EVIDENCE OF COVERAGE HEALTHTEAM ADVANTAGE PLAN I (PPO)

Transcription

1 EVIDENCE OF COVERAGE HEALTHTEAM ADVANTAGE PLAN I (PPO) 2018 HealthTeam Advantage, a prduct f Care N Care Insurance Cmpany f Nrth Carlina, Inc., is a Medicare Advantage rganizatin with a Medicare cntract. Enrllment in HealthTeam Advantage depends n cntract renewal. H9808_18_01 Accepted

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3 January 1 - December 31, 2018 Evidence f Cverage: Yur Medicare Health Benefits and Services and Prescriptin Drug Cverage as a Member f HealthTeam Advantage Plan I (PPO) This bklet gives yu the details abut yur Medicare health care and prescriptin drug cverage frm January 1 December 31, It explains hw t get cverage fr the health care services and prescriptin drugs yu need. This is an imprtant legal dcument. Please keep it in a safe place. This plan, HealthTeam Advantage Plan I, is ffered by Care N Care Insurance Cmpany f Nrth Carlina. (When this Evidence f Cverage says we, us, r ur, it means Care N Care Insurance Cmpany f Nrth Carlina. When it says plan r ur plan, it means HealthTeam Advantage Plan I.) Care N Care Insurance Cmpany f Nrth Carlina is a Medicare Advantage rganizatin with a Medicare cntract. Enrllment in HealthTeam Advantage Plan I depends n cntract renewal. This dcument is available fr free in ther languages. Please cntact yur Healthcare Cncierge at fr additinal infrmatin. (TTY users shuld call 711). Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. Yur Healthcare Cncierge als has free language interpreter services available fr nn-english speakers (phne numbers are printed n the back cver f this bklet). Esta infrmación se encuentra dispnible y gratis en trs idimas. Cmuníquese cn nuestrs servici para Miembrs al para btener infrmación adicinal. Ls usuaris de TTY deben llamar al 711. Las hras de atención sn 1 de Octubre - 14 de Febrer 8AM - 8PM Este,, 7 días a la semana ; 15 de de Febrer de - 30 de Septiembre 8 a.m.-8 p.m. Este, de lunes a viernes. Ls Servici para Miembrs también tienen servici de intérpretes de idimas gratis dispnibles para las persnas que n hablan ingles. This infrmatin is available in a different frmat, including large print and Spanish. Please call yur Healthcare Cncierge at the number listed abve if yu need plan infrmatin in anther frmat r language. Benefits, premium, and/r cpayments/cinsurance may change n January 1, The frmulary, pharmacy netwrk, and/r prvider netwrk may change at any time. Yu will receive ntice when necessary. Frm CMS ANOC/EOC Apprved (05/2017) OMB Apprval (Expires: May 31, 2020) H9808_18_01 Accepted

4 Table f Cntents Evidence f Cverage Table f Cntents This list f chapters and page numbers is 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... 4 Explains 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, the Part D late enrllment penalty, yur plan membership card, and keeping yur membership recrd up t date. Chapter 2. Imprtant phne numbers and resurces Tells yu hw t get in tuch with ur plan (HealthTeam Advantage Plan I) and with ther rganizatins including Medicare, the State Health Insurance Assistance Prgram (SHIP), 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 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) Gives the details abut which types f medical care are cvered and nt cvered fr yu as a member f ur plan. Explains 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 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 cverage fr certain drugs. Explains where t get yur prescriptins filled. Tells abut the plan s prgrams fr drug safety and managing medicatins. Chapter 6. What yu pay fr yur Part D prescriptin drugs Tells abut the three stages f drug cverage (Initial Cverage Stage, Cverage Gap Stage, Catastrphic Cverage Stage) and hw these stages affect what yu pay fr yur drugs. Explains the five cst-sharing tiers fr yur Part D drugs and tells what yu must pay fr a drug in each cst-sharing tier. Tells abut the late enrllment penalty.

5 Table f Cntents 3 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs Explains 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 r drugs. Chapter 8. Yur rights and respnsibilities 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) 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 Explains 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 Includes ntices abut gverning law and abut nndiscriminatin. Chapter 12. Definitins f imprtant wrds Explains key terms used in this bklet.

6 CHAPTER 1 Getting started as a member

7 Chapter 1. Getting Started as a Member 5 SECTION 1 Intrductin...7 Sectin 1.1 Yu are enrlled in HealthTeam Advantage Plan I, which is a Medicare PPO... 7 Sectin 1.2 What is the Evidence f Cverage bklet abut?... 7 Sectin 1.3 Legal infrmatin abut the Evidence f Cverage... 7 SECTION 2 Sectin 2.1 Sectin 2.2 Sectin 2.3 Sectin 2.4 SECTION 3 Sectin 3.1 Sectin 3.2 Sectin 3.3 Sectin 3.4 Sectin 3.5 SECTION 4 Sectin 4.1 SECTION 5 Sectin 5.1 Sectin 5.2 Sectin 5.3 Sectin 5.4 SECTION 6 Sectin 6.1 Sectin 6.2 What makes yu eligible t be a plan member?...8 Yur eligibility requirements... 8 What are Medicare Part A and Medicare Part B?... 8 Here is the plan service area fr HealthTeam Advantage Plan I... 8 U.S. Citizen r Lawful Presence...9 What ther materials will yu get frm us?...9 Yur plan membership card: Use it t get all cvered care and prescriptin drugs... 9 The Prvider/Pharmacy Directry: Yur guide t all prviders in the plan s netwrk... 9 The Prvider/Pharmacy Directry: Yur guide t pharmacies in ur netwrk The plan s List f Cvered Drugs (Frmulary) The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs...11 Yur mnthly premium fr HealthTeam Advantage Plan I...11 Hw much is yur plan premium?...11 D yu have t pay the Part D late enrllment penalty?...12 What is the Part D late enrllment penalty? Hw much is the Part D late enrllment penalty? In sme situatins, yu can enrll late and nt have t pay the penalty What can yu d if yu disagree abut yur Part D late enrllment penalty?14 D yu have t pay an extra Part D amunt because f yur incme?...14 Wh pays an extra Part D amunt because f incme? Hw much is the extra Part D amunt?... 14

8 Chapter 1. Getting Started as a Member 6 Sectin 6.3 Sectin 6.4 SECTION 7 Sectin 7.1 Sectin 7.2 SECTION 8 Sectin 8.1 SECTION 9 Sectin 9.1 SECTION 10 Sectin 10.1 What can yu d if yu disagree abut paying an extra Part D amunt? What happens if yu d nt pay the extra Part D amunt? Mre infrmatin abut yur mnthly premium...15 If yu pay a Part D late enrllment penalty, there are several ways yu can pay yur penalty Can we change yur mnthly plan premium during the year? Please keep yur plan membership recrd up t date...18 Hw t help make sure that we have accurate infrmatin abut yu We prtect the privacy f yur persnal health infrmatin...19 We make sure that yur health infrmatin is prtected Hw ther insurance wrks with ur plan...19 Which plan pays first when yu have ther insurance?... 19

9 Chapter 1. Getting Started as a Member 7 SECTION 1 Sectin 1.1 Intrductin Yu are enrlled in HealthTeam Advantage Plan I, which is a Medicare PPO Yu are cvered by Medicare, and yu have chsen t get yur Medicare health care and yur prescriptin drug cverage thrugh ur plan, HealthTeam Advantage Plan I. There are different types f Medicare health plans. HealthTeam Advantage Plan I is a Medicare Advantage PPO Plan (PPO stands fr Preferred Prvider Organizatin). Like all Medicare health plans, this Medicare PPO is apprved by Medicare and run by a private cmpany. Sectin 1.2 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 cvered thrugh ur plan. This bklet explains yur rights and respnsibilities, what is cvered, and what yu pay as a member f the 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 HealthTeam Advantage Plan I. It s imprtant fr yu t learn what the plan s 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 yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Sectin 1.3 It s part f ur cntract with yu Legal infrmatin abut the Evidence f Cverage This Evidence f Cverage is part f ur cntract with yu abut hw HealthTeam Advantage Plan I 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. The cntract is in effect fr mnths in which yu are enrlled in HealthTeam Advantage Plan I between January 1, 2018 and December 31, Each calendar year, Medicare allws us t make changes t the plans that we ffer. This means we can change the csts and benefits f HealthTeam Advantage Plan I after December 31, We can als chse t stp ffering the plan, r t ffer it in a different service area, after December 31, 2018.

10 Chapter 1. Getting Started as a Member 8 Medicare must apprve ur plan each year Medicare (the Centers fr Medicare & Medicaid Services) must apprve HealthTeam Advantage Plan I each year. Yu can cntinue t get Medicare cverage as a member f ur plan as lng as we chse t cntinue t ffer the plan and Medicare 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 have bth Medicare Part A and Medicare Part B (sectin 2.2 tells yu abut Medicare Part A and Medicare Part B) -- and -- yu live in ur gegraphic service area (sectin 2.3 belw describes ur service area) -- and -- yu are a United States citizen r are lawfully present in the United States -- 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 first signed up fr Medicare, yu received infrmatin abut what services are cvered under Medicare Part A and Medicare Part B. Remember: Medicare Part A generally helps cver services prvided by hspitals (fr inpatient services, 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) and certain items (such as durable medical equipment and supplies). Sectin 2.3 Here is the plan service area fr HealthTeam Advantage Plan I Althugh Medicare is a Federal prgram, HealthTeam Advantage Plan I is available nly t individuals wh live in ur plan service area. T remain a member f ur plan, yu must cntinue t reside in the plan service area. The service area is described belw. Our service area includes these cunties in Nrth Carlina: Alamance, Guilfrd, Randlph and Rckingham. If yu plan t mve ut f the service area, please cntact yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). When yu mve, yu will have a Special Enrllment Perid that will allw yu t switch t Original Medicare r enrll in a Medicare health r drug plan that is available in yur new lcatin. It is als imprtant that yu call Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5.

