Your Medicare Health Coverage and Prescription Drug Coverage as a Member of PERS ODS Advantage PPORX

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1 900641_PERS_ODS_Adv_PPO_Rx_EOC_Cover_QUARK7:Layout 1 9/15/ :43 AM Page PERS ODS Advantage PPORX Annual Notice of Changes and Evidence of Coverage January 1 - December 31, 2011 Your Medicare Health Coverage and Prescription Drug Coverage as a Member of PERS ODS Advantage PPORX This booklet gives you the details about your Medicare health and prescription drug coverage from January 1 to December 31, 2011, and explains how to get the health care and prescription drugs you need. This is an important legal document. Please keep it in a safe place. Member Services: For help or information, please call Member Services at (calls to these numbers are free). TTY/TDD users call , or go to our plan website at Hours of Operation: For help or information, please call Member Services from 7 a.m. to 8 p.m. Monday through Friday, Pacific Time. Pharmacy Customer Service: For help or information, please call Customer Service at (calls to these numbers are free). TTY/TDD users call , or go to our plan website at Hours of Operation: For help or information, please call Customer Service from 7 a.m. to 8 p.m. Pacific Time seven days a week, from November 15 to March 1, (After March 1, 2011, your call will be handled by our automated phone system Saturdays, Sundays and holidays. When leaving a message, please include your name, number and the time that you called, and a Customer Service Representative will return your call the next business day.) This Plan is offered by ODS Health Plan, Inc., referred throughout the EOC as we, us or our. PERS ODS Advantage PPORX is referred to as Plan or our Plan. This information may be available in a different format, including large print. Please call Member Services at the number listed above if you need plan information in another format or language. A PPO with a Medicare contract. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, H H3813_1027EGPPORX11A FILE & USE (09/15/2010)

2 October 2010 Dear Member, Here are two documents with important information for you. 1. Please start by reading the Annual Notice of Changes for It gives you a summary of changes to your benefits and costs for next year. These changes will take effect on January 1, Please take a moment very soon to look through this summary and see how the changes might affect you. If you decide to stay with PERS ODS Advantage PPORX for 2011 you do not have to tell us or fill out any paperwork. You will automatically remain enrolled as a member of PERS ODS Advantage PPORX. If you decide to leave PERS ODS Advantage PPORX, you can switch to a different Medicare Advantage Plan or to Original Medicare from November 15 through December 31 of The Annual Notice of Changes tells you more. 2. We re including a copy of next year s Evidence of Coverage. It s the legal, detailed description of your benefits and costs for 2011 if you stay enrolled as a member of PERS ODS Advantage PPORX. It also explains your rights and rules you need to follow when using your coverage for medical care and prescription drugs. Please look through this document so you know what s in it, then keep it handy for reference. 3. We re also including a copy of the PERS ODS Advantage PPORX plan s List of Covered Drugs (Formulary), effective January 1, If you have questions, we re here to help. Please call Member Services at (TTY only, call ). Hours are from 7 am to 8 pm, Pacific time, Monday through Friday, November 15 through March 1, 2011 (After March 1, 2011 your call will be handled by our automated phone system, Saturdays, Sundays and holidays) and calls to these numbers are free. You can also visit our website, We value your membership and hope to continue to serve you next year.

3 PERS ODS Advantage PPORX Annual Notice of Changes for 2011 This booklet tells you how your benefits and costs as a member of PERS ODS Advantage PPORX will change next year from your current benefits. The changes take effect on January 1, To decide what s best for you, compare this information we re sending with the benefits and costs of other Medicare Advantage plans in your area, as well as the benefits and costs of Original Medicare. PERS ODS Advantage Member Services: For help or information, please call Member Services or go to our plan website at ( ) , 7 am to 8 pm, Pacific time, Monday through Friday. Calls to these numbers are free. TTY users call ODS Advantage Pharmacy Customer Service: For help or information, please call Customer Service or go to our plan website at ( ) , 7 am to 8 pm seven days a week. Calls to these numbers are free. TTY users call Hours of Operation: 7 am to 8 pm, Pacific time, seven days a week from November 15 through March 1, 2011 (After March 1, 2011 your call will be handled by our automated phone system, Saturdays, Sundays and holidays) This plan is offered by ODS Health Plan, Inc., referred throughout the Annual Notice of Changes as we, us, or our. PERS ODS Advantage PPORX is referred to as plan or our plan. A PPO with a Medicare contract. This information is available in a different format, including large print. Please call Member Services at the number listed above if you need plan information in another format or language. H3813_1027EGPPORX11A File & Use (09/15/2010)

