Catastrophic Prescription Coverage


Emory provides eligible Post-65 retirees and spouses with Catastrophic Prescription coverage. The Catastrophic Coverage Special Payments Benefit is for participants with high prescription drug expenses. This benefit provides additional funds to reimburse you for prescription drug out-of-pocket expenses once you meet the catastrophic coverage threshold. This threshold amount changes each year as directed by the Center for Medicare Services (CMS). The threshold is calculated by your Medicare prescription drug plan and documented on your Explanation of Benefits (EOB) statement. The threshold is defined as the true out-of-pocket cost (TrOOP).

When do I submit a reimbursement request?
Once you have met the threshold, you must submit a Catastrophic Coverage Special Payments Reimbursement Request Form from OneExchange each time you incur a prescription expense. You will need to provide supporting documentation with the form, such as an EOB statement from your Medicare prescription drug plan. All requests for reimbursement must be received by March 31 of the following year. Eligible prescription drug expenses incurred in the calendar year are reimbursable for participants with an active Health Reimbursement Arrangement.

How am I reimbursed?
Once your reimbursement request is approved, you will receive 100% of your eligible prescription drug out-of-pocket expenses incurred after the date you meet the catastrophic coverage threshold.

What else do I need to know?
Prescription drug expenses that qualify toward the catastrophic coverage threshold are the same expenses that apply toward your Medicare Part D Stage 4 catastrophic coverage. These expenses include the amounts paid by you for deductibles, coinsurance and copays for the cost of your prescription drugs. Medications not covered by your Medicare prescription drug plan are not eligible expenses and will not be included in the summary.

The reimbursement of your prescription drug expense is limited to the cost of drugs incurred after the date you meet the catastrophic coverage threshold. Prescription drug plan premium payments and prescription drug expenses reimbursed from any other source are not eligible for reimbursement. Please contact OneExchange at 1-855-241-5720 for additional information.