PACE

PROVIDER BULLETIN

January 26, 2007

PACE Plus Medicare

 

Listed below are the Medicare Part D plans that have partnered with PACE for 2007.  Providers will notice three additional plans (identified by an asterisk *). Providers should also take note that some plans have changed their copay as well as their formulary.

 

As before, the PACE Program is recommending that cardholders using the prescription drug benefit enroll in one of the following plans if they are not currently enrolled in a Medicare Advantage Plan or an employer retiree plan.

 

PACENET cardholders not enrolled in a Part D plan listed below will be responsible for a monthly PACENET premium of $28.45 plus the copay(s).

 

 

 

 

 

Plan

BIN

Premium

Deductible

Generic Copay

Copays:

Brand, NP, Specialty

 

 

 

 

 

 

AmeriHealth Advantage (IBC)

 

012353

 

$28.45

 

$265

25%

30-day retail &

 mail order (Walgreens)

Brand--25%

NP Brand--25%

Specialty--25%

 

 

 

 

 

 

First Health Premier

 

 

610029

 

$28.45

 

$265

 

$5 (& few brands)

90-day retail, 3 copays

No Mail Order

CAREMARK Spcty

Brand--$25

NP Brand--$58

Specialty--25%

90-day retail, 3 copays

No Mail Order

 

 

 

 

 

 

* Elder Health

   BravoRx II

610014

$23.60

$265

25%

90-day mail 25%

Brand--25%

90-day mail 25%

Specialty--25%

90-day mail 25%

 

 

 

 

 

 

* Geisinger Gold Rx

Submission Time—

60 days from DOS

012353

22.80

0

$5

90-day mail, $12.50

Medco

Brand -$36

90-day mail, $90

NP Brand--$78

90-day mail, $195

 

 

 

 

 

 

 

 

 

(over)

Plan

BIN

Premium

Deductible

Generic Copay

Copays:

Brand, NP, Specialty

 

 

 

 

 

 

Highmark BlueRx Plus

90 days submission

610014

$23.20

$0

$6

90 day retail, $18

90 day mail,  $15

 

MEDCO Mail Order

 Brand-$29;

90 day retail-- $87

90 day mail-- $72.50

 NP --$50

90 day retail-- $150

90 day mail-- $125

 Spec –25%

90 day retail—25%

90 day mail—25%

 

 

 

 

 

 

Humana --Standard

610649

 

$14.80

 

$265

25%

30 or 90-day retail & mail-

3 copays

Brand—N/A

NP Brand—N/A

Specialty—N/A

 

 

 

 

 

 

Humana--Enhanced

610649

 

$22.90

 

$0

$5

90 day mail—3 copays

Brand--$30

NP Brand--$60

Specialty-- 25%

90 day mail—3 copays-- applicable to all

 

 

 

 

 

 

MemberHealth Community Care Rx Basic

012304

 

$28.70

 

$265

 

$0

90-day retail, $0 copay

Brands—25%

90-day retail, 25% copay

NP Brands—50%

90-day retail, 50% copay

 

 

 

 

 

 

Ovations: AARP Medicare RX Saver

(Managed Formulary)

610097

 

$20.80

 

$265

 

$5

90-day mail,  $5 copay

Mail Order-- Rx Solutions; WHI (Walgreens)

Brand--$20

90-day mail,  $45 copay

NP Brand--$45.20

90-day mail,  $120 copay

Specialty-- 25%

90-day mail, 25% copay

 

 

 

 

 

 

* UPMC for Life

 

Submission time-

14 days from DOS

003858

 

 

PCN: Medicare Part D only: PMDA

$23.50

$0

$5

90 day retail & mail –3 copays

 

NOTE: Not all retail can do 90 day.

Express Scripts for Mail  Order

 Brands:$32

90 day retail & mail –3 copays

NP Brands $64

90 day retail & mail –3 copays

Low cost Injectables—25%

90 day retail & mail –3 copays

Specialty—33% copay

90-day mail 33% copay.

 

CATASTROPHIC COVERAGE:  The listed plans have a $2 generic; $5 brand or 5% copay--whichever is greater.

 

Note:

·                     Part D plans may require specific provider contracts to dispense 90 days at retail.

·                     PACE cardholders may belong to plans other than the plans listed above. In all cases providers should ask PACE cardholders for their PACE card and if they are enrolled in a Part D plan.

·                     When a Part D’s plan’s copay is greater than the PACE/PACENET copay, be sure to bill the Program to allow the cardholder to pay the lower copay.

·                     Claims with copays lower than PACE/PACENET need not be billed to PACE/PACENET.  

 

Questions may be directed to Provider Services at 1-800-835-4080.