4 If you remain enrolled in PERS ODS Advantage PPORX for 2011, there will be some changes to your benefits and what you pay. You are currently enrolled as a member of PERS ODS Advantage PPORX. We are pleased to be providing your Medicare health care coverage including your prescription drug coverage. This notice describes changes in benefits from PERS ODS Advantage PPORX in 2010 to PERS ODS Advantage PPORX in Each year, Medicare health plans may decide to adjust their offerings to reflect annual changes in medical costs and payment rates. Plan adjustments can include changing premiums and costsharing amounts and adding or subtracting benefits. We re sending you this Annual Notice of Changes to tell you how your benefits and costs as a member of PERS ODS Advantage PPORX will change next year from your current benefits. The changes take effect on January 1, Medicare has approved these changes. What should you do? We want you to know what s ahead for next year, so please read this document very soon to see how the changes in benefits and costs will affect you if you stay enrolled in PERS ODS Advantage PPORX for With this Annual Notice of Changes, we are notifying you of all plan changes for the coming year, including any changes to the monthly plan premium. You will also get information from Medicare about other plan options in your area. To decide what s best for you, compare this information we re sending with the benefits and costs of other Medicare Advantage plans in your area as well as the benefits and costs of Original Medicare. You can find information about plans available in your area by visiting the Medicare website ( The Medicare website includes information about plans benefits and costs, as well as information about how Medicare rates the plans in different categories (for example, detecting and preventing illness, ratings from members, and customer service). If you have access to the web, you may use the web tools on by clicking on the Health and Drug Plans button and then choosing either Find & Compare Drug Plans or Find & Compare Health Plans. You can also call us directly at ( ) from 7 am to 8 pm, Pacific time, Monday through Friday to obtain a copy of the plan ratings for this plan. TTY users call We hope to keep you as a member of PERS ODS Advantage PPORX. But if you want to make a change for 2011, see When can you change in Section 7 for time periods when you can make a change.

5 Table of Contents Section 1. Important things to know... 1 This Annual Notice of Changes is only a summary (see your Evidence of Coverage for the details)...1 There are programs to help people with limited resources pay for their prescription drugs...1 What if you are currently getting help to pay for your drugs?...1 Section 2. Changes to your monthly premium... 2 Section 3. Medical services: Changes to your benefits and out-of-pocket costs... 2 Changes to your benefits...2 Changes to your out-of-pocket costs...3 Section 4. Part D prescription drugs: Changes to your benefits and out-ofpocket costs... 8 Changes to your benefits...8 Changes to your out-of-pocket costs...9 What if changes for 2011 affect drugs you are taking now?...10 Section 5. What about changes to the plan s network of providers? Will your doctors and other providers still be in the plan s network next year?...11 Section 6. Do you want to stay in the plan or make a change? Do you want to stay with PERS ODS Advantage PPORX?...11 Do you want to make a change?...11 Section 7. Do you need some help? Would you like more information? We have information and answers for you...12 You can get help and information from your State Health Insurance Assistance Program (SHIP)...13

6 You can get help and information from Medicare...13

7 Annual Notice of Changes in PERS ODS Advantage PPORX for Section 1. Important things to know This Annual Notice of Changes is only a summary (see your Evidence of Coverage for the details) This Annual Notice of Changes gives you a summary of the changes in your benefits and what you will pay for these services in The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact the plan or look in your Evidence of Coverage. To get the details, you can look in the 2011 Evidence of Coverage for PERS ODS Advantage PPORX. The Evidence of Coverage is the legal, detailed description of your benefits and costs for It explains your rights and the rules you need to follow to get your covered services and prescription drugs. (We have included a copy of the Evidence of Coverage in the same booklet with this Annual Notice of Changes. If you do not have this copy, call Member Services.) If you have questions or need more information, you can always call Member Services at (local in Portland ) (TTY only, call ). The hours are from 7 am to 8 pm, Pacific time, Monday through Friday, November 15 through March 1, 2011 (After March 1, 2011 your call will be handled by our automated phone system, Saturdays, Sundays and holidays) and calls to these numbers are free. There are programs to help people with limited resources pay for their prescription drugs You might qualify to get help in paying for your drugs. There are two basic kinds of help: Extra Help from Medicare. This program is also called the low-income subsidy or LIS. People whose yearly income and resources are below certain limits can qualify for this help. See Section III of the new Medicare & You 2011 Handbook or call MEDICARE ( ). TTY users should call You can call these numbers for free, 24 hours a day, 7 days a week. Help from your state s pharmaceutical assistance program. Many states have State Pharmaceutical Assistance Programs (SPAPs) that help some people pay for prescription drugs based on financial need, age, or medical condition. Each state has different rules. Check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Chapter 2, Section 3 of your Evidence of Coverage). What if you are currently getting help to pay for your drugs? If you already get help paying for your drugs, some of the information in this Annual Notice of Changes is not correct for you. We have included a separate insert, called the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider) that tells you about your drug coverage. If you don t have this insert, please call Member Services and ask for the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (LIS Rider). Phone numbers for Member Services are on the front cover.

