT plan considered creditable coverage?

Considering the information we have been provided, the PFT plan is at least as good as the standard Medicare drug benefit.

If I have drug coverage from TRICARE or the Department of Veteran's Affairs (VA), can I keep that coverage and elect coverage through HOP?

Yes. You can have the HOP Basic Medicare Rx Option or the HOP Enhanced Medicare Rx Option with your TRICARE or VA coverage. Contact the HOP Administration Unit for more information or if you have any questions.

What happens to my prescription drug benefits if I go into an assisted living center and/or nursing home?

Medicare Part D coverage extends to multiple patient settings. If someone is in a nursing home under skilled nursing care, Medicare Part A will be responsible for the costs of the drugs. Once the level of care in the nursing care facility is no longer at a skilled level, the Medicare Part D coverage takes over. PSERS has an extensive pharmacy network that includes nursing homes and assisted living facilities. If you have a question regarding a specific nursing home, you can contact OptumRx at 1-888-239-1301.

If I'm on my wife's medical plan, can I sign up for prescription drug coverage through the Health Options Program and still get Premium Assistance?

No. The Premium Assistance is a reimbursement for basic hospital, medical and major medical premiums. Accordingly, PSERS cannot pay Premium Assistance for standalone prescription drug coverage. To qualify for the Premium Assistance benefit, you must sign up for the HOP Medical Plan, HOP Medical Plan with Enhanced Medicare Rx Option, HOP Medical Plan with Basic Medicare Rx Option, or a Health Options Program Medicare Advantage/managed care plan.

Premium Assistance

Why does PSERS limit Premium Assistance to $100 per month?

The amount of the Premium Assistance benefit, currently $100, is set by the Pennsylvania legislature, not PSERS.

Are retirees who live outside of Pennsylvania eligible for Premium Assistance?

Yes, provided the retiree has an out-of-pocket premium expense from the Health Options Program or a Pennsylvania school district (employer) plan.