Frequently Asked Questions
About HOP
- What is the PSERS Health Options Program (HOP)?
- Does HOP offer Medicare Prescription Drug Coverage?
- Is HOP medical and prescription drug coverage available if I move out of Pennsylvania?
- How do I decide which HOP coverage Option is best for me?
- How is my HOP coverage affected if I live in different parts of the country during the year?
- Will HOP offer the same prescription drug plans (Basic and Enhanced Medicare Rx Options) next year?
- How do I pay my HOP premium?
- How do I find out about the HOP Options available to me?
About HOP Covered Drugs and Filling Prescriptions
- What prescription drugs does HOP cover?
- Where can I get my prescriptions filled?
- How much do I have to pay when getting prescriptions filled?
- How will the pharmacist know what to charge me?
- Can I get a 90-day supply of my drugs?
- How can I find out how much a drug will cost under the Basic or Enhanced Medicare Rx Options?
- If I am currently taking a non-formulary drug, what do I need to do to ensure I maximize my HOP prescription drug benefits?
- What happens if I currently get my drugs from abroad?
- What if I'm in a state pharmacy assistance program?
- What if I get free drugs from a drug manufacturer's patient assistance program?
- What does QLL or quantity limit mean?
- What is step therapy?
About Medicare Prescription Drug Coverage
- Who is eligible for Medicare Prescription Drug Coverage?
- If I'm Medicare eligible, am I required to sign up for Medicare Prescription Drug Coverage?
- Is there much difference between the different Medicare Prescription Drug Plans?
- When does the late enrollment penalty apply?
- Who is eligible for the low-income subsidy for Medicare Prescription Drug Coverage?
- What's the "coverage gap"? Do the HOP Enhanced and Basic Medicare Rx Options have a coverage gap?
- What types of drugs are covered under Part B versus Part D of Medicare?
HOP Eligibility
- If I will be turning 65 in a few months, how will this affect my HOP coverage and what will happen?
- If I (the PSERS retiree) die, can my spouse continue coverage through HOP?
- Can my Medicare-eligible spouse have coverage under HOP if I am not covered under HOP and I am the PSERS retiree?
- Are medical and prescription drug coverage available if I travel overseas?
- When can I and/or my dependents enroll in HOP?
HOP Medical
- Is there a network for the HOP Medical Plan?
- Why does the same HMO offer plans to individuals that are cheaper than their plan in HOP?
- Who selects what HMO Plan is offered through HOP?
- How can one HMO company charge different rates for the same coverage in different counties in PSERS' HOP?
- Can I elect HOP medical coverage on a standalone basis and elect prescription drug coverage elsewhere?
- Why don't I have an HMO/POS option in my area?
HOP Prescription Drug Coverage
- If I have HOP prescription drug coverage, will I need to sign up for other Medicare Prescription Drug Coverage?
- If I am currently enrolled in a Medicare Advantage Plan, can I enroll for HOP prescription drug coverage?
- If I elect the Basic or Enhanced Medicare Rx Option, can I switch my selection next year?
- 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?
- How do I decide if the Basic or Enhanced Medicare Rx Option is better for me?
- 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 I enroll for the Basic or Enhanced Medicare Rx Options, will I have premiums deducted from my Social Security check?
- Can I elect HOP medical coverage (HOP Medical Plan) on a standalone basis and elect prescription drug coverage elsewhere?
- What is creditable prescription drug coverage?
- Is the PFT plan considered creditable coverage?
- 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?
- What happens to my HOP prescription drug benefits if I go into an assisted living center and/or nursing home?
- Can I stay on my wife's medical plan and only sign up for the prescription drug coverage through HOP and still receive Premium Assistance?
Premium Assistance
About HOP
What is the PSERS Health Options Program (HOP)?
The Pennsylvania Public School Employees' Retirement System (PSERS) sponsors the Health Options Program (HOP) for the sole benefit of PSERS retirees, their spouses or surviving spouses, and their dependents. HOP is a voluntary program, and each retiree must decide whether or not to participate. HOP 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 HOP.
Does HOP offer Medicare Prescription Drug Coverage?
Yes. The HOP prescription drug coverage options offered to Medicare-eligible individuals are Medicare Prescription Drug Coverage.
Is HOP medical and prescription drug coverage available if I move out of Pennsylvania?
Yes. HOP Medical Plan, the Medicare Rx Options, the HOP Managed Care Plan/Highmark Freedom Blue, the HOP Pre-65 Medical Plan, and the HOP Pre-65 Managed Care Plan/Highmark PPOBlue provide coverage and benefits in all 50 states.
How do I decide which HOP 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 HOP coverage affected if I live in different parts of the country during the year?
If you have coverage in one of the HOP 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 HOP offer the same prescription drug plans (Basic and Enhanced Medicare Rx Options) next year?
HOP anticipates offering these same Options next year, but cannot guarantee that these same Options will be available next year.