11 Chapter 1. Getting Started as a Member 9 Sectin 2.4 U.S. Citizen r Lawful Presence A member f a Medicare health plan must be a U.S. citizen r lawfully present in the United States. Medicare (the Centers fr Medicare & Medicaid Services) will ntify HealthTeam Advantage Plan I if yu are nt eligible t remain a member n this basis. HealthTeam Advantage Plan I must disenrll yu if yu d nt meet this requirement. 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 prescriptin 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. Yu shuld als shw the prvider yur Medicaid Card, if applicable. 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 studies 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 HealthTeam Advantage Plan I 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 yur Healthcare Cncierge right away and we will send yu a new card. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Sectin 3.2 The Prvider/Pharmacy Directry: Yur guide t all prviders in the plan s netwrk The Prvider/Pharmacy Directry lists ur netwrk prviders and durable medical equipment suppliers. What are netwrk prviders? Netwrk prviders are the dctrs and ther health care prfessinals, medical grups, durable medical

12 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 10 equipment suppliers, hspitals, and ther health care facilities that have an agreement with us t accept ur payment and any plan cst-sharing as payment in full. We have arranged fr these prviders t deliver cvered services t members in ur plan. The mst recent list f suppliers is available n ur website at Why d yu need t knw which prviders are part f ur netwrk? As a member f ur plan, yu can chse t receive care frm ut-f-netwrk prviders. Our plan will cver services frm either in-netwrk r ut-f-netwrk prviders, as lng as the services are cvered benefits and medically necessary. Hwever, if yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. See Chapter 3 (Using the plan s cverage fr yur medical services) fr mre specific infrmatin. If yu dn t have yur cpy f the Prvider/Pharmacy Directry, yu can request a cpy frm yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu may ask yur Healthcare Cncierge fr mre infrmatin abut ur netwrk prviders, including their qualificatins. Yu can als see the Prvider/Pharmacy Directry at r dwnlad it frm this website. Bth yur Healthcare Cncierge and the website can give yu the mst up-t-date in frmatin abut changes in ur netwrk prviders. Sectin 3.3 What are netwrk pharmacies? The Prvider/Pharmacy Directry: Yur guide t pharmacies in ur netwrk Netwrk pharmacies are 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 Prvider/Pharmacy Directry t find the netwrk pharmacy yu want t use. An updated Prvider/Pharmacy Directry is lcated n ur website at Yu may als call yur Healthcare Cncierge fr updated prvider infrmatin r t ask us t mail yu a Prvider/Phar macy Directry. Please review the 2018 Prvider/Pharmacy Directry t see which pharmacies are in ur netwrk. 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 under the Part D benefit included in HealthTeam Advantage Plan I. The drugs n this list are 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 HealthTeam Advantage Plan I Drug List. The Drug List als tells yu if there are any rules that restrict cverage fr yur drugs.

13 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 11 We will send yu a cpy f the Drug List. The Drug List we send t yu includes infrmatin fr the cvered drugs that are mst cmmnly used by ur members. Hwever, we cver additinal drugs that are nt included in the printed Drug List. If ne f yur drugs is nt listed in the Drug List, yu shuld visit ur website r cntact yur Healthcare Cncierge t find ut if we cver it. T get the mst cmplete and current infrmatin abut which drugs are cvered, yu can visit the plan s website ( madvantage.cm) r call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Sectin 3.5 The Part D Explanatin f Benefits (the Part D EOB ): Reprts with a summary f payments made fr yur Part D prescriptin drugs When yu use yur Part D prescriptin drug benefits, we will send yu a summary reprt t help yu understand and keep track f payments fr yur Part D prescriptin drugs. This summary reprt is called the Part D Explanatin f Benefits (r the Part D EOB ). The Part D Explanatin f Benefits tells yu the ttal amunt yu, r thers n yur behalf, have spent n yur Part D prescriptin drugs and the ttal amunt we have paid fr each f yur Part D prescrip tin drugs during the mnth. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut the Part D Explanatin f Benefits and hw it can help yu keep track f yur drug cverage. A Part D Explanatin f Benefits summary is als available upn request. T get a cpy, please cntact yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). SECTION 4 Yur mnthly premium fr HealthTeam Advantage Plan I Sectin 4.1 Hw much is yur plan premium? Yu d nt pay a separate mnthy plan premium fr HealthTeam Advantage Plan I. Yu must cntinue t pay yur Medicare Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). 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. If yu signed up fr extra benefits, als called ptinal supplemental benefits, then yu pay an additinal premium each mnth fr these extra benefits. If yu have any questins abut yur plan premiums, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Optinal Supplemental Benefits Mnthly Plan Premium HealthTeam Advantage Dental Rider $25 HealthTeam Advantage Cmbinatin Rider (Dental, Visin and Hearing) $40 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

14 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 12 r mre when they didn t have creditable prescriptin drug cverage. ( Creditable means the drug cverage is at least as gd as Medicare s standard drug 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 and d nt pay it, yu culd be disenrlled frm the plan. SECTION 5 D yu have t pay the Part D late enrllment penalty? Sectin 5.1 What is the Part D late enrllment penalty? Nte: If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs, yu will nt pay a late enrllment penalty. The late enrllment penalty is an amunt that is added t yu Part D premium. Yu may we a late enrllment penalty if at any time after yur initial enrllment perid is ver, there is a perid f 63 days r mre in a rw when yu did nt have Part D r ther creditable prescriptin drug cverage. Creditable prescriptin drug cverage is cverage that meets Medicare s minimum standards since it is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) The amunt f the penalty depends n hw lng yu waited t enrll in a creditable prescriptin drug cverage plan any time after the end f yur initial enrllment perid r hw many full calendar mnths yu went withut creditable prescriptin drug cverage. Yu will have t pay this penalty fr as lng as yu have Part D cverage. When yu first enrll in HealthTeam Advantage Plan I, we let yu knw the amunt f the penalty. Yur Part D late enrllment penalty is cnsidered yur plan premium. If yu d nt pay yur Part D late enrll ment premium, yu culd lse prescriptin drug benefits. Sectin 5.2 Hw much is the Part D late enrllment penalty? Medicare determines the amunt f the penalty. Here is hw it wrks: First cunt the number f full mnths that yu delayed enrlling in a Medicare drug plan, after yu were eligible t enrll. Or cunt the number f full mnths in which yu did nt have creditable prescriptin drug cverage, if the break in cverage was 63 days r mre. The penalty is 1% fr every mnth that yu didn t have creditable cverage. Fr example, if yu g 14 mnths withut cverage, the penalty will be 14%. Then Medicare determines the amunt f the average mnthly premium fr Medicare drug plans in the natin frm the previus year. Fr 2017, this average premium amunt was $ This amunt may change fr 2018.

15 Chapter 1. Getting Started as a Member 13 T calculate yur mnthly penalty, yu multiply the penalty percentage and the average mnthly premium and then rund it t the nearest 10 cents. In the example here it wuld be 14% times $35.63 which equals $4.99. This runds t $5.00. This amunt wuld be added t the mnthly premium fr smene with a late enrllment penalty. There are three imprtant things t nte abut this mnthly late enrllment penalty: First, the penalty may change each year, because the average mnthly premium can change each year. If the natinal average premium (as determined by Medicare) increases, yur penalty will increase. Secnd, yu will cntinue t pay a penalty every mnth fr as lng as yu are enrlled in a plan that has Medicare Part D drug benefits. Third, if yu are under 65 and currently receiving Medicare benefits, the late enrllment penalty will reset when yu turn 65. After age 65, yur late enrllment penalty will be based nly n the mnths that yu dn t have cverage after yur initial enrllment perid fr aging int Medicare. Sectin 5.3 In sme situatins, yu can enrll late and nt have t pay the penalty Even if yu have delayed enrlling in a plan ffering Medicare Part D cverage when yu were first eligible, smetimes yu d nt have t pay the late enrllment penalty. Yu will nt have t pay a penalty fr late enrllment if yu are in any f these situatins: If yu already have prescriptin drug cverage that is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. Medicare calls this creditable drug cverage. Please nte: Creditable cverage culd include drug cverage frm a frmer emplyer r unin, TRI CARE, r the Department f Veterans Affairs. Yur insurer r yur human resurces department will tell yu each year if yur drug cverage is creditable cverage. This infrmatin may be sent t yu in a letter r included in a newsletter frm the plan. Keep this infrmatin, because yu may need it if yu jin a Medicare drug plan later. Please nte: If yu receive a certificate f creditable cverage when yur health cverage ends, it may nt mean yur prescriptin drug cverage was creditable. The ntice must state that yu had creditable prescriptin drug cverage that expected t pay as much as Medicare s standard prescriptin drug plan pays. The fllwing are nt creditable prescriptin drug cverage: prescriptin drug discunt cards, free clinics, and drug discunt websites. Fr additinal infrmatin abut creditable cverage, please lk in yur Medicare & Yu 2018 Handbk r call Medicare at MEDICARE ( ). TTY users call Yu can call these numbers fr free, 24 hurs a day, 7 days a week.

16 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 14 If yu were withut creditable cverage, but yu were withut it fr less than 63 days in a rw. If yu are receiving Extra Help frm Medicare. Sectin 5.4 What can yu d if yu disagree abut yur late enrllment penalty? If yu disagree abut yur late enrllment penalty, yu r yur representative can ask fr a review f the decisin abut yur late enrllment penalty. Generally, yu must request this review within 60 days frm the date n the letter yu receive stating yu have t pay a late enrllment penalty. Call yur Healthcare Cncierge t find ut mre abut hw t d this (phne numbers are printed n the back cver f this bklet). Imprtant: D nt stp paying yur late enrllment penalty while yu re waiting fr a review f the de cisin abut yur late enrllment penalty. If yu d, yu culd be disenrlled fr failure t pay yur plan premiums. SECTION 6 D yu have t pay an extra Part D amunt because f yur incme? Sectin 6.1 Wh pays an extra Part D amunt because f incme? Mst peple pay a standard mnthly Part D premium. Hwever, sme peple pay an extra amunt because f their yearly incme. If yur incme is $85,000 r abve fr an individual (r married individuals filing separately) r $170,000 r abve fr married cuples, yu must pay an extra amunt directly t the gvernment fr yur Medicare Part D cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be and hw t pay it. The extra amunt will be withheld frm yur Scial Security, Railrad Retirement Bard, r Office f Persnnel Management benefit check, n matter hw yu usually pay yur plan premium, unless yur mnthly benefit isn t enugh t cver the extra amunt wed. If yur benefit check isn t enugh t cver the extra amunt, yu will get a bill frm Medicare. Yu must pay the extra amunt t the gvernment. It cannt be paid with yur mnthly plan premium. Sectin 6.2 Hw much is the extra Part D amunt? If yur mdified adjusted grss incme (MAGI) as reprted n yur IRS tax return is abve a certain amunt, yu will pay an extra amunt in additin t yur mnthly plan premium. The chart belw shws the extra amunt based n yur incme.

