Medi-Pak Advantage MA-PD Option 1 (PFFS) is a Medicare Advantage organization with a Medicare contract.

Transcription

1 January 1 December 31, 2011 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) This bklet gives yu the details abut yur Medicare health and prescriptin drug cverage frm January 1 December 31, It explains hw t get the health care and prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Member Services: Fr help r infrmatin, please call Member Services r g t ur plan website at r call , Mnday Friday, 8 am t 8 pm. (Calls t these numbers are free.) TTY users call: This plan is ffered by Arkansas Blue Crss and Blue Shield, referred thrughut the Evidence f Cverage as we, us, r ur. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is referred t as plan r ur plan. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is a Medicare Advantage rganizatin with a Medicare cntract. This infrmatin is available in a different frmat, including audi CD. Please call Member Services at the number listed abve if yu need plan infrmatin in anther frmat r language. Benefits, frmulary, pharmacy netwrk, premium and/r cpayments/c-insurance may change n January 1, H4213_REV1_EOC_MAPD1_A2 File & Use 09/21/2010

2 Table f Cntents Table f Cntents This list f chapters and page numbers is just yur starting pint. Fr mre help in finding infrmatin yu need, g t the first page f a chapter. Yu will find a detailed list f tpics at the beginning f each chapter. Chapter 1. Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 1 Tells what it means t be in a Medicare health plan and hw t use this bklet. Tells abut materials we will send yu, yur plan premium, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces 10 Tells yu hw t get in tuch with ur plan (Medi-Pak Advantage MA-PD Optin 1 (PFFS)) and with ther rganizatins including Medicare, the State Health Insurance Assistance Prgram, the Quality Imprvement Organizatin, Scial Security, Medicaid (the state health insurance prgram fr peple with lw incmes), prgrams that help peple pay fr their prescriptin drugs, and the Railrad Retirement Bard. Chapter 3. Using the plan s cverage fr yur medical services 21 Explains imprtant things yu need t knw abut getting yur medical care as a member f ur plan. Tpics include using the prviders in the plan s netwrk and hw t get care when yu have an emergency. Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 29 Gives the details abut which types f medical care are cvered and nt cvered fr yu as a member f ur plan. Tells hw much yu will pay as yur share f the cst fr yur cvered medical care. Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 48 Explains rules yu need t fllw when yu get yur Part D drugs. Tells hw t use the plan s List f Cvered Drugs (Frmulary) t find ut which drugs are cvered. Tells which kinds f drugs are nt cvered. Explains several kinds f restrictins that apply t yur cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins.

3 Table f Cntents Chapter 6. What yu pay fr yur Part D prescriptin drugs 64 Tells abut the fur stages f drug cverage (Deductible Stage, Initial Cverage Stage, Cverage Gap Stage, Catastrphic Cverage Stage) and hw these stages affect what yu pay fr yur drugs. Explains the 4 cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr (cpayments r cinsurance) as yur share f the cst fr a drug in each cst-sharing tier. Tells abut the late enrllment penalty. Chapter 7. Asking the plan t pay its share f a bill yu have received fr cvered services r drugs 78 Tells when and hw t send a bill t us when yu want t ask us t pay yu back fr ur share f the cst fr yur cvered services. Chapter 8. Yur rights and respnsibilities 84 Explains the rights and respnsibilities yu have as a member f ur plan. Tells what yu can d if yu think yur rights are nt being respected. Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 92 Tells yu step-by-step what t d if yu are having prblems r cncerns as a member f ur plan. Explains hw t ask fr cverage decisins and make appeals if yu are having truble getting the medical care r prescriptin drugs yu think are cvered by ur plan. This includes asking us t make exceptins t the rules r extra restrictins n yur cverage fr prescriptin drugs, and asking us t keep cvering hspital care and certain types f medical services if yu think yur cverage is ending t sn. Explains hw t make cmplaints abut quality f care, waiting times, custmer service, and ther cncerns. Chapter 10. Ending yur membership in the plan 137 Tells when and hw yu can end yur membership in the plan. Explains situatins in which ur plan is required t end yur membership. Chapter 11. Legal ntices 144 Includes ntices abut gverning law and abut nndiscriminatin. Chapter 12. Definitins f imprtant wrds 146 Explains key terms used in this bklet.

4 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 1 Chapter 1. Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) SECTION 1 Intrductin 2 Sectin 1.1 What is the Evidence f Cverage bklet abut? 2 Sectin 1.2 What des this Chapter tell yu? 2 Sectin 1.3 What if yu are new t Medi-Pak Advantage MA-PD Optin 1 (PFFS)? 2 Sectin 1.4 Legal infrmatin abut the Evidence f Cverage 2 SECTION 2 What makes yu eligible t be a plan member? 3 Sectin 2.1 Yur eligibility requirements 3 Sectin 2.2 What are Medicare Part A and Medicare Part B? 3 Sectin 2.3 Here is the plan service area fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) 3 SECTION 3 What ther materials will yu get frm us? 4 Sectin 3.1 Yur plan membership card Use it t get all cvered care and drugs 4 Sectin 3.2 The Prvider Directry: yur guide t all prviders in the plan s netwrk 4 Sectin 3.3 The Pharmacy Directry: yur guide t pharmacies in ur netwrk 5 Sectin 3.4 The plan s List f Cvered Drugs (Frmulary) 5 Sectin 3.5 Reprts with a summary f payments made fr yur prescriptin drugs 6 SECTION 4 Yur mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) 6 Sectin 4.1 Hw much is yur plan premium? 6 Sectin 4.2 There are several ways yu can pay yur plan premium 7 Sectin 4.3 Can we change yur mnthly plan premium during the year? 8 SECTION 5 Please keep yur plan membership recrd up t date 9 Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu 9