8 Annual Notice of Changes in PERS ODS Advantage PPORX for Section 2. Changes to your monthly premium You must continue to pay your Medicare Part B premium and your monthly PERS Health Insurance Program premiums. If you have questions about your premium please contact PERS Health Insurance Program at or local from 7:30 am to 5:30 pm, Monday through Friday, Pacific time. Your premium may be more in 2011: If you are required to pay a late enrollment penalty (because you went at least 63 days without Part D or other creditable prescription drug coverage anytime after the end of your Part D initial enrollment period), PERS Health Insurance Program will pay your late enrollment penalty. For more information about this penalty, see Chapter 6 of your Evidence of Coverage. Most people will pay the standard monthly Part D premium. However, starting January 1, 2011, some people will pay a higher premium because of their yearly income (over $85,000 for singles , $170,000 for married couples ). For more information about Part D premiums based on income, you can visit on the web or call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call You may also call the Social Security Administration at TTY users should call Section 3. Medical services: Changes to your benefits and out-of-pocket costs Changes to your benefits As shown below PERS ODS Advantage PPORX is changing our covered benefits for next year. For details, see Chapters 3 and 4 in your Evidence of Coverage (this year) 2011 (next year) Skilled Nursing Facility (SNF) (In and out-of-network) Partial Hospitalization Services Outpatient Services/Surgery (In - network) Outpatient hospital facility benefits and Ambulatory Surgical Center (ASC) Prior two day hospital stay is required No prior authorization required in network No prior authorization required in network No prior hospital stay is required Prior authorization required in network Prior authorization required in network

9 Annual Notice of Changes in PERS ODS Advantage PPORX for (this year) 2011 (next year) Dental Services (In network) No prior authorization required Prior Authorization required Changes to your out-of-pocket costs The chart below summarizes changes to your out-of-pocket costs, the amounts you will pay as your share of the cost of covered medical services, usually at the time services are received. For details, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your Evidence of Coverage (this year) 2011 (next year) Out-of-pocket maximum for both in-network and out-of-network medical services The out-of-pocket maximum for both in-network and out-of-network services is also called the catastrophic out-of-pocket maximum. This is the maximum amount you pay during the calendar year for covered Part A and Part B services received from both in-network and out-of-network providers. (The amount you pay for your plan premium does not count toward your out-of-pocket maximum.) $ This is the maximum amount you pay for covered Part A and Part B services from both in-network and out-of-network providers. $ This is the maximum amount you pay for covered Part A and Part B services from both in-network and out-of-network providers. Medicare-covered preventive services For all Medicare covered preventive services (except for Routine Physical exams) the cost sharing for office visits, outpatient facility or ASC copayment rules apply Our plan covers all Medicare-covered preventive services at no cost to you. Inpatient Hospital Care (In and out-of-network) $ copayment Days 1 3 $ copayment per day

10 Annual Notice of Changes in PERS ODS Advantage PPORX for Inpatient Mental Health Care (In and out-of-network) $ copayment Days 1 3 $ copayment per day Inpatient services covered when the hospital or SNF days aren t, or are no longer covered Home health agency care Outpatient Mental Health Care Outpatient Substance Abuse Partial Hospitalization Services $10.00 copayment for x-rays 10% to $100 maximum copayment for MRI/CT/CAT/PET $10.00 copayment for prosthetic devices DME $10.00 copayment $15.00 copayment for physical therapy, speech therapy, and occupational therapy $10.00 copayment for durable medical equipment $10.00 copayment for prosthetic devices $15.00 copayment for individual therapy visit $15.00 copayment for group therapy visit $15.00 copayment for individual therapy visit $15.00 copayment for group therapy visit $15.00 copayment for each Medicare covered visit You pay 10% of the total cost for x-rays, diagnostic radiology and therapeutic radiology services You pay 10% of the total cost for prosthetics, orthotic devices and durable medical equipment $20.00 copayment for physical therapy, speech therapy and occupational therapy $20.00 copayment for physical therapy, speech therapy, and occupational therapy You pay 10% of the total cost for prosthetics, orthotic devices and durable medical equipment $20.00 copayment for individual therapy visit $20.00 copayment for group therapy visit $20.00 copayment for individual therapy visit $20.00 copayment for group therapy visit Prior authorization required in network $20.00 copayment for each Medicare covered visit