17 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 15 If yu filed an individual tax return and yur incme in 2015 was: Equal t r less than $85,000 Greater than $85,000 and less than r equal t $107,000 Greater than $107,000 and less than r equal t $133,500 Greater than $133,500 and less than r equal t $160,000 Greater than $160,000 If yu were married but filed a separate tax return and yur incme in 2015 was: Equal t r less than $85,000 Greater than $85,000 If yu filed a jint tax return and yur incme in 2015 was: Equal t r less than $170,000 Greater than $170,000 and less than r equal t $214,000 Greater than $214,000 and less than r equal t $267,000 Greater than $267,000 and less than r equal t $320,000 This is the mnthly cst f yur extra Part D amunt (t be paid in additin t yur plan premium) $0 $13.00 $33.60 $54.20 Greater than $320,000 $84.80 Sectin 6.3 What can yu d if yu disagree abut paying an extra Part D amunt? If yu disagree abut paying an extra amunt because f yur incme, yu can ask Scial Security t re view the decisin. T find ut mre abut hw t d this, cntact Scial Security at (TTY ). Sectin 6.4 What happens if yu d nt pay the extra Part D amunt? The extra amunt is paid directly t the gvernment (nt yur Medicare plan) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm the plan and lse prescriptin drug cverage. SECTION 7 Mre infrmatin abut yur mnthly premium Many members are required t pay ther Medicare premiums In additin t paying the mnthly 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 be entitled t Medicare Part A and enrlled in Medicare Part B. Fr that reasn, sme plan members (thse wh aren t eligible fr premium-free Part A) pay a premium fr Medicare Part A. And mst plan members pay a premium fr Medicare Part B. Yu must cntinue paying yur Medicare premiums t remain a member f the plan.

18 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 16 Sme peple pay an extra amunt fr Part D because f their yearly incme, this is knwn Incme Re lated Mnthly Adjustment Amunts, als knwn as IRMAA. If yur incme is greater than $85,000 fr an individual (r married individuals filing separately) r greater than $170,000 fr married cuples, yu must pay an extra amunt directly t the gvernment (nt the Medicare plan) fr yur Medicare Part D cverage. If yu are required t pay the extra amunt and yu d nt pay it, yu will be disenrlled frm the plan and lse prescriptin drug cverage. If yu have t pay an extra amunt, Scial Security, nt yur Medicare plan, will send yu a letter telling yu what that extra amunt will be. Fr mre infrmatin abut Part D premiums based n incme, g t Chapter 6, Sectin 10 f this bklet. Yu can als visit n the Web r call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Or yu may call Scial Security at TTY users shuld call Yur cpy f Medicare & Yu 2018 gives infrmatin abut the Medicare premiums in the sectin called 2018 Medicare Csts. This explains hw the Medicare Part B and Part D premiums differ 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 2018 frm the Medicare website ( Or, yu can rder a printed cpy by phne at MEDICARE ( ), 24 hurs a day, and 7 days a week, TTY users call Sectin 7.1 If yu pay a Part D late enrllment penalty, there are several ways yu can pay yur penalty. If yu pay a Part D late enrllment penalty, there are three ways yu can pay the penalty. Yu may call yur Healthcare Cncierge fr mre infrmatin n hw t change yur penalty payment ptins. See cntact infrmatin shwn n the back cver. If yu decide t change the way yu pay yur Part D late enrllment penalty, 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 Part D late enrllment penalty is paid n time. Optin 1: Yu can pay by check r mney rder Yu can pay by check r mney rder. Yu will receive an invice fr the fllwing mnth s premium. (If yu wish t pay yur premiums annually, please cntact us s we can send yu an invice fr the apprpriate amunt). The invice will include a business reply envelpe fr mailing. Payment is due by the 5th f each mnth. Checks r mney rders shuld be made payable t HealthTeam Advantage, nt t CMS r HHS. Checks r mney rders may be mailed t: HealthTeam Advantage P.O. Bx Dallas, TX

19 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 17 Yu may drp ff a payment (check r mney rder) in persn at: HealthTeam Advantage 7800 McClud Rad Suite 100 Greensbr, NC Optin 2: Electrnic Funds Transfer Yu can have yur Part D late enrllment penalty autmatically withdrawn frm yur checking r savings accunt. This prgram is free and eliminates the need fr yu t send a mnthly check. Deductins frm yur bank accunt will ccur n the 5th f each mnth. Please nte that if the 5 th falls n a weekend r hliday yur penalty will be deducted the 1 st business day after. Cntact yur Healthcare Cncierge at the phne number n the back cver f this bklet fr mre infrmatin n hw t set up autmatic with drawal frm yur checking r savings accunt. Optin 3: Yu can have the Part D late enrllment penalty taken ut f yur mnthly S- cial Security check Yu can have the Part D late enrllment penalty taken ut f yur mnthly Scial Security check. Cntact yur Healthcare Cncierge fr mre infrmatin n hw t pay yur penalty this way. We will be happy t help yu set this up. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) What t d if yu are having truble paying yur Part D late enrllment penalty Yur Part D late enrllment penalty is due in ur ffice by the 5th day f the mnth. If we have nt received yur penalty payment by the 5th day f the mnth, we will send yu a ntice telling yu that yur plan membership will end if we d nt receive yur penalty payment within (3) calendar mnths. If yu are required t pay a late enrllment penalty, yu must pay the penalty t keep yur prescriptin drug cverage. If yu are having truble paying yur penalty n time, please cntact yur Healthcare Cncierge t see if we can direct yu t prgrams that will help with yur penalty. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) If we end yur membership because yu did nt pay yur penalty, yu will have health cverage under Original Medicare. If we end yur membership with the plan because yu did nt pay yur penalty, and yu dn t currently have prescriptin drug cverage then yu may nt be able t receive Part D cverage until the fllwing year if yu enrll in a new plan during the annual enrllment perid. During the annual enrllment perid, yu may either jin a stand-alne prescriptin drug plan r a health plan that als prvides drug cverage. (If yu g withut creditable drug cverage fr mre than 63 days, yu may have t pay a late enrllment penalty fr as lng as yu have Part D cverage.) At the time we end yur membership, yu may still we us fr the penalty yu have nt paid. We have the right t pursue cllectin f the penalty amunt yu we. In the future, if yu want t enrll again in ur plan (r anther plan that we ffer), yu will need t pay the amunt yu we befre yu can enrll.

20 Chapter 1. Getting Started as a Member 18 If yu think we have wrngfully ended yur membership, yu have a right t ask us t recnsider this decisin by making a cmplaint. Chapter 9, Sectin 10 f this bklet tells hw t make a cmplaint. If yu had an emergency circumstance that was ut f yur cntrl and it caused yu t nt be able t pay yur premiums within ur grace perid, yu can ask us t recnsider this decisin by calling between 8AM 8PM Eastern, 7 days a week frm Octber 1 - February 14, and 8AM 8PM Eastern, Mnday thrugh Friday, February 15 - September 30. TTY users shuld call 711. Yu must make yur request n later than 60 days after the date yur membership ends. Sectin 7.2 Can we change yur mnthly plan premium during the year? N. We are nt allwed t begin charging a mnthly plan premium during the year. If the mnthly plan premium changes fr next year we will tell yu in September and the change will take effect n January 1. Hwever, in sme cases, yu may need t start paying r may be able t stp paying a late enrllment penalty. (The late enrllment penalty may apply if yu had a cntinuus perid f 63 days r mre when yu didn t have creditable prescriptin drug cverage.) This culd happen if yu becme eligible fr the Extra Help prgram r if yu lse yur eligibility fr the Extra Help prgram during the year: If yu currently pay the Part D late enrllment penalty and becme eligible fr Extra Help during the year, yu wuld be able t stp paying yur penalty. If yu ever lse yur lw incme subsidy ( Extra Help ), yu wuld be subject t the mnthly Part D late enrllment penalty if yu have ever gne withut creditable prescriptin drug cverage fr 63 days r mre. Yu can find ut mre abut the Extra Help prgram in Chapter 2, Sectin 7. SECTION 8 Please keep yur plan membership recrd up t date Sectin 8.1 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 including yur Primary Care Prvider. 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 and the cst-sharing amunts fr yu. Because f this, it is very imprtant that yu help us keep yur infrmatin up t date. 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.