5 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 2 SECTION 1 Intrductin Sectin 1.1 What is the Evidence f Cverage bklet abut? This Evidence f Cverage bklet tells yu hw t get yur Medicare medical care and prescriptin drugs thrugh ur plan, a Medicare Advantage Plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the plan. Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, Medi-Pak Advantage MA-PD Optin 1 (PFFS). There are different types f Medicare Advantage Plans. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is a Medicare Advantage Plan PFFS plan (PFFS stands fr Private Fee-fr-Service). This plan is ffered by Arkansas Blue Crss and Blue Shield, referred thrughut the Evidence f Cverage as we, us, r ur. Medi-Pak Advantage MA-PD Optin 1 (PFFS) is referred t as plan r ur plan. The wrd cverage and cvered services refers t the medical care and services and the prescriptin drugs available t yu as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS). Sectin 1.2 What des this Chapter tell yu? Lk thrugh Chapter 1 f this Evidence f Cverage t learn: What makes yu eligible t be a plan member? What is yur plans service area? What materials will yu get frm us? What is yur plan premium and hw can yu pay it? Hw d yu keep the infrmatin in yur membership recrd up t date? Sectin 1.3 What if yu are new t Medi-Pak Advantage MA-PD Optin 1 (PFFS)? If yu are a new member, then it s imprtant fr yu t learn hw the plan perates what the rules are and what services are available t yu. We encurage yu t set aside sme time t lk thrugh this Evidence f Cverage bklet. If yu are cnfused r cncerned r just have a questin, please cntact ur plan s Member Services (cntact infrmatin is n the cver f this bklet). Sectin 1.4 Legal infrmatin abut the Evidence f Cverage It s part f ur cntract with yu This Evidence f Cverage is part f ur cntract with yu abut hw Medi-Pak Advantage MA-PD Optin 1 (PFFS) cvers yur care. Other parts f this cntract include yur enrllment frm, the List f Cvered Drugs (Frmulary), and any ntices yu receive frm us abut changes t yur cverage r cnditins that affect yur cverage. These ntices are smetimes called riders r amendments.

6 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 3 The cntract is in effect fr mnths in which yu are enrlled in Medi-Pak Advantage MA-PD Optin 1 (PFFS) between January 1, 2011 t December 31, Medicare must apprve ur plan each year Medicare (the Centers fr Medicare & Medicaid Services) must apprve Medi-Pak Advantage MA-PD Optin 1 (PFFS) each year. Yu can cntinue t get Medicare cverage as a member f ur plan nly as lng as we chse t cntinue t ffer the plan fr the year in questin and the Centers fr Medicare & Medicaid Services renews its apprval f the plan. SECTION 2 What makes yu eligible t be a plan member? Sectin 2.1 Yur eligibility requirements Yu are eligible fr membership in ur plan as lng as: Yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu are entitled t Medicare Part A -- and -- yu are enrlled in Medicare Part B. -- and -- yu d nt have End Stage Renal Disease (ESRD), with limited exceptins, such as if yu develp ESRD when yu are already a member f a plan that we ffer, r yu were a member f a different plan that was terminated. Sectin 2.2 What are Medicare Part A and Medicare Part B? When yu riginally signed up fr Medicare, yu received infrmatin abut hw t get Medicare Part A and Medicare Part B. Remember: Medicare Part A generally cvers services furnished by institutinal prviders such as hspitals, skilled nursing facilities r hme health agencies. Medicare Part B is fr mst ther medical services, such as physician s services and ther utpatient services. Sectin 2.3 Here is the plan service area fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) Althugh Medicare is a Federal prgram, Medi-Pak Advantage MA-PD Optin 1 (PFFS) is available nly t individuals wh live in ur plan service area. T stay a member f ur plan, yu must keep living in this service area. The service area is described belw. Our service area includes these cunties in Arkansas: Ashley, Bradley, Cleveland, Craighead, Crittenden, Dallas, Faulkner, Grant, Hward, Izard, Jeffersn, Lnke, Miller, Mnre, Mntgmery, Nevada, Pike, Pinsett, Plk, Pulaski, Sevier, Sharp, Unin, Wdruff, Yell Our service area includes these parts f cunties in Arkansas: Sme Central, Suthern and Eastern AR cunties. If yu plan t mve ut f the service area, please cntact Member Services.

