Retirees enrolled in the Princeton Medicare Plan (PMP) automatically receive prescription drug coverage through the Princeton Medicare Prescription Drug Plan (PDP). It is also known as an Employer Group Waiver Plan (EGWP), offered through OptumRx. It is fully integrated with the Medicare Part D Program.
Retirees who enroll in the PMP are automatically enrolled in both the PDP and the EGWP including Medicare Part D. Medicare D becomes the primary coverage and OptumRx serves as secondary coverage. This also applies to eligible dependents enrolled in a Princeton retiree medical plan and who are Medicare eligible.
The PDP is administered by OptumRx. As an EGWP, it provides additional coverage to Medicare Part D and is very similar to the coverage for active employees. In addition:
- The PDP is designed to work seamlessly together with Medicare D.
- Each enrolled individual receives an OptumRx ID card to use at the pharmacy.
- Participants pay a copay for eligible prescription drugs and have no Medicare Part D deductible to meet. Retirees in the Standard and Premium plans must first meet an annual prescription plan deductible.
- The PDP covers certain medications not covered by a regular Medicare Part D plan formulary, such as certain sedative and anxiety medications.
- There is a “Prior Authorization” process to receive coverage for clinical drug exceptions. For example, if the medical provider prescribes a non-preferred brand or excluded medication for the participant that causes an allergic reaction, the participants needs to ask the provider to file a Prior Authorization Request with OptumRx in order for the medication to be covered. If OptumRx approves the request, payment for a non-preferred drug is the preferred brand copay. If OptumRx approves an excluded drug, payment is the non-preferred brand copay.
Other relevant information is:
- Participants may buy up to a 90-day supply at a retail pharmacy.
- The plan provides greater access to prescription drug benefits at long-term care facilities and to programs that help very low income seniors.
- The cost of the PDP is included in the monthly medical plan premium.
- Some high-income retirees may be subject to surcharges, referred to as Income Related Monthly Adjustment Amounts (IRMAA), determined by the Social Security Administration based on the retiree’s income in a prior period. For example, the IRMAA surcharge for 2020 is based on income earned in 2018. Refer to frequently asked question #2 ("Do I pay an additional premium for the PDP?") for more information.
- OptumRX mails ID cards for each individual enrolled to home addresses within three to four weeks following enrollment in or changes to medical coverage. Individuals can view and/or print their ID cards from the OptumRx website or mobile app.
Participants who choose to enroll in a Medicare Part D plan other than the PDP or opt-out of the PDP may no longer be enrolled in or have prescriptions covered by Princeton. If the retiree coverage includes Medicare-eligible dependents, one can opt out and the other can stay enrolled. When this occurs, be aware that individuals who opt out or disenroll:
- Continue to be enrolled in the retiree medical plan and pay the same monthly premium with no adjustment
- Must enroll in prescription coverage elsewhere, including Medicare, as required by the Medicare Modernization Act (MMA), that is considered “creditable coverage,” or possibly pay a Late Enrollment Penalty (LEP) in addition to the premium for a Medicare prescription drug plan in the future
The Center for Medicare and Medicaid Services (CMS) requires standard communications be sent to all participants in the PDP, which are sent to participants by OptumRx. For more information, refer to the frequently asked questions or contact OptumRx Customer Service at (855) 209-1299, 24 hours a day, 7 days a week.