11 Annual Notice of Changes in PERS ODS Advantage PPORX for (this year) 2011 (next year) Outpatient Services/Surgery (In and out-of-network) Outpatient hospital facility benefits and Ambulatory Surgical Center (ASC) Urgently needed care Physician services - Specialist Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory Therapy Services, Social/Psychological Services, Cardiac Rehab Services and Comprehensive Outpatient Rehabilitation Facility (CORF) services) (In and out-of-network) $10 to $ copayment or 10% of the total cost up to a max $ copayment $15.00 copayment for each Medicare covered urgently needed care visit $15.00 copayment for each Medicare covered visit $15.00 copayment for each Medicare covered visit Prior authorization required In network $125 copayment for each Medicare covered visit $20.00 copayment for each Medicare covered urgently needed care visit $20.00 copayment for each Medicare covered specialist visit $20.00 copayment for each Medicare covered visit Chiropractic Services (In and out-of-network) Podiatry Services (In and out-of-network) Diagnostic Tests, X-rays, Lab Services and Radiology Services (In and out-of-network) $15.00 copayment for each Medicare covered visit $15.00 copayment for each Medicare covered visit $10.00 copayment for Medicare covered X- rays $10 to $ copayment for Medicare covered diagnostic radiology services or 10% up to a max copayment of $20.00 copayment for each Medicare covered visit $20.00 copayment for each Medicare covered visit You pay 10% of the total cost for Medicare covered X-rays You pay 10% of the total cost for Medicare covered diagnostic radiology

12 Annual Notice of Changes in PERS ODS Advantage PPORX for $ for Medicare covered diagnostic radiology $35.00 copayment for Medicare covered radiation therapy services Separate office visit cost sharing of $0 to $30 may apply You pay 10% of the total cost for Medicare covered radiation therapy services 2010 (this year) 2011 (next year) Durable Medical Equipment (In and out-of-network) Prosthetic Devices (In and out-of-network) $10.00 copayment for Medicare covered items $10.00 copayment for Medicare covered items You pay 10% of the total cost for Medicare covered items You pay 10% of the total cost for Medicare covered items Medical nutrition therapy $10 copayment $0 copayment for nutrition therapy Diabetes Self-Monitoring Training, Nutrition Therapy and Supplies (In and out of network) Vision care $10.00 copayment for diabetes self monitoring training $10.00 copayment for nutrition therapy for diabetes $10.00 copayment for custom molded shoes and inserts for custom molded shoes $0 copayment for glaucoma screening test $15.00 copayment for routine eye exam $0 copayment for diabetes self management training $0 copayment for nutrition therapy for diabetes You pay 10% of the total cost for custom molded shoes and inserts for custom molded shoes $0 copayment for exams to diagnose and treat diseases and conditions of the eye $20.00 copayment for routine eye exam one per year

13 Annual Notice of Changes in PERS ODS Advantage PPORX for (this year) 2011 (next year) Dialysis (In and out-of-network) $200 copayment for Inpatient services per benefit period Days 1 3 $ copayment per day for in and out of network Inpatient hospital stay $10.00 copayment for nutrition therapy for end-stage renal disease $0 copay for nutrition therapy for end-stage renal disease Bone Mass Measurement (In and out-of-network) $15.00 copayment for each Medicare covered visit $0 copayment for Medicare covered bone mass measurement Colorectal Screening Exams (In and out-of-network) Immunizations (In and out-of-network) Mammograms (In and out-of-network) Pap Smears and Pelvic Exams (In and out-of-network) Prostate Cancer Screening Exams (In and out-of-network) Cardiovascular disease testing $0 to $ copayment for office visit copayment or outpatient facility or ASC copayment rules apply 10% of the total cost for Hepatitis B vaccines $10.00 copayment for Medicare covered screening mammograms Separate office visit cost sharing of $0 to $15.00 may apply Separate office visit cost sharing of $0 to $15 may apply Separate office visit cost sharing of $0 to $15 may apply $0 copayment office visit copayment or outpatient facility or ASC copayment rules do not apply $0 copayment for Hepatitis B vaccine $0 copayment for Medicare covered screening mammograms Separate office visit cost sharing rules do not apply Separate office visit cost sharing rules do not apply Separate office visit cost sharing rules do not apply

14 Annual Notice of Changes in PERS ODS Advantage PPORX for (this year) 2011 (next year) Dental Services (In and out-of-network) $20 to $200 copayment for Medicare covered dental benefits Separate office visit cost sharing of $0 to $15.00 may apply Prior Authorization required In network only $20.00 copayment for Medicare covered dental benefits Hearing Services (In and out-of-network) Vision Services $15.00 copayment for each Medicare covered visit $15.00 copayment for up to one routine eye exam every year $20.00 copayment for each Medicare covered visit $20.00 copayment for up to one routine eye exam every year Section 4. Part D prescription drugs: Changes to your benefits and out-of-pocket costs Changes to your benefits PERS ODS Advantage PPORX has a List of Covered Drugs (Formulary) or Drug List for short. It tells which Part D prescription drugs are covered by the plan. (Chapter 5, Section 1.1 of your Evidence of Coverage explains about Part D drugs.) We may make changes to the plan s Drug List from time to time throughout the year. In addition, there are a number of changes to the Drug List that will take effect on January 1, Changes to the plan s Drug List have been approved by Medicare. We have added some new drugs to the list and removed others We have added some new drugs that became available. We have replaced some brand name drugs with new generic drugs. We have replaced some expensive drugs with less costly drugs that have been shown to work just as well or better. We have removed a few drugs due to safety concerns or because medical research has shown they are not effective. We have added some new restrictions to certain drugs, and reduced the restrictions on others. Restrictions can include a requirement to get plan approval in advance or to try a different drug first to see how well it works. Restrictions can also include limits on the quantity of the drug that the plan will cover for you. Please check to see if any of these changes to drug coverage affect the drugs you use.