21 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 1. Getting Started as a Member 19 If yu receive care in an ut-f-area r ut-f-netwrk hspital r emergency rm. If yur designated respnsible party (such as a caregiver) changes. If yu are participating in a clinical research study. If any f this infrmatin changes, please let us knw by calling yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). It is als imprtant t cntact Scial Security if yu mve r change yur mailing address. Yu can find phne numbers and cntact infrmatin fr Scial Security in Chapter 2, Sectin 5. 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 cv erage that yu have. That s because we must crdinate any ther cverage yu have with yur benefits under ur plan. (Fr mre infrmatin abut hw ur cverage wrks when yu have ther insurance, see Sectin 7 in this chapter.) Once each year, we will send yu a letter that lists any ther medical r 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 yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). SECTION 9 We prtect the privacy f yur persnal health infrmatin Sectin 9.1 We make sure that yur health infrmatin is prtected Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Fr mre infrmatin abut hw we prtect yur persnal health infrmatin, please g t Chapter 8, Sectin 1.4 f this bklet. SECTION 10 Hw ther insurance wrks with ur plan Sectin 10.1 Which plan pays first when yu have ther insurance? When yu have ther insurance (like emplyer grup health cverage), there are rules set by Medicare that decide whether ur plan r yur ther insurance pays first. The insurance that pays first is called the primary payer and pays up t the limits f its cverage. The ne that pays secnd, called the secndary payer, nly pays if there are csts left uncvered by the primary cverage. The secndary payer may nt pay all f the uncvered csts. These rules apply fr emplyer r unin grup health plan cverage:

22 Chapter 1. Getting Started as a Member 20 If yu have retiree cverage, Medicare pays first. If yur grup health plan cverage is based n yur r a family member s current emplyment, wh pays first depends n yur age, the number f peple emplyed by yur emplyer, and whether yu have Medicare based n age, disability, r End-stage Renal Disease (ESRD): If yu re under 65 and disabled and yu r yur family member is still wrking, yur grup health plan pays first if the emplyer has 100 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 100 emplyees. If yu re ver 65 and yu r yur spuse is still wrking, yur grup health plan pays first if the emplyer has 20 r mre emplyees r at least ne emplyer in a multiple emplyer plan that has mre than 20 emplyees. If yu have Medicare because f ESRD, yur grup health plan will pay first fr the first 30 mnths after yu becme eligible fr Medicare. These types f cverage usually pay first fr services related t each type: N-fault insurance (including autmbile insurance) Liability (including autmbile insurance) Black lung benefits Wrkers cmpensatin Medicaid and TRICARE never pay first fr Medicare-cvered services. They nly pay after Medicare, emplyer grup health plans, and/r Medigap have paid. If yu have ther insurance, tell yur dctr, hspital, and pharmacy. If yu have questins abut wh pays first, r yu need t update yur ther insurance infrmatin, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu may need t give yur plan member ID number t yur ther insurers (nce yu have cnfirmed their identity) s yur bills are paid crrectly and n time.

23 CHAPTER 2 Imprtant phne numbers and resurces

24 Chapter 2. Imprtant Phne Numbers and Resurces 22 Chapter 2. Imprtant phne numbers and resurces SECTION 1 SECTION 2 SECTION 3 SECTION 4 SECTION 5 SECTION 6 SECTION 7 SECTION 8 SECTION 9 HealthTeam Advantage Plan I cntacts (hw t cntact us, including hw t reach yur Healthcare Cncierge at the plan)...23 Medicare (hw t get help and infrmatin directly frm the Federal Medicare prgram)...30 State Health Insurance Assistance Prgram (free help, infrmatin, and answers t yur questins abut Medicare)...31 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare)...32 Scial Security...32 Medicaid (a jint Federal and state prgram that helps with medical csts fr sme peple with limited incme and resurces)...33 Infrmatin abut prgrams t help peple pay fr their prescriptin drugs...34 Hw t cntact the Railrad Retirement Bard...37 D yu have grup insurance r ther health insurance frm an emplyer?...37

25 Chapter 2. Imprtant Phne Numbers and Resurces 23 SECTION 1 HealthTeam Advantage Plan I cntacts (hw t cntact us, including hw t reach yur Healthcare Cncierge at the plan) Hw t cntact yur Healthcare Cncierge Fr assistance with claims, billing r member card questins, please call r write t HealthTeam Advantage Plan I yur Healthcare Cncierge. We will be happy t help yu. Methd Yur Healthcare Cncierge Cntact Infrmatin CALL Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. Yur Healthcare Cncierge als has free language interpreter services available fr nn-english speakers. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. FAX WRITE HealthTeam Advantage 7800 McClud Rad Suite 100 Greensbr, NC WEBSITE Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will

26 Chapter 2. Imprtant Phne Numbers and Resurces 24 pay fr yur medical services. 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)). Yu may call us if yu have questins abut ur cverage decisin prcess. Methd Cverage Decisins fr Medical Care Cntact Infrmatin CALL Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. FAX WRITE HealthTeam Advantage, Inc. Attn: Cverage Determinatins 7800 McClud Rad, Suite 100 Greensbr, NC WEBSITE Hw t cntact us when yu are making an appeal abut yur medical care An appeal is a frmal way f asking us t review and change a cverage decisin we have made. 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)).

27 Chapter 2. Imprtant Phne Numbers and Resurces 25 Methd Appeals fr Medical Care Cntact Infrmatin CALL TTY 711 Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. FAX WRITE HealthTeam Advantage, Inc. Attn: Appeals and Grievances Department 7800 McClud Rad, Suite 100 Greensbr, NC WEBSITE Hw t cntact us when yu are making a cmplaint abut yur medical care Yu can make a cmplaint abut us r ne f ur netwrk prviders, including a cmplaint abut the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes. (If yu have a prblem abut the plan s cverage r payment, yu shuld lk at the sectin abve abut making an appeal.) Fr mre infrmatin n making a cmplaint abut yur medical care, see Chapter 9 (What t d

28 Chapter 2. Imprtant Phne Numbers and Resurces 26 if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Methd Cmplaints abut Medical Care Cntact Infrmatin CALL Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs:Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. FAX WRITE HealthTeam Advantage, Inc. Attn: Appeals and Grievances Department 7800 McClud Rad, Suite 100 Greensbr, NC MEDICARE WEB- SITE Yu can submit a cmplaint abut HealthTeam Advantage Plan I directly t Medicare. T submit an nline cmplaint t Medicare g t MedicareCmplaintFrm/hme.aspx Hw t cntact us when yu are asking fr a cverage decisin abut yur Part D prescriptin drugs A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur prescriptin drugs cvered under the Part D benefit included in yur plan. Fr mre infrmatin n asking fr cverage decisins abut yur Part D prescriptin drugs, see Chapter 9 (What t d if u have a prblem r cmplaint (cverage decisins, appeals, cmplaints)).

29 Chapter 2. Imprtant Phne Numbers and Resurces 27 Methd Cverage Decisins fr Part D Prescriptin Drugs Cntact Infrmatin CALL Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. FAX WRITE EnvisinRx Optins 2181 E. Aurra Rad, Suite 201 Twinsburg, OH WEBSITE Hw t cntact us when yu are making an appeal abut yur Part D prescriptin drugs An appeal is a frmal way f asking us t review and change a cverage decisin we have made. 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)). Methd Appeals fr Part D Prescriptin Drugs Cntact Infrmatin CALL Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. FAX WRITE EnvisinRx Optins 2181 E. Aurra Rad, Suite 201 Twinsburg, OH WEBSITE

30 Chapter 2. Imprtant Phne Numbers and Resurces 28 Hw t cntact us when yu are making a cmplaint abut yur Part D prescriptin drugs Yu can make a cmplaint abut us r ne f ur netwrk pharmacies, including a cmplaint abut the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes. (If yur prblem is abut the plan s cverage r payment, yu shuld lk at the sectin abve abut making an appeal.) 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)). Methd Cmplaints abut Part D prescriptin drugs Cntact Infrmatin CALL Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. FAX WRITE HealthTeam Advantage Attn: Part D Appeals and Grievances 7800 McClud Rad, Suite 100 Greensbr, NC MEDICARE WEB- Yu can submit a cmplaint abut HealthTeam Advantage Plan I directly t SITE Medicare. T submit an nline cmplaint t Medicare, g t MedicareCmplaintFrm/hme.aspx. Where t send a request asking us t pay fr ur share f the cst fr medical care r a drug yu have received Fr mre infrmatin n situatins in which yu may need t ask us fr reimbursement r t pay a bill yu have received frm a prvider, see Chapter 7 (Asking us t pay ur share f a bill yu have received fr cvered 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.

31 Chapter 2. Imprtant Phne Numbers and Resurces 29 Methd Payment Request fr Medical Benefits Cntact Infrmatin CALL Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. FAX WRITE WEBSITE HealthTeam Advantage Attn: Organizatinal Determinatins 7800 McClud Rad, Suite 100 Greensbr, NC Methd Payment Request fr Part D Prescriptin Drug Benefits Cntact Infrmatin CALL Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. TTY 711 This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. Calls t this number are free. Hurs: 24 hurs a day, 7 days a week. FAX WRITE WEBSITE EnvisinRx Optins 2181 E. Aurra Rad, Suite 201 Twinsburg, OH

32 Chapter 2. Imprtant Phne Numbers and Resurces 30 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 Medicare Advantage rganizatins including us. Methd Medicare Cntact Infrmatin 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.

33 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 2. Imprtant Phne Numbers and Resurces 31 WEBSITE This is the fficial gvernment website fr Medicare. It gives yu up-t-date infr matin 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. Yu can als find Medi care cntacts in yur state. The Medicare website als has detailed infrmatin abut yur Medicare eligibility and enrllment ptins with the fllwing tls: Medicare Eligibility Tl: Prvides Medicare eligibility status infrmatin. Medicare Plan Finder: Prvides persnalized infrmatin abut available Medicare prescriptin drug plans, Medicare health plans, and Medigap (Medicare Supplement Insurance) plicies in yur area. These tls prvide an estimate f what yur ut-f-pcket csts might be in different Medicare plans. Yu can als use the website t tell Medicare abut any cmplaints yu have abut HealthTeam Advantage Plan I: Tell Medicare abut yur cmplaint: Yu can submit a cmplaint abut HealthTeam Advantage Plan I directly t Medicare. T submit a cmplaint t Medicare, g t aspx. Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. 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 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. (Yu can call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call ) 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 Nrth Carlina, the SHIP is called Senirs Health Insurance Infrmatin Prgram (SHIIP). Senirs Health Insurance Infrmatin Prgram (SHIIP) 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. Senirs Health Insurance Infrmatin Prgram (SHIIP) 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. Senirs Health Insurance Infrmatin Prgram (SHIIP) cunselrs can als help yu understand yur Medicare plan chices and answer questins abut switching plans.