7 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 4 SECTION 3 What ther materials will yu get frm us? Sectin 3.1 Yur plan membership card Use it t get all cvered care and drugs While yu are a member f ur plan, yu must use yur membership card fr ur plan whenever yu get any services cvered by this plan and fr prescriptin drugs yu get at netwrk pharmacies. Here s a sample membership card t shw yu what yurs will lk like: As lng as yu are a member f ur plan yu must nt use yur red, white, and blue Medicare card t get cvered medical services (with the exceptin f rutine clinical research and hspice services). Keep yur red, white, and blue Medicare card in a safe place in case yu need it later. Here s why this is s imprtant: If yu get cvered services using yur red, white, and blue Medicare card instead f using yur Medi-Pak Advantage MA-PD Optin 1 (PFFS) membership card while yu are a plan member, yu may have t pay the full cst yurself. If yur plan membership card is damaged, lst, r stlen, call Member Services right away and we will send yu a new card. Sectin 3.2 The Prvider Directry: yur guide t all prviders in the plan s netwrk Every year that yu are a member f ur plan, we will send yu either a new Prvider Directry r an update t yur Prvider Directry. This directry lists ur netwrk prviders. What are netwrk prviders? Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities we have signed cntracts with t deliver certain cvered services t members in ur plan. These prviders have already agreed t see members f ur plan. See Chapter 3, Sectin 1.2 fr infrmatin abut the rules fr getting yur cvered services under ur plan. We have netwrk prviders fr all services cvered under Original Medicare. Yu can still receive cvered services frm ut-f-netwrk prviders (thse wh d nt have a signed cntract with ur plan), as lng as thse prviders agree t accept ur plan s terms and cnditins f payment, as described in Chapter 3, Sectin 1.2.

8 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 5 Why d yu need t knw which prviders are part f ur netwrk? There are several reasns why it is imprtant fr yu t knw whether ur plan uses a netwrk and if s, which prviders are part f the netwrk: A netwrk prvider must furnish yu care while an ut-f-netwrk prvider has the right t refuse t treat yu; A netwrk prvider frequently charges less cst-sharing than an ut-f-netwrk prvider. The amunt f cst sharing yu pay a prvider wh is nt ne f ur netwrk prviders may be mre than the cst sharing yu pay a netwrk prvider. In the plan s Medical Benefits Chart in Chapter 4 f this bklet, we indicate the services fr which the cst-sharing amunt differs between netwrk prviders and utf-netwrk prviders. If ur plan chses t have a netwrk, we must prvide a sufficient number and range f prviders t meet yur needs. These requirements are ver and abve the access standards used by Original Medicare. If yu dn t have yur cpy f the Prvider Directry, yu can request a cpy frm Member Services. Yu may ask Member Services fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Yu can als see the Prvider Directry at r dwnlad it frm this website. Bth Member Services and the website can give yu the mst up-t-date infrmatin abut changes in ur netwrk prviders. Sectin 3.3 The Pharmacy Directry: yur guide t pharmacies in ur netwrk What are netwrk pharmacies? Our Pharmacy Directry gives yu a cmplete list f ur netwrk pharmacies that means all f the pharmacies that have agreed t fill cvered prescriptins fr ur plan members. Why d yu need t knw abut netwrk pharmacies? Yu can use the Pharmacy Directry t find the netwrk pharmacy yu want t use. This is imprtant because, with few exceptins, yu must get yur prescriptins filled at ne f ur netwrk pharmacies if yu want ur plan t cver (help yu pay fr) them. We will send yu a cmplete Pharmacy Directry at least nce every three years. Every year that yu dn t get a new Pharmacy Directry, we ll send yu an update that shws changes t the directry. If yu dn t have the Pharmacy Directry, yu can get a cpy frm Member Services (phne numbers are n the frnt cver). At any time, yu can call Member Services t get up-t-date infrmatin abut changes in the pharmacy netwrk. Yu can als find this infrmatin n ur website at Sectin 3.4 The plan s List f Cvered Drugs (Frmulary) The plan has a List f Cvered Drugs (Frmulary). We call it the Drug List fr shrt. It tells which Part D prescriptin drugs are cvered by Medi-Pak Advantage MA-PD Optin 1 (PFFS). The drugs n this list are

9 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 6 selected by the plan with the help f a team f dctrs and pharmacists. The list must meet requirements set by Medicare. Medicare has apprved the Medi-Pak Advantage MA-PD Optin 1 (PFFS) Drug List. We will send yu a cpy f the Drug List. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website ( r call Member Services (phne numbers are n the frnt cver f this bklet). Sectin 3.5 Reprts with a summary f payments made fr yur prescriptin drugs When yu use yur prescriptin drug benefits, we will send yu a reprt t help yu understand and keep track f payments fr yur prescriptin drugs. This summary reprt is called the Explanatin f Benefits. The Explanatin f Benefits tells yu the ttal amunt yu have spent n yur prescriptin drugs and the ttal amunt we have paid fr each f yur prescriptin drugs during the mnth. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. An Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact Member Services. SECTION 4 Yur mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) Sectin 4.1 Hw much is yur plan premium? As a member f ur plan, yu pay a mnthly plan premium. Fr 2011, the mnthly premium fr Medi-Pak Advantage MA-PD Optin 1 (PFFS) is $ In additin, yu must cntinue t pay yur Medicare Part B premium. In sme situatins, yur plan premium culd be less The Extra Help prgram helps peple with limited resurces pay fr their drugs. Chapter 2, Sectin 7 tells mre abut this prgram. If yu qualify, enrlling in the prgram might make lwer yur mnthly plan premium. If yu are already enrlled and getting help frm ne f these prgrams, sme f the payment infrmatin in this Evidence f Cverage may nt apply t yu. We have included a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs, (LIS Rider) that tells yu abut yur drug cverage. If yu dn t have this insert, please call Member Services and ask fr the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescriptin Drugs (LIS Rider). Phne numbers fr Member Services are n the frnt cver. In sme situatins, yur plan premium culd be mre In sme situatins, yur plan premium culd be mre than the amunt listed abve in Sectin 4.1. These situatins are described belw.