15 Annual Notice of Changes in PERS ODS Advantage PPORX for You can look for your drugs on the Drug List we sent with this Annual Notice of Changes. If you can t find some of your drugs on this Drug List, you can call Member Services for help finding your drugs. Changes to your out-of-pocket costs The chart below summarizes changes to the plan s Drug Payment Stages. These changes affect Part D prescription drugs only (this year) 2011 (next year) Initial Coverage Stage During the Initial Coverage Stage, the plan pays its share of the cost of your covered drugs, and you pay your share. (Changes to your share of the costs are described in the next chart.) You stay in this stage until the total cost of your Part D drugs reaches the limit for the Initial Coverage Stage. Once you reach this limit, you move on to the Coverage Gap Stage. You pay 40% of the cost of drugs up to a maximum out of pocket $ for each prescription up to a 30 day supply $ When the total costs for your Part D drugs reaches this amount, you move on to the Coverage Gap Stage. You pay 40% of the cost of drugs up to a maximum out of pocket $ for each prescription up to a 30 day supply $ When the total costs for your Part D drugs reaches this amount, you move on to the Coverage Gap Stage.

16 Annual Notice of Changes in PERS ODS Advantage PPORX for Coverage Gap Stage You stay in the Coverage Gap Stage until your out-of-pocket costs for your Part D drugs reaches the amount that qualifies you for Catastrophic Coverage (this year) During the Coverage Gap Stage, you pay 40% of the cost of drugs up to a maximum out of pocket $ for each prescription up to a 30 day supply You stay in this stage until your out-of-pocket costs reach: $ This is the amount you must pay out-of-pocket to leave the Coverage Gap Stage and qualify for Catastrophic Coverage (next year) During the Coverage Gap Stage, you pay 40% of the cost of drugs up to a maximum out of pocket $ for each prescription up to a 30 day supply You stay in this stage until your out-of-pocket costs reach: $ This is the amount you must pay out-of-pocket to leave the Coverage Gap Stage and qualify for Catastrophic Coverage. Catastrophic Coverage Stage During the Catastrophic Coverage Stage, the plan will pay most of the cost for your Part D drugs. You will stay in this stage until the end of the calendar year (this year) After your yearly out of pocket drug costs reach $ , the plan will pay the entire cost of your drugs (next year) After your yearly out of pocket drug costs reach $ , the plan will pay the entire cost of your drugs. The coinsurance amount you pay for covered drugs will be exactly the same in 2011 as it is in What if changes for 2011 affect drugs you are taking now? What if a drug you are taking now is not on the Drug List for 2011? What if it has been moved to a higher cost-sharing tier? What if a new restriction has been added to the coverage for this drug? If you are in any of these situations, here s what you can do: In some situations, the plan will cover a one-time, temporary supply of your drug when your current supply runs out. This temporary supply will be for a maximum of 30 days, or less if your prescription is written for fewer days. Chapter 5, Section 6.2 explains when you can get a temporary supply and how to ask for one.

17 Annual Notice of Changes in PERS ODS Advantage PPORX for Meanwhile, you and your doctor will need to decide what to do before your temporary supply of the drug runs out. Perhaps you can find a different drug covered by the plan that might work just as well for you. You can call Member Services to ask for a list of covered drugs that treat the same medical condition. This list can help your doctor find a covered drug that might work for you. You and your doctor can ask the plan to make an exception for you and cover the drug. You can ask for an exception in advance for next year and we will give you an answer to your request before the change takes effect. To learn what you must do to ask for an exception, see the Evidence of Coverage that was included in the mailing with this Annual Notice of Changes. Look for Chapter 9 (What to do if you have a problem or complaint). Section 5. What about changes to the plan s network of providers? Will your doctors and other providers still be in the plan s network next year? There are a few changes to the network of providers for In addition, it s possible for the network of plan providers to change at any time during the year. Please check with your doctors and other providers you currently use to make sure they will continue to be part of the provider network for PERS ODS Advantage PPORX in For the most up-to-date information on the network of providers, check our website ( or call Member Services (see phone numbers on the front cover). Section 6. Do you want to stay in the plan or make a change? Do you want to stay with PERS ODS Advantage PPORX? If you want to keep your membership in PERS ODS Advantage PPORX for 2011, it s easy. You don t need to tell us or fill out any paperwork. You will automatically remain enrolled as a member if you do not sign up for a different plan or Original Medicare. Do you want to make a change? PERS ODS Advantage PPORX is sponsored by PERS Health Insurance Program. Disenrolling from the PERS ODS Advantage PPORX may disenroll you from PERS. You may call PERS Health Insurance Program to discuss your options, at or toll free at or TTY , Monday through Friday from 7:30 am to 5:30 pm Pacific time. If you leave PERS Health Insurance Program, you may not be able to return to the PERS Health Insurance Program.