34 Chapter 2. Imprtant Phne Numbers and Resurces 32 Methd Senirs Health Insurance Infrmatin Prgram (Nrth Carlina SHIP) Cntact Infrmatin CALL WRITE Senirs Health Insurance Infrmatin Prgram (SHIIP) 1201 Mail Service Center Raleigh, NC WEBSITE SECTION 4 Quality Imprvement Organizatin (paid by Medicare t check n the quality f care fr peple with Medicare) There is a designated Quality Imprvement Organizatin in each state. Fr Nrth Carlina, the Quality Imprvement Organizatin is called KePRO. KePRO 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. KePRO is an independent rganizatin. It is nt cnnected with ur plan. Yu shuld cntact KePRO 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. Methd KePRO (Nrth Carlina s Quality Imprvement Organizatin) Cntact Infrmatin CALL TTY fr all areas: WRITE KePRO 5201 W Kennedy Blvd. Suite 900 Tampa, FL FAX WEBSITE SECTION 5 Scial Security Scial Security is respnsible fr determining eligibility and handling enrllment fr Medicare. U.S. citizens wh are 65 r lder and lawful permanent residents, r wh have a disability r End-Stage Renal Disease and meet 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

35 Chapter 2. Imprtant Phne Numbers and Resurces 33 enrll in Medicare. Scial Security handles the enrllment prcess fr Medicare. T apply fr Medicare, yu can call Scial Security r visit yur lcal Scial Security ffice. Scial Security is als respnsible fr determining wh has t pay an extra amunt fr their Part D drug cverage because they have a higher incme. If yu gt a letter frm Scial Security telling yu that yu have t pay the extra amunt and have questins abut the amunt r if yur incme went dwn because f a life-changing event, yu can call Scial Security t ask fr recnsideratin. If yu mve r change yur mailing address, it is imprtant that yu cntact Scial Security t let them knw. Methd Scial Security Cntact Infrmatin CALL Calls t this number are free. Available 7:00 a.m. t 7:00 p.m., Mnday thrugh Friday. Yu can use Scial Security s autmated telephne services t get recrded infrmatin and cnduct sme business 24 hurs a day. TTY WEBSITE 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 a.m. t 7:00 p.m., Mnday thrugh Friday. 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. In additin, there are prgrams ffered thrugh Medicaid that help peple with Medicare pay their Medicare csts, such as their Medicare premiums. These Medicare Savings Prgrams help peple with limited incme and resurces save mney each year: Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and ther cst-sharing (like deductibles, cinsurance, and cpayments). (Sme peple with QMB are als eligible fr full Medicaid benefits (QMB+).) Specified Lw-Incme Medicare Beneficiary (SLMB): Helps pay Part B premiums. (Sme peple with SLMB are als eligible fr full Medicaid benefits (SLMB+).) Qualified Individual (QI): Helps pay Part B premiums. Qualified Disabled & Wrking Individuals (QDWI): Helps pay Part A premiums.

36 Chapter 2. Imprtant Phne Numbers and Resurces 34 T find ut mre abut Medicaid and its prgrams, cntact Nrth Carlina Department f Health and Human Service Center. Methd Nrth Carlina Department f Health and Human Service Center (Nrth Carlina s Medicaid prgram) - Cntact Infrmatin CALL TTY 711 r This number requires special telephne equipment and is nly fr peple wh have difficulties with hearing r speaking. WRITE Nrth Carlina Department f Health and Human Service Center 2501 Mail Service Center Raliegh, NC WEBSITE SECTION 7 Medicare s Extra Help Prgram Infrmatin abut prgrams t help peple pay fr their prescriptin drugs 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. Yu may be able t get Extra Help t pay fr yur prescriptin drug premiums and csts. T see if yu qualify fr getting Extra Help, call: MEDICARE ( ). TTY users shuld call , 24 hurs a day, 7 days a week; The Scial Security Office at , between 7 a.m. t 7 p.m., Mnday thrugh Friday. TTY users shuld call (applicatins); r Yur State Medicaid Office (applicatins). (See Sectin 6 f this chapter fr cntact infrmatin.) If yu believe yu have qualified 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. Cntact yur Healthcare Cncierge t request assistance in btaining best available evidence and fr prviding this evidence. If yu d nt have dcumentatin available, we will attempt t verify the status f yur extra help by wrking with Medicare t verify yur eligibility fr Extra help. 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

37 Chapter 2. Imprtant Phne Numbers and Resurces 35 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 yur Healthcare Cncierge if yu have questins (phne numbers are printed n the back cver f this bklet). Medicare Cverage Gap Discunt Prgram The Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs t Part D members wh have reached the cverage gap and are nt receiving Extra Help. Fr brand name drugs, the 50% discunt prvided by manufacturers excludes any fee fr csts in the gap. Members pay 35% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. If yu reach the cverage gap, we will autmatically apply the discunt when yur pharmacy bills yu fr yur prescriptin and yur Part D Explanatin f Benefits (Part D EOB) will shw any discunt prvided. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-fpcket csts as if yu had paid them and mve yu thrugh the cverage gap. The amunt paid by the plan (15%) des nt cunt tward yur ut-f-pcket csts. Yu als receive sme cverage fr generic drugs. If yu reach the cverage gap, the plan pays 56% f the price fr generic drugs and yu pay the remaining 44% f the price. Fr generic drugs, the amunt paid by the plan (56%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. Als, the dispensing fee is included as part f the cst f the drug. The Medicare Cverage Gap Discunt Prgram is available natinwide. Because HealthTeam Advantage ffers additinal gap cverage during the Cverage Gap Stage, yur ut-f-pcket csts will smetimes be lwer than the csts described here. Please g t Chapter 6, Sectin 6 fr mre infrmatin abut yur cverage during the Cverage Gap Stage. 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 yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). What if yu have cverage frm a State Pharmaceutical Assistance Prgram (SPAP)? If yu are enrlled in a State Pharmaceutical Assistance Prgram (SPAP), r any ther prgram that prvides cverage fr Part D drugs (ther than Extra Help ), yu still get the 50% discunt n cvered brand name drugs. Als, the plan pays 15% f the csts f brand drugs in the cverage gap. The 50% discunt and the 15% paid by the plan are bth applied t the price f the drug befre any SPAP r ther cverage. What if yu have cverage frm an AIDS Drug Assistance Prgram (ADAP)? What is the AIDS Drug Assistance Prgram (ADAP)? The AIDS Drug Assistance Prgram (ADAP) helps ADAP-eligible individuals living with HIV/AIDS have access t life-saving HIV medicatins. Medicare Part D prescriptin drugs that are als cvered by ADAP qualify fr prescriptin cst-sharing assistance. In Nrth Carlina, it is called the Nrth Carlina Department f Health and Human Services - HIV/STD Preventin and Care Branch. Nte: T be eligible fr the ADAP perating in yur State, individuals must meet certain criteria, including prf f State residence and HIV status, lw incme as defined by the State, and uninsured/under-insured status.

38 Chapter 2. Imprtant Phne Numbers and Resurces 36 If yu are currently enrlled in an ADAP, it can cntinue t prvide yu with Medicare Part D prescriptin cst-sharing assistance fr drugs n the ADAP frmulary. In rder t be sure yu cntinue receiving this assistance, please ntify yur lcal ADAP enrllment wrker f any changes in yur Medicare Part D plan name r plicy number. Cntact: Nrth Carlina HIV SPAP (Nrth Carlina State Pharmacy Assistance Prgram) at the phne number listed belw. Fr infrmatin n eligibility criteria, cvered drugs, r hw t enrll in the prgram, please call Nrth Carlina Drug Assistance Prgram at What if yu get Extra Help frm Medicare t help pay yur prescriptin drug csts? Can yu get the discunts? N. If yu get Extra Help, yu already get cverage fr yur prescriptin drug csts during the cverage gap. What if yu dn t get a discunt, and yu think yu shuld have? If yu think that yu have reached the cverage gap and did nt get a discunt when yu paid fr yur brand name drug, yu shuld review yur next Part D Explanatin f Benefits (Part D EOB) ntice. If the discunt desn t appear n yur Part D Explanatin f Benefits, yu shuld cntact us t make sure that yur prescriptin recrds are crrect and up-t-date. If we dn t agree that yu are wed a discunt, yu can appeal. Yu can get help filing an appeal frm yur State Health Insurance Assistance Prgram (SHIP) (telephne numbers are in Sectin 3 f this Chapter) r by calling MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call State Pharmaceutical Assistance Prgrams Many states have State Pharmaceutical Assistance Prgrams that help sme peple pay fr prescriptin drugs based n financial need, age, r medical cnditin. Each state has different rules t prvide drug cverage t its members. These prgrams prvide limited incme and medically needy senirs and individuals with disabilities financial help fr prescriptin drugs. In Nrth Carlina, the State Pharmaceutical Assistance Prgram are the Nrth Carlina HIV SPAP and Nrth Carlina AIDS Drug Assistance Prgram. Methd Nrth Carlina HIV SPAP (Nrth Carlina State Pharmaceutical Assistance Prgram) Cntact Infrmatin CALL WRITE Nrth Carlina HIV SPAP 1902 Mail Service Center Raleigh, NC WEBSITE

39 Chapter 2. Imprtant Phne Numbers and Resurces 37 Methd Nrth Carlina AIDS Drug Assistance Prgram: (Nrth Carlina State Pharmaceutical Assistance Prgram) Cntact Infrmatin CALL WRITE WEBSITE Nrth Carlina AIDS Drug Assistance Prgram 225 N McDwell Street Raleigh, NC SECTION 8 Hw t cntact the Railrad Retirement Bard 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. If yu receive yur Medicare thrugh the Railrad Retirement Bard, it is imprtant that yu let them knw if yu mve r change yur mailing address Methd Railrad Retirement Bard Cntact Infrmatin CALL Calls t this number are free. Available 9:00 a.m. t 3:30 p.m., 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. TTY WEBSITE 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 as part f this plan, yu may call the emplyer/unin benefits administratr r yur Healthcare Cncierge if yu have any questins. Yu can ask abut yur (r yur spuse s) emplyer r retiree health benefits, premiums, r the enrllment perid. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Yu may als call MEDICARE ( ; TTY: ) with questins related t yur Medicare cverage under this plan. 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.