10 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 7 Mst peple will pay the standard mnthly Part D premium. Hwever, starting January 1, 2011, sme peple will pay a higher premium because f their yearly incme (ver $85,000 fr singles--2010, $170,000 fr married cuples--2010). Fr mre infrmatin abut Part D premiums based n incme, yu can visit n the web r call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu may als call the Scial Security Administratin at TTY users shuld call Sme members are required t pay a late enrllment penalty because they did nt jin a Medicare drug plan when they first became eligible r because they had a cntinuus perid f 63 days r mre when they didn t keep their cverage. Fr these members, the late enrllment penalty is added t the plan s mnthly premium. Their premium amunt will be the mnthly plan premium plus the amunt f their late enrllment penalty. If yu are required t pay the late enrllment penalty, the amunt f yur penalty depends n hw lng yu waited befre yu enrlled in drug cverage r hw many mnths yu were withut drug cverage after yu became eligible. Chapter 6, Sectin 10 explains the late enrllment penalty. If yu have a late enrllment penalty, it is part f yur plan premium. If yu d nt pay the part f yur premium that is the late enrllment penalty, yu culd be disenrlled fr failure t pay yur plan premium. Many members are required t pay ther Medicare premiums As explained in Sectin 2 abve, in rder t be eligible fr ur plan, yu must maintain yur eligibility fr Medicare Parts A and B. Fr that reasn, sme plan members will be paying a premium fr Medicare Part A and mst plan members will be paying a premium fr Medicare Part B, in additin t paying the mnthly plan premium. Yu must cntinue paying yur Medicare Part B premium t remain a member f the plan. Yur cpy f Medicare & Yu 2011 tells abut these premiums in the sectin called 2011 Medicare Csts. This explains hw the Part B premium differs fr peple with different incmes. Everyne with Medicare receives a cpy f Medicare & Yu each year in the fall. Thse new t Medicare receive it within a mnth after first signing up. Yu can als dwnlad a cpy f Medicare & Yu 2011 frm the Medicare website ( Or, yu can rder a printed cpy by phne at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call Sectin 4.2 There are several ways yu can pay yur plan premium There are three ways yu can pay yur plan premium. Call Member Services if yu wish t change yur methd f payment. If yu decide t change the way yu pay yur premium, it can take up t three mnths fr yur new payment methd t take effect. While we are prcessing yur request fr a new payment methd, yu are respnsible fr making sure that yur plan premium is paid n time. Optin 1: Yu can pay by check

11 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 8 Checks shuld be made ut t the plan and sent t the plan. Checks shuld nt be made ut t the Centers fr Medicare & Medicaid Services (CMS) r the U.S. Department f Health and Human Services (HHS) and the checks shuld nt be sent t these agencies. Yu may decide t pay yur mnthly plan premium directly t ur Plan. Medi-Pak Advantage MA-PD Optin 1 (PFFS) will send yu an invice mnthly. Yur payment will be due the 1 st f each mnth. Yur check shuld be made ut t Arkansas Blue Crss Blue Shield and sent t Arkansas Blue Crss and Blue Shield, P.O. Bx , St. Luis, MO Optin 2: Yu can have yur premium taken directly frm yur bank accunt Instead f paying by check, yu can have yur mnthly plan premium autmatically withdrawn frm yur bank accunt. The apprximate day f the mnth the deductin will be made is the 3 rd. In rder t have yur premiums deducted frm yur bank accunt, please cntact Member Services t have the apprpriate frm frwarded t yu. Optin 3: Yu can have the plan premium taken ut f yur mnthly Scial Security check Yu can have the plan premium taken ut f yur mnthly Scial Security check. Cntact Member Services fr mre infrmatin n hw t pay yur mnthly plan premium this way. We will be happy t help yu set this up. What t d if yu are having truble paying yur plan premium Yur plan premium is due in ur ffice by the 1 st day f the Mnth. If we have nt received yur premium by the 1 st day f the Mnth, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur premium within 2 mnths. If yu are having truble paying yur premium n time, please cntact Member Services t see if we can direct yu t prgrams that will help with yur plan premium. If we end yur membership with the plan because f nn-payment f premiums, and yu dn t currently have prescriptin drug cverage then yu will nt be able t receive Part D cverage until the annual electin perid. At that time, yu may either jin a stand-alne prescriptin drug plan r a health plan that als prvides drug cverage. If we end yur membership due t nn-payment f premiums, yu will have cverage under Original Medicare. At the time we end yur membership, yu may still we us fr premiums yu have nt paid. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu will need t pay these late premiums befre yu can enrll. Sectin 4.3 Can we change yur mnthly plan premium during the year? N. We are nt allwed t change the amunt we charge fr the plan s mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu in Octber and the change will take effect n January 1. Hwever, in sme cases the part f the premium that yu have t pay can change during the year. This happens if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year. If a member qualifies fr Extra Help with their prescriptin drug csts, the Extra Help prgram will pay part f the member s mnthly plan premium. S a member wh becmes eligible fr Extra Help during the year wuld begin t pay less tward their mnthly premium. And a member wh lses their eligibility