18 Annual Notice of Changes in PERS ODS Advantage PPORX for If you want to change to a different plan, there are many choices. When can you change to a different plan within PERS? During the yearly enrollment period (called the PERS annual plan change ) from October 1 st through November 15, 2010, you can change to any other PERS Medicare Advantage plan or you can switch to Original Medicare with the PERS Medicare Supplement plan. Your new coverage will begin on January 1, Are these the only times of the year to choose a different plan? For most people, yes. Certain individuals, such as those with Medicaid, those who get Extra Help paying for their drugs, or those who move out of the geographic service area, can make changes at other times. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage. How do you make a change? See Chapter 10 of the enclosed Evidence of Coverage document. It tells what you need to do to make a change from PERS ODS Advantage PPORX to another plan. Things to check on before you make a change Are you a member of an employer or retiree group plan? If you are, please check with the benefits administrator of your employer or retiree group before you change your plan. This is important because you may lose benefits you currently receive under your employer or retiree group coverage if you switch plans. Are you getting help with paying for your drugs from a State Pharmaceutical Assistance Program (SPAP)? If you are, please check with this program before switching to another plan. The phone number for your State Pharmaceutical Assistance Program is listed in Chapter 2, Section 7 of the Evidence of Coverage. Section 7. Do you need some help? Would you like more information? We have information and answers for you To learn more, read the information we sent in the same package with this Annual Notice of Changes. This includes a copy of the Evidence of Coverage and of the List of Covered Drugs (Formulary). If you have any questions, we are here to help. Please call us at PERS ODS Advantage PPORX Member Services. We are available for phone calls from 7 am to 8 pm, Pacific time, Monday through Friday. Calls to these numbers are free: (TTY only, call ).

19 Annual Notice of Changes in PERS ODS Advantage PPORX for You can get help and information from your State Health Insurance Assistance Program (SHIP) The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Oregon, the SHIP is called Senior Health Insurance Benefits Assistance (SHIBA). SHIBA is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. SHIBA counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call SHIBA at Monday through Friday from 8:00 am to 5:00 pm, Pacific time. (Oregon TTY only call ). You can get help and information from Medicare Here are three ways to get information directly from Medicare: Call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Visit the Medicare website ( Read Medicare & You Every year in October, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website ( or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call

20 January 1 December 31, 2011 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of PERS ODS Advantage PPORX (PPO) This booklet gives you the details about your Medicare health and prescription drug coverage from January 1 December 31, It explains how to get the health care and prescription drugs you need. This is an important legal document. Please keep it in a safe place. PERS ODS Advantage PPORX Member Services: For help or information, please call Member Services or go to our plan website at (Portland local number ) From 7 am to 8 pm, Pacific time, Monday through Friday. Calls to these numbers are free. TTY users call: PERS ODS Advantage PPORX Pharmacy Customer Service: For help or information, please call Member Services or go to our plan website at (Portland local number ) From 7 am to 8 pm, Pacific time, seven days a week from November 15 through March 1, 2011 (After March 1, 2011 your call will be handled by our automated phone system, Saturdays, Sundays and holidays). Calls to these numbers are free. TTY users call: This plan is offered by ODS Health Plan, Inc., referred throughout the Evidence of Coverage as we, us, or our. PERS ODS Advantage PPORX is referred to as plan or our plan. A PPO with a Medicare contract. This information is available in a different format, including large print. Please call Member Services at the number listed above if you need plan information in another format or language. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, H3813_1027EGPPORX11A File & Use (09/15/2010)

21 Table of Contents Table of Contents This list of chapters and page numbers is just your starting point. For more help in finding information you need, go to the first page of a chapter. You will find a detailed list of topics at the beginning of each chapter. Chapter 1. Getting started as a member of PERS ODS Advantage PPORX... 1 Tells what it means to be in a Medicare health plan and how to use this booklet. Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date. Chapter 2. Important phone numbers and resources Tells you how to get in touch with our plan (PERS ODS Advantage PPORX) and with other organizations including Medicare, the State Health Insurance Assistance Program, the Quality Improvement Organization, Social Security, Medicaid (the state health insurance program for people with low incomes), programs that help people pay for their prescription drugs, and the Railroad Retirement Board. Chapter 3. Using the plan s coverage for your medical services Explains important things you need to know about getting your medical care as a member of our plan. Topics include using the providers in the plan s network and how to get care when you have an emergency. Chapter 4. Medical Benefits Chart (what is covered and what you pay) Gives the details about which types of medical care are covered and not covered for you as a member of our plan. Tells how much you will pay as your share of the cost for your covered medical care. Chapter 5. Using the plan s coverage for your Part D prescription drugs Explains rules you need to follow when you get your Part D drugs. Tells how to use the plan s List of Covered Drugs (Formulary) to find out which drugs are covered. Tells which kinds of drugs are not covered. Explains several kinds of restrictions that apply to your coverage for certain drugs. Explains where to get your prescriptions filled. Tells about the plan s programs for drug safety and managing medications.