40 CHAPTER 3 Using the plan s cverage fr yur medical services

41 Chapter 3. Using the plan s cverage fr yur medical services 39 Chapter 3. SECTION 1 Sectin 1.1 Sectin 1.2 SECTION 2 Sectin 2.1 Sectin 2.2 Sectin 2.3 Sectin 2.4 SECTION 3 Sectin 3.1 Sectin 3.2 Sectin 3.3 SECTION 4 Sectin 4.1 Sectin 4.2 SECTION 5 Sectin 5.1 Sectin 5.2 SECTION 6 Sectin 6.1 Sectin 6.2 Using the plan s cverage fr yur medical services Things t knw abut getting yur medical care cvered as a member f ur plan...40 What are netwrk prviders and cvered services? Basic rules fr getting yur medical care cvered by the plan Using netwrk and ut-f-netwrk prviders t get yur medical care...41 Yu may chse a Primary Care Prvider (PCP) t prvide and versee yur medical care What kinds f medical care can yu get withut getting apprval in advance frm yur PCP? Hw t get care frm specialists and ther netwrk prviders Hw t get care frm ut-f-netwrk prviders Hw t get cvered services when yu have an emergency r urgent need fr care r during a disaster...44 Getting care if yu have a medical emergency Getting care when yu have an urgent need fr services Getting care during a disaster.45 What if yu are billed directly fr the full cst f yur cvered services?...46 Yu can ask us t pay ur share f the cst f cvered services If services are nt cvered by ur plan, yu must pay the full cst Hw are yur medical services cvered when yu are in a clinical research study?...46 What is a clinical research study? When yu participate in a clinical research study, wh pays fr what? Rules fr getting care cvered in a religius nn-medical health care institutin...48 What is a religius nn-medical health care institutin? What care frm a religius nn-medical health care institutin is cvered by ur plan? SECTION 7 Rules fr wnership f durable medical equipment...49 Sectin 7.1 Will yu wn the durable medical equipment after making a certain number f payments under ur plan?... 49

42 Chapter 3. Using the plan s cverage fr yur medical services 40 SECTION 1 Things t knw abut getting yur medical care cvered as a member f ur plan This chapter explains what 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 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 licensed by the state 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 have an agreement with us t accept ur payment and yur cst-sharing amunt as payment in full. We have arranged fr these prviders t deliver cvered services t members in ur plan. The prviders in ur netwrk bill us directly fr care they give yu. When yu see a netwrk prvider, yu pay nly yur share f the cst fr their services. 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 cvered by the plan As a Medicare health plan, HealthTeam Advantage Plan I must cver all services cvered by Original Medicare and must fllw Original Medicare s cverage rules. HealthTeam Advantage Plan I 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. Medically necessary means that the services, supplies, r drugs are needed fr the preventin, diagnsis, r treatment f yur medical cnditin and meet accepted standards f medical practice. Yu receive yur care frm a prvider wh is eligible t prvide services under Original Medicare. As a member f ur plan, yu can receive yur care frm either a netwrk prvider r an ut-f-netwrk prvider (fr mre abut this, see Sectin 2 in this chapter). The prviders in ur netwrk are listed in the Prvider/Pharmacy Directry.

43 Chapter 3. Using the plan s cverage fr yur medical services 41 If yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. Please nte: While yu can get yur care frm an ut-f-netwrk prvider, the prvider must be eligible t participate in Medicare. Except fr emergency care, we cannt pay a prvider wh is nt eligible t participate in Medicare. If yu g t a prvider wh is nt eligible t participate in Medicare, yu will be respnsible fr the full cst f the services yu receive. Check with yur prvider befre receiving services t cnfirm that they are eligible t participate in Medicare. SECTION 2 Using netwrk and ut-f-netwrk prviders t get yur medical care Sectin 2.1 Yu may chse a Primary Care Prvider (PCP) t prvide and versee yur medical care What is a PCP and what des the PCP d fr yu? Yur PCP, r primary care prvider, is a physician wh meets state requirements and is trained t give yu basic medical care. As we explain belw, yu may get yur rutine r basic care frm yur PCP. A PCP can be a Family Practice, General Practice, r Internal Medicine dctr. Yur PCP will prvide mst f yur care and will help yu arrange r crdinate the rest f the cvered services yu get as a member f ur Plan. This includes, but is nt limited t: X-Rays Medicatins Labratry Tests Therapy Care frm dctrs wh are specialists Hspital admissins, and Fllw-up care Health Screenings Crdinating yur services includes checking r cnsulting with ther plan prviders abut yur care and hw it is ging. Since yur PCP will prvide and crdinate yur medical care, yu shuld have all f yur past medical recrds sent t yur PCP s ffice. Hw d yu chse yur PCP? T chse yur PCP, please cntact yur Healthcare Cncierge. (Phne numbers are printed n the back cver f this bklet.)

44 Chapter 3. Using the plan s cverage fr yur medical services 42 Changing yur PCP Yu may change yur PCP fr any reasn, at any time. Als, it s pssible that yur PCP might leave ur plan s netwrk f prviders and yu wuld have t find a new PCP in ur plan r yu will pay mre fr cvered services. T change yur PCP please cntact yur Healthcare Cncierge. (Phne numbers are printed n the back cver f this bklet.) The change will take effect n the first day f the mnth fllwing the date f the request. Sectin 2.2 What kinds f medical care can yu get withut getting apprval in advance frm yur PCP? Yu can get the services listed belw withut getting apprval in advance frm yur PCP. Rutine wmen s health care, which includes breast exams, screening mammgrams (x-rays f the breast), Pap tests, and pelvic exams. Flu shts, Hepatitis B vaccinatins, and pneumnia vaccinatins. Emergency services frm netwrk prviders r frm ut-f-netwrk prviders. Urgently needed services frm netwrk prviders r frm ut-f-netwrk prviders when netwrk prviders are temprarily unavailable r inaccessible, e.g., when yu are temprarily utside f the plan s service area. Kidney dialysis services that yu get at a Medicare-certified dialysis facility when yu are temprarily utside the plan s service area. If pssible, please let us knw befre yu leave the service area s we can help arrange fr yu t have maintenance dialysis while yu are away. Sectin 2.3 Hw t get care frm specialists and ther netwrk prviders A specialist is a dctr wh prvides health care services fr a specific disease r part f the bdy. There are many kinds f specialists. Here are a few examples: Onclgists care fr patients with cancer. Cardilgists care fr patients with heart cnditins. Orthpedists care fr patients with certain bne, jint, r muscle cnditins. HealthTeam Advantage is a Preferred Prvider Organizatin (PPO); this means that yu are nt required t get referrals. Yu are able t use any PCP r specialist yu chse whether the prvider is in r ut f the HealthTeam Advantage netwrk. What if a specialist r anther netwrk prvider leaves ur plan? We may make changes t the hspitals, dctrs, and specialists (prviders) that are part f yur plan during the year. There are a number f reasns why yur prvider might leave yur plan but if yur dctr

45 Chapter 3. Using the plan s cverage fr yur medical services 43 r specialist des leave yur plan yu have certain rights and prtectins that are summarized belw: Even thugh ur netwrk f prviders may change during the year, Medicare requires that we furnish yu with uninterrupted access t qualified dctrs and specialists. We will make a gd faith effrt t prvide yu with at least 30 days ntice that yur prvider is leaving ur plan s that yu have time t select a new prvider. We will assist yu in selecting a new qualified prvider t cntinue managing yur health care needs. If yu are underging medical treatment yu have the right t request, and we will wrk with yu t ensure, that the medically necessary treatment yu are receiving is nt interrupted. If yu believe we have nt furnished yu with a qualified prvider t replace yur previus prvider r that yur care is nt being apprpriately managed yu have the right t file an appeal f ur decisin. If yu find ut that yur dctr r specialist is leaving yur plan please cntact us s we can assist yu in finding a new prvider and managing yur care. If yu need help finding anther prvider, please cntact yur Healthcare Cncierge. (Phne numbers are printed n the back cver f this bklet). Sectin 2.4 Hw t get care frm ut-f-netwrk prviders As a member f ur plan, yu can chse t receive care frm ut-f-netwrk prviders. Hwever, please nte prviders that d nt cntract with us are under n bligatin t treat yu, except in emergency situatins. Our plan will cver services frm either netwrk r ut-f-netwrk prviders, as lng as the services are cvered benefits and are medically necessary. Hwever, if yu use an ut-f-netwrk prvider, yur share f the csts fr yur cvered services may be higher. Here are ther imprtant things t knw abut using ut-f-netwrk prviders: Yu can get yur care frm an ut-f-netwrk prvider, hwever, in mst cases that prvider must be eligible t participate in Medicare. Except fr emergency care, we cannt pay a prvider wh is nt eligible t participate in Medicare. If yu receive care frm a prvider wh is nt eligible t participate in Medicare, yu will be respnsible fr the full cst f the services yu receive. Check with yur prvider befre receiving services t cnfirm that they are eligible t participate in Medicare. Yu dn t need t get a referral r prir authrizatin when yu get care frm ut-f-netwrk prviders. Hwever, befre getting services frm ut-f-netwrk prviders yu may want t ask fr a pre-visit cverage decisin t cnfirm that the services yu are getting are cvered and are medically necessary. (See Chapter 9, Sectin 4 fr infrmatin abut asking fr cverage decisins.) This is imprtant because: Withut a pre-visit cverage decisin, if we later determine that the services are nt cvered r were nt medically necessary, we may deny cverage and yu will be respnsible fr the entire cst. If we say we will nt cver yur services, yu have the right t appeal ur decisin nt t cver yur care. See Chapter 9 (What t d if yu have a prblem r cmplaint) t learn hw t make an appeal.