12 Chapter 1: Getting started as a member f Medi-Pak Advantage MA-PD Optin 1 (PFFS) 9 during the year will need t start paying their full mnthly premium. Yu can find ut mre abut Extra Help in Chapter 2, Sectin 7. SECTION 5 Please keep yur plan membership recrd up t date Sectin 5.1 Hw t help make sure that we have accurate infrmatin abut yu Yur membership recrd has infrmatin frm yur enrllment frm, including yur address and telephne number. It shws yur specific plan cverage. The dctrs, hspitals, pharmacists, and ther prviders in the plan s netwrk need t have crrect infrmatin abut yu. These netwrk prviders use yur membership recrd t knw what services and drugs are cvered fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. Call Member Services t let us knw abut these changes: Changes t yur name, yur address, r yur phne number Changes in any ther health insurance cverage yu have (such as frm yur emplyer, yur spuse s emplyer, wrkers cmpensatin, r Medicaid) If yu have any liability claims, such as claims frm an autmbile accident If yu have been admitted t a nursing hme If yu are participating in a clinical research study Read ver the infrmatin we send yu abut any ther insurance cverage yu have Medicare requires that we cllect infrmatin frm yu abut any ther medical r drug insurance cverage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. Once each year, we will send yu a letter that lists any ther medical and drug insurance cverage that we knw abut. Please read ver this infrmatin carefully. If it is crrect, yu dn t need t d anything. If the infrmatin is incrrect, r if yu have ther cverage that is nt listed, please call Member Services (phne numbers are n the cver f this bklet).

13 Chapter 2: Imprtant phne numbers and resurces 10 Chapter 2. Imprtant phne numbers and resurces SECTION 1 Medi-Pak Advantage MA-PD Optin 1 (PFFS) cntacts (hw t cntact us, including hw t reach Member Services at the plan) 11 SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) 15 SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) 16 SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) 16 SECTION 5 Scial Security 17 SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) 17 SECTION 7 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs 18 SECTION 8 Hw t cntact the Railrad Retirement Bard 19 SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer? 20

14 Chapter 2: Imprtant phne numbers and resurces 11 SECTION 1 Medi-Pak Advantage MA-PD Optin 1 (PFFS) cntacts (hw t cntact us, including hw t reach Member Services at the plan) Fr assistance with claims, billing, r member card questins, please call r write t Medi-Pak Advantage MA- PD Optin 1 (PFFS) Member Services. We will be happy t help yu. Member Services CALL TTY/TDD WRITE WEBSITE (877) Calls t this number are free. Office hurs are Mnday thrugh Friday, 8 a.m. t 8 p.m. (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Office hurs are Mnday thrugh Friday, 8 a.m. t 8 p.m. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss and Blue Shield P O Bx 3835 Scrantn, PA Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care Yu may call us if yu have questins abut ur cverage decisin prcess. Cverage Decisins fr Medical Care CALL TTY WRITE (877) Calls t this number are free. (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR 72203

15 Chapter 2: Imprtant phne numbers and resurces 12 Fr mre infrmatin n asking fr cverage decisins abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making an appeal abut yur medical care Appeals fr Medical Care CALL (877) Calls t this number are free. TTY (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR Fr mre infrmatin n making an appeal abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making a cmplaint abut yur medical care Fr mre infrmatin n making a cmplaint abut yur medical care, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Cmplaints abut Medical Care CALL (877) Calls t this number are free. TTY (888) This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free.

16 Chapter 2: Imprtant phne numbers and resurces 13 Cmplaints abut Medical Care WRITE Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR Hw t cntact us when yu are asking fr a cverage decisin abut yur Part D prescriptin drugs Cverage Decisins fr Part D Prescriptin Drugs CALL TTY WRITE Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ Fr mre infrmatin n asking fr cverage decisins abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making an appeal abut yur Part D prescriptin drugs Appeals fr Part D Prescriptin Drugs ALL TTY Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. FAX WRITE Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ

17 Chapter 2: Imprtant phne numbers and resurces 14 Fr mre infrmatin n making an appeal abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Hw t cntact us when yu are making a cmplaint abut yur Part D prescriptin drugs Cmplaints abut Part D prescriptin drugs CALL TTY WRITE Calls t this number are free This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Caremark Clinical Department P. O. Bx Phenix, AZ Fr mre infrmatin n making a cmplaint abut yur Part D prescriptin drugs, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints). Where t send a request that asks us t pay fr ur share f the cst fr medical care r drug yu have received Fr mre infrmatin n situatins in which yu may need t ask the plan fr reimbursement r t pay a bill yu have received frm a prvider, see Chapter 7 (Asking the plan t pay its share f a bill yu have received fr medical services r drugs). Please nte: If yu send us a payment request and we deny any part f yur request, yu can appeal ur decisin. See Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) fr mre infrmatin. Payment Requests CALL Calls t this number are free. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking.