22 Table of Contents Chapter 6. What you pay for your Part D prescription drugs Tells about the three stages of drug coverage (Initial Coverage Stage, Coverage Gap Stage, and Catastrophic Coverage Stage) and how these stages affect what you pay for your drugs. Explains the three cost-sharing tiers for your Part D drugs and tells what you must pay for (coinsurance) as your share of the cost for a drug in each cost-sharing tier. Tells about the late enrollment penalty. Chapter 7. Asking the plan to pay its share of a bill you have received for covered services or drugs Tells when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services. Chapter 8. Your rights and responsibilities Explains the rights and responsibilities you have as a member of our plan. Tells what you can do if you think your rights are not being respected. Chapter 9. What to do if you have a problem or complaint (coverage decisions, appeals, complaints) Tells you step-by-step what to do if you are having problems or concerns as a member of our plan. Explains how to ask for coverage decisions and make appeals if you are having trouble getting the medical care or prescription drugs you think are covered by our plan. This includes asking us to make exceptions to the rules or extra restrictions on your coverage for prescription drugs, and asking us to keep covering hospital care and certain types of medical services if you think your coverage is ending too soon. Explains how to make complaints about quality of care, waiting times, customer service, and other concerns. Chapter 10. Ending your membership in the plan Tells when and how you can end your membership in the plan. Explains situations in which our plan is required to end your membership. Chapter 11. Legal notices Includes notices about governing law and about nondiscrimination.

23 Table of Contents Chapter 12. Definitions of important words Explains key terms used in this booklet.

24 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 1 Chapter 1. Getting started as a member of PERS ODS Advantage PPORX SECTION 1 Introduction... 3 Section 1.1 What is the Evidence of Coverage booklet about?...3 Section 1.2 What does this Chapter tell you?...3 Section 1.3 What if you are new to PERS ODS Advantage PPORX?...3 Section 1.4 Legal information about the Evidence of Coverage...4 SECTION 2 What makes you eligible to be a plan member?... 4 Section 2.1 Your eligibility requirements...4 Section 2.2 What are Medicare Part A and Medicare Part B?...4 Section 2.3 Here is the plan service area for PERS ODS Advantage PPORX...5 SECTION 3 What other materials will you get from us?... 5 Section 3.1 Your plan membership card Use it to get all covered care and drugs...5 Section 3.2 The Provider Directory: your guide to all providers in the plan s network...6 Section 3.3 The Pharmacy Directory: your guide to pharmacies in our network...7 Section 3.4 The plan s List of Covered Drugs (Formulary)...7 Section 3.5 Reports with a summary of payments made for your prescription drugs...8 SECTION 4 Your monthly premium for PERS ODS Advantage PPORX... 8 Section 4.1 How much is your plan premium?...8 Section 4.2 There are several ways you can pay your plan premium...10 Section 4.3 Can we change your monthly plan premium during the year?...10 SECTION 5 Please keep your plan membership record up to date... 11

25 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 2 Section 5.1 How to help make sure that we have accurate information about you...11

26 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 3 SECTION 1 Section 1.1 Introduction What is the Evidence of Coverage booklet about? This Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs through our plan, a Medicare Advantage Plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan. You are covered by Medicare, and you have chosen to get your Medicare health care and your prescription drug coverage through our plan, PERS ODS Advantage PPORX. There are different types of Medicare Advantage Plans. PERS ODS Advantage PPORX is a Medicare Advantage Plan PPO (PPO stands for Preferred Provider Organization). This plan is offered by ODS Health Plan, Inc., referred throughout the Evidence of Coverage as we, us, or our. PERS ODS Advantage PPORX is referred to as plan or our plan. The word coverage and covered services refers to the medical care and services and the prescription drugs available to you as a member of PERS ODS Advantage PPORX. Section 1.2 What does this Chapter tell you? Look through Chapter 1 of this Evidence of Coverage to learn: What makes you eligible to be a plan member? What is your plan s service area? What materials will you get from us? What is your plan premium and how can you pay it? How do you keep the information in your membership record up to date? Section 1.3 What if you are new to PERS ODS Advantage PPORX? If you are a new member, then it s important for you to learn how the plan operates what the rules are and what services are available to you. We encourage you to set aside some time to look through this Evidence of Coverage booklet. If you are confused or concerned or just have a question, please contact our plan s Member Services (contact information is on the cover of this booklet).