46 Chapter 3. Using the plan s cverage fr yur medical services 44 It is best t ask an ut-f-netwrk prvider t bill the plan first. But, if yu have already paid fr the cvered services, we will reimburse yu fr ur share f the cst fr cvered services. Or if an ut-f-netwrk prvider sends yu a bill that yu think we shuld pay, yu can send it t us fr payment. See Chapter 7 (Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs) fr infrmatin abut what t d if yu receive a bill r if yu need t ask fr reimbursement. If yu are using an ut-f-netwrk prvider fr emergency care, urgently needed services, r utf-area dialysis, yu may nt have t pay a higher cst-sharing amunt. See Sectin 3 fr mre infrmatin abut these situatins. SECTION 3 Hw t get cvered services when yu have an emergency r urgent need fr care r during a disaster Sectin 3.1 Getting care if yu have a medical emergency What is a medical emergency and what shuld yu d if yu have ne? A medical emergency is when yu, r any ther prudent laypersn with an average knwledge f health and medicine, believe that yu have medical symptms that require immediate medical attentin t prevent lss f life, lss f a limb, r lss f functin f a limb. The medical symptms may be an illness, injury, severe pain, r a medical cnditin that is quickly getting wrse. If yu have a medical emergency: Get help as quickly as pssible. Call 911 fr help r g t the nearest emergency rm r hspital. Call fr an ambulance if yu need it. Yu d nt need t get apprval r a referral first frm yur PCP. As sn as pssible, make sure that ur plan has been tld abut yur emergency. We need t fllw up n yur emergency care. Yu r smene else shuld call t tell us abut yur emergency care, usually within 48 hurs. Please cntact yur Healthcare Cncierge. (Phne numbers are printed n the back cver f this bklet). What is cvered if yu have a medical emergency? Yu may get cvered emergency medical care whenever yu need it, anywhere in the United States r its territries. Our plan cvers ambulance services in situatins where getting t the emergency rm in any ther way culd endanger yur health. Fr mre infrmatin, see the Medical Benefits Chart in Chapter 4 f this bklet. If yu have an emergency, we will talk with the dctrs wh are giving yu emergency care t help manage and fllw up n yur care. The dctrs wh are giving yu emergency care will decide when yur cnditin is stable and the medical emergency is ver. After the emergency is ver yu are entitled t fllw-up care t be sure yur cnditin cntinues t be stable. Yur fllw-up care will be cvered by ur plan. If yu get yur fllw-up care frm ut-f-netwrk prviders, yu will pay the higher ut-f-netwrk cst-sharing.

47 Chapter 3. Using the plan s cverage fr yur medical services 45 As a supplemental benefit, ur plan prvides wrldwide emergency cverage up t a fixed limit. This benefit des nt include transprtatin r nn-emergent medical care utside the United States. Please refer t Chapter 4 fr mre infrmatin and limitatins n this supplemental benefit. What if it wasn t a medical emergency? Smetimes it can be hard t knw if yu have a medical emergency. Fr example, yu might g in fr emergency care thinking that yur health is in serius danger and the dctr may say that it wasn t a medical emergency after all. If it turns ut that it was nt an emergency, as lng as yu reasnably thught yur health was in serius danger, we will cver yur care. Hwever, after the dctr has said that it was nt an emergency, the amunt f cst-sharing that yu pay will depend n whether yu get the care frm netwrk prviders r ut-f-netwrk prviders. If yu get the care frm netwrk prviders, yur share f the csts will usually be lwer than if yu get the care frm ut-f-netwrk prviders. Sectin 3.2 Getting care when yu have an urgent need fr services What are urgently needed services? Urgently needed services are nn-emergency, unfreseen medical illness, injury, r cnditin that requires immediate medical care. Urgently needed services may be furnished by netwrk prviders r by ut-f-netwrk prviders when netwrk prviders are temprarily unavailable r inaccessible. The unfreseen cnditin culd, fr example, be an unfreseen flare-up f a knwn cnditin that yu have. What if yu are in the plan s service area when yu have an urgent need fr care? In mst situatins, if yu are in the plan s service area and yu use an ut-f-netwrk prvider, yu will pay a higher share f the csts fr yur care. Hwever, if the circumstances are unusual r extrardinary, and netwrk prviders are temprarily unavailable r inaccessible, we will allw yu t get cvered services frm an ut-f-netwrk prvider at the lwer in-netwrk cst-sharing amunt by visiting an urgent care center. When circumstances are unusual r extrardinary, and the netwrk prviders are temprarily unavailable r inaccessible, prceed t the nearest urgent care center fr immediate treatment. What if yu are utside the plan s service area when yu have an urgent need fr care? When yu are utside the service area and cannt get care frm a netwrk prvider, ur plan will cver urgently needed services that yu get frm any prvider at the lwer in-netwrk cst-sharing amunt. Our plan des nt cver urgently needed care r any ther nn-emergency care if yu receive the care utside f the United States. Sectin 3.3 Getting care during a disaster If the Gvernr f yur state, the U.S. Secretary f Health and Human Services, r the President f the United States declares a state f disaster r emergency in yur gegraphic area, yu are still entitled t care frm yur plan.

48 Chapter 3. Using the plan s cverage fr yur medical services 46 Please visit the fllwing website: fr infrmatin n hw t btain needed care during a disaster. Generally, if yu cannt use a netwrk prvider during a disaster, yur plan will allw yu t btain care frm ut-f-netwrk prviders at in-netwrk cst-sharing. If yu cannt use a netwrk pharmacy during a disaster, yu may be able t fill yur prescriptin drugs at an ut-f-netwrk pharmacy. Please see Chapter 5, Sectin 2.5 fr mre infrmatin. SECTION 4 What if yu are billed directly fr the full cst f yur cvered services? Sectin 4.1 Yu can ask us t pay ur share f the cst f cvered services If yu have paid mre than yur share fr cvered services, r if yu have received a bill fr the full cst f cvered medical services, g t Chapter 7 (Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs) fr infrmatin abut what t d. Sectin 4.2 If services are nt cvered by ur plan, yu must pay the full cst HealthTeam Advantage Plan I cvers all medical services that are medically necessary, are listed in the plan s Medical Benefits Chart (this chart is in Chapter 4 f this bklet), and are btained cnsistent with plan rules. Yu are respnsible fr paying the full cst f services that aren t cvered by ur plan, either because they are nt plan cvered services, r plan rules were nt fllwed. If yu have any questins abut whether we will pay fr any medical service r care that yu are cnsidering, yu have the right t ask us whether we will cver it befre yu get it. Yu als have the right t ask fr this in writing. If we say we will nt cver yur services, yu have the right t appeal ur decisin nt t cver yur care. Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)) has mre infrmatin abut what t d if yu want a cverage decisin frm us r want t appeal a decisin we have already made. Yu may als call yur Healthcare Cncierge t get mre infrmatin (phne numbers are printed n the back cver f this bklet). Fr cvered services that have a benefit limitatin, yu pay the full cst f any services yu get after yu have used up yur benefit fr that type f cvered service. Once yu reach yur benefit limit, any mney yu spend n that service wuld nt cunt tward yur ut-f-pcket maximum. Yu can call yur Healthcare Cncierge when yu want t knw hw much f yur benefit limit yu have already used. SECTION 5 Hw are yur medical services cvered when yu are in a clinical research study? Sectin 5.1 What is a clinical research study? A clinical research study (als called a clinical trial ) is a way that dctrs and scientists test new types f medical care, like hw well a new cancer drug wrks. They test new medical care prcedures r drugs by asking fr vlunteers t help with the study. This kind f study is ne f the final stages f a research

49 Chapter 3. Using the plan s cverage fr yur medical services 47 prcess that helps dctrs and scientists see if a new apprach wrks and if it is safe. Nt all clinical research studies are pen t members f ur plan. Medicare first needs t apprve the research study. If yu participate in a study that Medicare has nt apprved, yu will be respnsible fr paying all csts fr yur participatin in the study. Once Medicare apprves the study, smene wh wrks n the study will cntact yu t explain mre abut the study and see if yu meet the requirements set by the scientists wh are running the study. Yu can participate in the study as lng as yu meet the requirements fr the study and yu have a full understanding and acceptance f what is invlved if yu participate in the study. If yu participate in a Medicare-apprved study, Original Medicare pays mst f the csts fr the cvered services yu receive as part f the study. When yu are in a clinical research study, yu may stay enrlled in ur plan and cntinue t get the rest f yur care (the care that is nt related t the study) thrugh ur plan. If yu want t participate in a Medicare-apprved clinical research study, yu d nt need t get apprval frm us r yur PCP. The prviders that deliver yur care as part f the clinical research study d nt need t be part f ur plan s netwrk f prviders. Althugh yu d nt need t get ur plan s permissin t be in a clinical research study, yu d need t tell us befre yu start participating in a clinical research study. Here is why yu need t tell us: 1. We can let yu knw whether the clinical research study is Medicare-apprved. 2. We can tell yu what services yu will get frm clinical research study prviders instead f frm ur plan. If yu plan n participating in a clinical research study, cntact yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet), t let them knw that yu will be participating in a clinical trial and t find ut mre specific details abut what yu will pay. Sectin 5.2 When yu participate in a clinical research study, wh pays fr what? Once yu jin a Medicare-apprved clinical research study, yu are cvered fr rutine items and services yu receive as part f the study, including: Rm and bard fr a hspital stay that Medicare wuld pay fr even if yu weren t in a study. An peratin r ther medical prcedure if it is part f the research study. Treatment f side effects and cmplicatins f the new care. Original Medicare pays mst f the cst f the cvered services yu receive as part f the study. After Medicare has paid its share f the cst fr these services, ur plan will als pay fr part f the csts. We will pay the difference between the cst-sharing in Original Medicare and yur cst-sharing as a member f ur plan. This means yu will pay the same amunt fr the services yu receive as part f the study as yu wuld if yu received these services frm ur plan.