18 Chapter 2: Imprtant phne numbers and resurces 15 Payment Requests WRITE Calls t this number are free. Medi-Pak Advantage MA-PD Optin 1 (PFFS) Arkansas Blue Crss Blue Shield P. O. Bx 2181 Little Rck, AR SECTION 2 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram) Medicare is the Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with disabilities, and peple with End-Stage Renal Disease (permanent kidney failure requiring dialysis r a kidney transplant). The Federal agency in charge f Medicare is the Centers fr Medicare & Medicaid Services (smetimes called CMS ). This agency cntracts with and regulates Medicare Advantage Organizatins including us. Medicare CALL MEDICARE, r Calls t this number are free. 24 hurs a day, 7 days a week. TTY This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. WEBSITE This is the fficial gvernment website fr Medicare. It gives yu up-t-date infrmatin abut Medicare and current Medicare issues. It als has infrmatin abut hspitals, nursing hmes, physicians, hme health agencies, and dialysis facilities. It includes bklets yu can print directly frm yur cmputer. It has tls t help yu cmpare Medicare Advantage Plans and Medicare drug plans in yur area. Yu can als find Medicare cntacts in yur state by selecting Helpful Phne Numbers and Websites. If yu dn t have a cmputer, yur lcal library r senir center may be able t help yu visit this website using its cmputer. Or, yu can call Medicare at the number abve and tell them what infrmatin yu are lking fr. They will find the infrmatin n the website, print it ut, and send it t yu.

19 Chapter 2: Imprtant phne numbers and resurces 16 SECTION 3 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare) The State Health Insurance Assistance Prgram (SHIP) is a gvernment prgram with trained cunselrs in every state. In Arkansas, the State Health Insurance Assistance Prgram is called Arkansas Senir Health Insurance Infrmatin Prgram. Arkansas Senir Health Insurance Infrmatin Prgram is independent (nt cnnected with any insurance cmpany r health plan). It is a state prgram that gets mney frm the Federal gvernment t give free lcal health insurance cunseling t peple with Medicare. Arkansas Senir Health Insurance Infrmatin Prgram cunselrs can help yu with yur Medicare questins r prblems. They can help yu understand yur Medicare rights, help yu make cmplaints abut yur medical care r treatment, and help yu straighten ut prblems with yur Medicare bills. Arkansas Senir Health Insurance Infrmatin Prgram cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans. Arkansas Senir Health Insurance Infrmatin Prgram CALL WRITE 1200 West Third Street Little Rck, AR SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a Quality Imprvement Organizatin in each state. In Arkansas, the Quality Imprvement Organizatin is called Arkansas Fundatin fr Medical Care. Arkansas Fundatin fr Medical Care has a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. Arkansas Fundatin fr Medical Care is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact Arkansas Fundatin fr Medical Care in any f these situatins: Yu have a cmplaint abut the quality f care yu have received. Yu think cverage fr yur hspital stay is ending t sn. Yu think cverage fr yur hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services are ending t sn.

20 Chapter 2: Imprtant phne numbers and resurces 17 Arkansas Fundatin fr Medical Care CALL WRITE SECTION West Capitl Little Rck, AR Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder, r wh have a disability r end stage renal disease and meets certain cnditins, are eligible fr Medicare. If yu are already getting Scial Security checks, enrllment int Medicare is autmatic. If yu are nt getting Scial Security checks, yu have t enrll in Medicare and pay the Part B premium. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call the Scial Security r visit yur lcal Scial Security ffice. Scial Security Administratin CALL TTY Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. Yu can use ur autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Available 7:00 am t 7:00 pm, Mnday thrugh Friday. WEBSITE SECTION 6 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces) Medicaid is a jint Federal and state gvernment prgram that helps with medical csts fr certain peple with limited incmes and resurces. Sme peple with Medicare are als eligible fr Medicaid. Medicaid has prgrams that can help pay fr yur Medicare premiums and ther csts, if yu qualify. T find ut mre abut Medicaid and its prgrams, cntact Arkansas Department f Health and Human Services.

21 Chapter 2: Imprtant phne numbers and resurces 18 Arkansas Department f Health and Human Services CALL TTY WRITE SECTION This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. P. O. Bx 1437 Slt 1100 Dnaghey Plaza Suth Little Rck, AR Infrmatin abut prgrams t help peple pay fr their prescriptin drugs Medicare s Extra Help Prgram Medicare prvides Extra Help t pay prescriptin drug csts fr peple wh have limited incme and resurces. Resurces include yur savings and stcks, but nt yur hme r car. If yu qualify, yu get help paying fr any Medicare drug plan s mnthly premium, yearly deductible, and prescriptin cpayments. This Extra Help als cunts tward yur ut-f-pcket csts. Peple with limited incme and resurces may qualify fr Extra Help. Sme peple autmatically qualify fr Extra Help and dn t need t apply. Medicare mails a letter t peple wh autmatically qualify fr Extra Help MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 am t 7 pm, Mnday thrugh Friday. TTY users shuld call ; r Yur State Medicaid Office. (See Sectin 6 f this chapter fr cntact infrmatin) If yu believe yu have qualify fr Extra Help and yu believe that yu are paying an incrrect cst-sharing amunt when yu get yur prescriptin at a pharmacy, ur plan has established a prcess that allws yu t either request assistance in btaining evidence f yur prper cpayment level, r, if yu already have the evidence, t prvide this evidence t us. Please frward t Medi-Pak Advantage MA-PD Optin 1 (PFFS) a cpy f any f the fllwing dcuments: A cpy f the yur Medicaid card which includes yur name and an eligibility date during the discrepant perid; A reprt f cntact including the date a verificatin call was made t the State Medicaid Agency and the name, title and telephne number f the state staff persn wh verified the Medicaid status during the discrepant perid; A cpy f a state dcument that cnfirms active Medicaid status during the discrepant perid; A print ut frm the State electrnic enrllment file shwing Medicaid status during the discrepant perid;