How do I pay my HOP premium?
Premiums are normally deducted from your PSERS pension check. New enrollees, however, usually start out paying by check on a monthly basis until the PSERS benefit system deducts your premium. If your monthly pension check is less than the amount of your monthly HOP premium, you will have to pay the full amount of the premium by check. 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. In any event, if your premium is not being deducted from your monthly retirement benefit you will receive a payment (coupon) book giving you the information you need to make payments by check.
There are two ways that monthly plan premiums are paid.
If you can pay for the entire HOP Medical Plan and Medicare Rx Option coverage premium with your PSERS retirement benefit, your monthly plan premium is deducted from your monthly PSERS retirement benefit. This option is only available to annuitants choosing both Medicare prescription drug coverage and medical coverage.
If you cannot pay for the entire HOP Medical Plan and Medicare Rx Option premium with your PSERS retirement benefit, or if you have HOP 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 HOP, PO 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 for a new one.
Contact the HOP Administration Unit for more information or if you have any questions about your plan premiums.
How do I find out about the HOP Options 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 HOP cover?
For information about prescription drugs covered through the Basic or Enhanced Medicare Rx Option, download the HOP abridged and/or comprehensive formulary.
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 page 8 of the 2009 Welcome to HOP 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 HOP 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 Prescription Solutions 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 page 8 of the 2009 Welcome to HOP brochure.
If I am currently taking a non-formulary drug, what do I need to do to ensure I maximize my HOP 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 Prescription Solutions at 1-888-239-1301 to request an exception.
What happens if I currently get my drugs from abroad?
HOP 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
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 HOP Enhanced and Basic Medicare Rx Options have a coverage gap?
Under the Basic Medicare Prescription Drug Coverage, once your total drug costs (what your plan has paid plus your deductible and copays) exceed $2,700, Medicare will not cover any more covered expenses in the year until you spend $4,350 out of pocket. This gap in coverage is called the "coverage gap." When you reach the $4,350 limit, catastrophic drug coverage kicks in automatically and your plan pays 95% of your remaining costs until the end of the year.
Under the Enhanced Medicare Prescription Drug Coverage, once your total drug costs (what your plan has paid plus your deductible and copays) exceed $2,700, Medicare will cover 50% of the cost of covered expenses up to the maximum plan payment ($100 for up to an 83-day supply and $300 for over an 83-day supply) in the year until you spend $4,350 out of pocket. This gap in coverage is called the "coverage gap." When you reach the $4,350 limit, catastrophic drug coverage kicks in automatically and your plan pays 95% of your remaining costs until the end of the year.
What types of drugs are covered under Part B versus Part D of Medicare?
Click here to see a list of drugs covered under Part B versus Part D of Medicare and click here for more information about Medicare Part B and Part D coverage issues.
HOP Eligibility
If I will be turning 65 in a few months, how will this affect my HOP coverage and what will happen?
If you are not currently covered under HOP, turning age 65 is considered a Qualifying Event and gives you the right to enroll in HOP. If you are currently enrolled in HOP, 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 and provide you with a personalized statement showing you information about 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 through HOP?
Yes. Your surviving spouse is eligible to continue coverage through HOP provided timely premium payments are received.
Can my Medicare-eligible spouse have coverage under HOP if I am not covered under HOP and I am the 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 medical expenses incurred out of the United States for reimbursement (you would submit claims and they would be treated like a major medical expense). 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 HOP?
If you or your dependent(s) are not currently enrolled in HOP, your next opportunity to enroll would be if you experience a Qualifying Event, which include:
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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.
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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).
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You or your spouse reach age 65 or become eligible for Medicare.
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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).
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You become eligible for Premium Assistance due to a change in legislation.
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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 HOP?
HMOs market different/lesser benefit plans to individuals than the group plan offered through HOP. 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 HOP?
Once an HMO is approved to participate in HOP, 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 PSERS' HOP?
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 HOP 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:
- For a Medicare risk HMO, a primary consideration is the Medicare reimbursement rate that varies by county.
- 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.
- 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 HOP, you do not need to sign up for other Medicare Prescription Drug Coverage outside of HOP. 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 HOP prescription drug coverage.
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 Open Selection Period and decide you want coverage under the Enhanced Medicare Rx Option during the next Open 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 2009 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 HOP, you may be eligible to enroll for HOP coverage 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 Medicare Rx Options on a standalone basis, you will be billed for the cost of your HOP 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 HOP medical coverage (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 HOP Medicare Prescription Drug Coverage (with either the Basic or Enhanced Medicare Rx Options) with your TRICARE or VA coverage. For more information, see the following related Web links:
For TRICARE Coverage
What happens to my HOP 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 Prescription Solutions at 1-888-239-1301.
Can I stay on my wife's medical plan and only sign up for the prescription drug coverage through HOP and still receive 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 HOP 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 HOP or a Pennsylvania school district (employer) plan.