27 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 4 Section 1.4 Legal information about the Evidence of Coverage It s part of our contract with you This Evidence of Coverage is part of our contract with you about how PERS ODS Advantage PPORX covers your care. Other parts of this contract include your enrollment form, the List of Covered Drugs (Formulary), and any notices you receive from us about changes to your coverage or conditions that affect your coverage. These notices are sometimes called riders or amendments. The contract is in effect for the months in which you are enrolled in PERS ODS Advantage PPORX between January 1, 2011 to December 31, Medicare must approve our plan each year Medicare (the Centers for Medicare & Medicaid Services) must approve PERS ODS Advantage PPORX each year. You can continue to get Medicare coverage as a member of our plan only as long as we choose to continue to offer the plan for the year in question and the Centers for Medicare & Medicaid Services renews its approval of the plan. SECTION 2 Section 2.1 What makes you eligible to be a plan member? Your eligibility requirements You are eligible for membership in our plan as long as: You live in our geographic service area (section 2.3 below describes our service area) -- and -- you are entitled to Medicare Part A -- and -- you are enrolled in Medicare Part B -- and -- you do not have End Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated. Section 2.2 What are Medicare Part A and Medicare Part B? When you originally signed up for Medicare, you received information about how to get Medicare Part A and Medicare Part B. Remember: Medicare Part A generally covers services furnished by institutional providers such as hospitals, skilled nursing facilities or home health agencies. Medicare Part B is for most other medical services, such as physician s services and other outpatient services.

28 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 5 Section 2.3 Here is the plan service area for PERS ODS Advantage PPORX Although Medicare is a Federal program, PERS ODS Advantage PPORX is available only to individuals who live in our plan service area. To stay a member of our plan, you must keep living in this service area. The service area is described below. Our service area includes this state: Oregon Our service area includes all of the counties in Oregon: Baker, Benton, Clackamas, Clatsop, Columbia, Coos, Crook, Curry, Deschutes, Douglas, Gilliam, Grant, Harney, Hood River, Jackson, Jefferson, Josephine, Klamath, Lake, Lane, Lincoln, Linn, Malheur, Marion, Morrow, Multnomah, Polk, Sherman, Tillamook, Umatilla, Union, Wallowa, Wasco, Washington, Wheeler, and Yamhill. If you plan to move out of the service area, please contact Member Services. SECTION 3 Section 3.1 What other materials will you get from us? Your plan membership card Use it to get all covered care and drugs While you are a member of our plan, you must use your membership card for our plan whenever you get any services covered by this plan and for prescription drugs you get at network pharmacies. Here s a sample membership card to show you what yours will look like:

29 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 6 As long as you are a member of our plan you must not use your red, white, and blue Medicare card to get covered medical services (with the exception of routine clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your PERS ODS Advantage PPORX membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. Section 3.2 The Provider Directory: your guide to all providers in the plan s network Every year that you are a member of our plan, we will send you either a new Provider Directory or an update to your Provider Directory. This directory lists our network providers. What are network providers? Network providers are the doctors and other health care professionals, medical groups, hospitals, and other health care facilities that have an agreement with us to accept our payment

30 Chapter 1: Getting started as a member of PERS ODS Advantage PPORX 7 and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. Why do you need to know which providers are part of our network? As a member of our plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either in-network or out-of-network providers, as long as the services are covered benefits and medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher. See Chapter 3 (Using the plan s coverage for your medical services) for more specific information. If you don t have your copy of the Provider Directory, you can request a copy from Member Services. You may ask Member Services for more information about our network providers, including their qualifications. You can also see the Provider Directory at or download it from this website. Both Member Services and the website can give you the most up-to-date information about changes in our network providers. Section 3.3 The Pharmacy Directory: your guide to pharmacies in our network What are network pharmacies? Our Pharmacy Directory gives you a complete list of our network pharmacies that means all of the pharmacies that have agreed to fill covered prescriptions for our plan members. Why do you need to know about network pharmacies? You can use the Pharmacy Directory to find the network pharmacy you want to use. This is important because, with few exceptions, you must get your prescriptions filled at one of our network pharmacies if you want our plan to cover (help you pay for) them. We will send you a complete Pharmacy Directory at least once every three years. Every year that you don t get a new Pharmacy Directory, we ll send you an update that shows changes to the directory. If you don t have the Pharmacy Directory, you can get a copy from Member Services (phone numbers are on the front cover). At any time, you can call Member Services to get up-to-date information about changes in the pharmacy network. You can also find this information on our website at Section 3.4 The plan s List of Covered Drugs (Formulary) The plan has a List of Covered Drugs (Formulary). We call it the Drug List for short. It tells which Part D prescription drugs are covered by PERS ODS Advantage PPORX. The drugs on

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