22 Chapter 2: Imprtant phne numbers and resurces 19 A screen print frm the State s Medicaid systems shwing Medicaid status during the discrepant perid; r Other dcumentatin prvided by the State shwing Medicaid status during the discrepant perid. T establish that yu are institutinalized and qualify fr a zer cst-sharing level, please furnish ne r mre f the fllwing frms f prf: A remittance frm the facility shwing Medicaid payment r a full calendar mnth fr yu during the discrepant perid; A cpy f a state dcumentatin that cnfirms Medicaid payment t the facility fr a full calendar mnth n behalf f yu; r A screen print frm the State s Medicaid system shwing that individual s institutinal status based n at least a full calendar mnth stay fr Medicaid payment purpses during the discrepant perid. Please send a cpy f yur dcuments t: Medi-Pak Advantage MA-PD Optin 1 (PFFS), Arkansas Blue Crss and Blue Shield, P.O. Bx 3835, Scrantn, PA If yu cannt prvide prf f ne f the required dcuments listed abve, yu will need t cntact the plan at The plan will ntify CMS n yur behalf t assist in btaining evidence. When we receive the evidence shwing yur cpayment level, we will update ur system s that yu can pay the crrect cpayment when yu get yur next prescriptin at the pharmacy. If yu verpay yur cpayment, we will reimburse yu. Either we will frward a check t yu in the amunt f yur verpayment r we will ffset future cpayments. If the pharmacy hasn t cllected a cpayment frm yu and is carrying yur cpayment as a debt wed by yu, we may make the payment directly t the pharmacy. If a state paid n yur behalf, we may make payment directly t the state. Please cntact Member Services if yu have questins. Medicare Cverage Gap Discunt Prgram Beginning in 2011, the Medicare Cverage Gap Discunt Prgram will prvide manufacturer discunts n brand name drugs t Part D enrllees wh have reached the cverage gap and are nt already receiving Extra Help. A 50% discunt n the negtiated price (excluding the dispensing fee) will be available fr thse brand name drugs frm manufacturers that have agreed t pay the discunt. We will autmatically apply the discunt when yur pharmacy bills yu fr yur prescriptin and yur Explanatin f Benefits will shw any discunt prvided. The amunt discunted by the manufacturer cunts tward yur ut-f-pckets csts as if yu had paid this amunt and mves yu thrugh the cverage gap. If yu have any questins abut the availability f discunts fr the drugs yu are taking r abut the Medicare Cverage Gap Discunt Prgram in general, please cntact Member Services (phne numbers are n the frnt cver). SECTION 8 Hw t cntact the Railrad Retirement Bard

23 Chapter 2: Imprtant phne numbers and resurces 20 The Railrad Retirement Bard is an independent Federal agency that administers cmprehensive benefit prgrams fr the natin s railrad wrkers and their families. If yu have questins regarding yur benefits frm the Railrad Retirement Bard, cntact the agency. Railrad Retirement Bard CALL TTY WEBSITE Calls t this number are free. Available 9:00 am t 3:30 pm, Mnday thrugh Friday If yu have a tuch-tne telephne, recrded infrmatin and autmated services are available 24 hurs a day, including weekends and hlidays This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are nt free. SECTION 9 D yu have grup insurance r ther health insurance frm an emplyer? If yu (r yur spuse) get benefits frm yur (r yur spuse s) emplyer r retiree grup, call the emplyer/unin benefits administratr r Member Services if yu have any questins. Yu can ask abut yur (r yur spuse s) emplyer r retiree health benefits, premiums, r the enrllment perid. If yu have ther prescriptin drug cverage thrugh yur (r yur spuse s) emplyer r retiree grup, please cntact that grup s benefits administratr. The benefits administratr can help yu determine hw yur current prescriptin drug cverage will wrk with ur plan.

24 Chapter 3: Using the plan s cverage fr yur medical services 21 Chapter 3. Using the plan s cverage fr yur medical services SECTION 1 Things t knw abut getting yur medical care as a member f ur plan 22 Sectin 1.1 What are netwrk prviders and cvered services? 22 Sectin 1.2 Basic rules fr getting yur medical care that is cvered by the plan 22 SECTION 2 Use prviders in the plan s netwrk t get yur medical care 24 Sectin 2.1 Hw t get care frm netwrk prviders 24 SECTION 3 Hw t get cvered services when yu have an emergency 24 Sectin 3.1 Getting care if yu have a medical emergency 24 SECTION 4 What if yu are billed directly fr the full cst f yur cvered services? 25 Sectin 4.1 Yu can ask the plan t pay ur share f the cst f yur cvered services 25 Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst 26 SECTION 5 Hw are yur medical services cvered when yu are in a clinical research study? 26 Sectin 5.1 What is a clinical research study? 26 Sectin 5.2 When yu participate in a clinical research study, wh pays fr what? 27 SECTION 6 Rules fr getting care in a religius nn-medical health care institutin 27 Sectin 6.1 What is a religius nn-medical health care institutin? 27 Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan? 28

25 Chapter 3: Using the plan s cverage fr yur medical services 22 SECTION 1 Things t knw abut getting yur medical care as a member f ur plan This chapter tells things yu need t knw abut using the plan t get yur medical care cverage. It gives definitins f terms and explains the rules yu will need t fllw t get the medical treatments, services, and ther medical care that are cvered by the plan. Fr the details n what medical care is cvered by ur plan and hw much yu pay as yur share f the cst when yu get this care, use the benefits chart in the next chapter, Chapter 4 (Medical benefits chart, what is cvered and what yu pay). Sectin 1.1 What are netwrk prviders and cvered services Here are sme definitins that can help yu understand hw yu get the care and services that are cvered fr yu as a member f ur plan: Prviders are dctrs and ther health care prfessinals that the state licenses t prvide medical services and care. The term prviders als includes hspitals and ther health care facilities. Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, hspitals, and ther health care facilities that we have signed cntracts with t deliver cvered services t members in ur plan. These prviders have already agreed t see members f ur plan. Sectin 1.2 describes the rules fr getting cvered services using ur netwrk prviders. Cvered services include all the medical care, health care services, supplies, and equipment that are cvered by ur plan. Yur cvered services fr medical care are listed in the benefits chart in Chapter 4. Sectin 1.2 Basic rules fr getting yur medical care that is cvered by the plan Medi-Pak Advantage MA-PD Optin 1 (PFFS) will generally cver yur medical care as lng as: The care yu receive is included in the plan s Medical Benefits Chart (this chart is in Chapter 4 f this bklet). The care yu receive is cnsidered medically necessary. It needs t be accepted treatment fr yur medical cnditin. Yu can receive yur care frm any prvider in the United States, if the prvider agrees t accept ur plan s terms and cnditins f payment prir t prviding services t yu and is eligible t prvide services under Original Medicare r eligible t be paid by Medi-Pak Advantage MA-PD Optin 1 (PFFS) fr benefits that are nt cvered under Original Medicare.

26 Chapter 3: Using the plan s cverage fr yur medical services 23 A Medicare Advantage Private Fee-fr-Service plan wrks differently than a Medicare supplement plan. We have netwrk prviders (that is, prviders wh have signed cntracts with ur plan) fr all services cvered under Original Medicare. These prviders have already agreed t see members f ur plan. If yur prvider is nt ne f ur netwrk prviders, then the prvider is nt required t agree t accept the plan s terms and cnditins, f payment, they may chse nt t prvide health care services t yu, except in emergencies. If this happens, yu will need t find anther prvider that will accept ur terms and cnditins f payment. Prviders can find the plan s terms and cnditins f payment n ur website at A prvider is cnsidered t have agreed t accept the terms and cnditins f payment if the prvider was aware that yu are a member f the PFFS plan befre prviding services t yu (fr example: if yu shwed them yur PFFS plan card); the prvider had reasnable access t ur terms and cnditins f payment; and the prvider prvided cvered services t yu. The prvider desn t have t actually read the terms and cnditins f payment - If the prvider had the pprtunity t read them and treats yu, the law deems this prvider t have agreed t accept ur plan s terms and cnditins f payment fr that specific visit. Yu must shw yur plan membership card every time yu visit a prvider. A prvider can decide at every visit whether t accept ur plan s terms and cnditins, and thus treat yu. A prvider cannt change his/her mind abut accepting the terms and cnditins f payment after prviding services. Nt all prviders accept ur plan s terms and cnditins f payment r agree t treat yu. If a prvider frm whm yu seek care decides nt t accept ur plan s terms and cnditins f payment r refuses t treat yu, then yu will need t find anther prvider that will accept ur plan s terms and cnditins f payment. A prvider that decides nt t accept ur plan s terms and cnditins f payment shuld nt prvide services t yu, except in emergencies. Yu may cntact us at (877) fr assistance lcating anther prvider in yur area wh will accept ur plan s terms and cnditins f payment. If yu need emergency care, it is cvered whether a prvider agrees t accept the plan s payment terms r nt. Our plan has signed cntracts with sme prviders t deliver cvered services t members in ur plan. These prviders are ur netwrk prviders. Yu can get a list f these prviders at r yu may call Member Services at the number n the frnt cver f this bklet. We have netwrk prviders fr services cvered under Medicare. Yu can still receive cvered services frm ut-f-netwrk prviders (thse wh d nt have a signed cntract with ur plan), as lng as thse prviders agree t accept ur plan s terms and cnditins f payment, as described earlier in this sectin. Fr services fr which netwrk prviders are nt available, yu can receive cvered services frm any prvider wh agrees t accept ur plan s terms and cnditins f payment, as described earlier in this sectin.