50 Chapter 3. Using the plan s cverage fr yur medical services 48 Here s an example f hw the cst-sharing wrks: Let s say that yu have a lab test that csts $100 as part f the research study. Let s als say that yur share f the csts fr this test is $20 under Original Medicare, but the test wuld be $10 under ur plan s benefits. In this case, Original Medicare wuld pay $80 fr the test and we wuld pay anther $10. This means that yu wuld pay $10, which is the same amunt yu wuld pay under ur plan s benefits. In rder fr us t pay fr ur share f the csts, yu will need t submit a request fr payment. With yur request, yu will need t send us a cpy f yur Medicare Summary Ntices r ther dcumentatin that shws what services yu received as part f the study and hw much yu we. Please see Chapter 7 fr mre infrmatin abut submitting requests fr payment. When yu are part f a clinical research study, neither Medicare nr ur plan will pay fr any f the fllwing: Generally, Medicare will nt pay fr the new item r service that the study is testing unless Medicare wuld cver the item r service even if yu were nt in a study. Items and services the study gives yu r any participant fr free. Items r services prvided nly t cllect data, and nt used in yur direct health care. Fr example, Medicare wuld nt pay fr mnthly CT scans dne as part f the study if yur medical cnditin wuld nrmally require nly ne CT scan. D yu want t knw mre? Yu can get mre infrmatin abut jining a clinical research study by reading the publicatin Medicare and Clinical Research Studies n the Medicare website ( Yu can als call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 6 Rules fr getting care cvered in a religius nn-medical health care institutin Sectin 6.1 What is a religius nn-medical health care institutin? A religius nn-medical health care institutin is a facility that prvides care fr a cnditin that wuld rdinarily be treated in a hspital r skilled nursing facility. If getting care in a hspital r a skilled nursing facility is against a member s religius beliefs, we will instead prvide cverage fr care in a religius nn-medical health care institutin. Yu may chse t pursue medical care at any time fr any reasn. This benefit is prvided nly fr Part A inpatient services (nn-medical health care services). Medicare will nly pay fr nn-medical health care services prvided by religius nn-medical health care institutins.

51 Chapter 3. Using the plan s cverage fr yur medical services 49 Sectin 6.2 What care frm a religius nn-medical health care institutin is cvered by ur plan? T get care frm a religius nn-medical health care institutin, yu must sign a legal dcument that says yu are cnscientiusly ppsed t getting medical treatment that is nn-excepted. Nn-excepted medical care r treatment is any medical care r treatment that is vluntary and nt required by any federal, state, r lcal law. Excepted medical treatment is medical care r treatment that yu get that is nt vluntary r is required under federal, state, r lcal law. T be cvered by ur plan, the care yu get frm a religius nn-medical health care institutin must meet the fllwing cnditins: The facility prviding the care must be certified by Medicare. Our plan s cverage f services yu receive is limited t nn-religius aspects f care. If yu get services frm this institutin that are prvided t yu in a facility, the fllwing cnditins apply: Yu must have a medical cnditin that wuld allw yu t receive cvered services fr inpatient hspital care r skilled nursing facility care. and yu must get apprval in advance frm ur plan befre yu are admitted t the facility r yur stay will nt be cvered. Medicare Inpatient Hspital cverage limits apply. Please refer t the benefits chart in Chapter 4. SECTION 7 Rules fr wnership f durable medical equipment Sectin 7.1 Will yu wn the durable medical equipment after making a certain number f payments under ur plan? Durable medical equipment (DME) includes items such as xygen equipment and supplies, wheelchairs, walkers, pwered mattress systems, crutches, diabetic supplies, speech generating devices, IV infusin pumps, nebulizers and hspital beds rdered by a prvider fr use in the hme. The member always wns certain items such as prsthetics. In this sectin, we discuss ther types f DME that yu must rent. In Original Medicare, peple wh rent certain types f DME wn the equipment after paying cpayments fr the item fr 13 mnths. As a member f HealthTeam Advantage Plan I, hwever, yu usually will nt acquire wnership f rented DME items n matter hw many cpayments yu make fr the item while a member f ur plan. Under certain limited circumstances, we will transfer wnership f the DME item t yu. Call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) t find ut abut the requirements yu must meet and the dcumentatin yu need t prvide.

52 Chapter 3. Using the plan s cverage fr yur medical services 50 What happens t payments yu have made fr durable medical equipment if yu switch t Original Medicare? If yu did nt acquire wnership f the DME item while in ur plan, yu will have t make 13 new cnsecutive payments after yu swithc t Original Medicare in rder t wn the item. Payments made while in ur plan d nt cunt tward these 13 cnsecutive payments. If yu made fewer than 13 payments fr the DME item under Original Medicare befre yu jined ur plan, yur previus Original Medicare payments als d nt cunt tward the 13 cnsecutive payments. Yu will have t make 13 new cnsecutive payments after yu return t Original Medicare in rder t wn the item. There are n exceptins t this case when yu return t Original Medicare.

53 CHAPTER 4 Medical Benefits Chart (what is cvered and what yu pay)

54 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 52 Chapter 4. SECTION 1 Sectin 1.1 Sectin 1.2 Sectin 1.3 SECTION 2 Sectin 2.1 Sectin 2.2 SECTION 3 Sectin 3.1 Medical Benefits Chart (what is cvered and what yu pay) Understanding yur ut-f-pcket csts fr cvered services...53 Types f ut-f-pcket csts yu may pay fr yur cvered services What is the mst yu will pay fr Medicare Part A and Part B cvered medical services? Our plan des nt allw prviders t balance bill yu Use the Medical Benefits Chart t find ut what is cvered fr yu and hw much yu will pay...54 Yur medical benefits and csts as a member f the plan Extra ptinal supplemental benefits yu can buy What services are nt cvered by the plan?...82 Services we d nt cver (exclusins)... 82

55 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 53 SECTION 1 Understanding yur ut-f-pcket csts fr cvered services This chapter fcuses n yur cvered services and what yu pay fr yur medical benefits. It includes a Medical Benefits Chart that lists yur cvered services and shws hw much yu will pay fr each cvered service as a member f HealthTeam Advantage Plan I. Later in this chapter, yu can find infrmatin abut medical services that are nt cvered. It als explains limits n certain services. Sectin 1.1 Types f ut-f-pcket csts yu may pay fr yur cvered services T understand the payment infrmatin we give yu in this chapter, yu need t knw abut the types f ut-f-pcket csts yu may pay fr yur cvered services. A cpayment is the fixed amunt yu pay each time yu receive certain medical services. Yu pay a cpayment at the time yu get the medical service. (The Medical Benefits Chart in Sectin 2 tells yu mre abut yur cpayments.) Cinsurance is the percentage yu pay f the ttal cst f certain medical services. Yu pay a cinsurance at the time yu get the medical service. (The Medical Benefits Chart in Sectin 2 tells yu mre abut yur cinsurance.) Mst peple wh qualify fr Medicaid r fr the Qualified Medicare Beneficiary(QMB) prgram shuld never pay deductibles, cpayments r cinsurance. Be sure t shw yur prf f Medicaid r QMB eligibility t yur prvider, if applicable. If yu think that yu are being asked t pay imprperly, cntact yur Healthcare Cncierge. Sectin 1.2 What is the mst yu will pay fr Medicare Part A and Part B cvered medical services? Under ur plan, there are tw different limits n what yu have t pay ut-f-pcket fr cvered medical services: Yur in-netwrk maximum ut-f-pcket amunt is $3,400. This is the mst yu pay during the calendar year fr cvered Medicare Part A and Part B services received frm in-net wrk prviders. The amunts yu pay fr cpayments and cinsurance fr cvered services frm in-netwrk prviders cunt tward this in-netwrk maximum ut-f-pcket amunt. (The amunts yu pay fr plan premiums, Part D prescriptin drugs, and services frm ut-fnetwrk prviders d nt cunt tward yur in-netwrk maximum ut-f- pcket amunt. In additin, amunts yu pay fr sme services d nt cunt tward yur in-netwrk maximum ut-f-pcket amunt. These services are marked with an asterisk in the Medical Benefits Chart.) If yu have paid $3,400 fr cvered Part A and Part B services frm in-netwrk pr viders, yu will nt have any ut-f-pcket csts fr the rest f the year when yu see ur net wrk prviders. Hwever, yu must cntinue t pay yur plan premium and the Medicare Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). Yur cmbined maximum ut-f-pcket amunt is $5,100. This is the mst yu pay during the calendar year fr cvered Medicare Part A and Part B services received frm bth in-net wrk and ut-f-netwrk prviders. The amunts yu pay fr cpayments, and cinsurance fr cvered services cunt tward this cmbined maximum ut-f-pcket amunt. (The amunts yu pay fr yur plan premiums and fr yur Part D prescriptin drugs d nt cunt tward

56 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 54 Sectin 1.3 yur cmbined maximum ut-f-pcket amunt. In additin, amunts yu pay fr sme ser vices d nt cunt tward yur cmbined maximum ut-f- pcket amunt. These services are marked with an asterisk in the Medical Benefits Chart.) If yu have paid $5,100 fr cvered services, yu will have 100% cverage and will nt have any ut-f-pcket csts fr the rest f the year fr cvered Part A and Part B services. Hwever, yu must cntinue t pay the Medi care Part B premium (unless yur Part B premium is paid fr yu by Medicaid r anther third party). Our plan des nt allw prviders t balance bill yu As a member f HealthTeam Advantage Plan I, an imprtant prtectin fr yu is that yu nly have t pay yur cst-sharing amunt when yu get services cvered by ur plan. We d nt allw prviders t add additinal separate charges, called balance billing. This prtectin (that yu never pay mre than yur cst-sharing amunt) applies even if we pay the prvider less than the prvider charges fr a service and even if there is a dispute and we dn t pay certain prvider charges. Here is hw this prtectin wrks. If yur cst-sharing is a cpayment (a set amunt f dllars, fr example, $15.00), then yu pay nly that amunt fr any cvered services frm a netwrk prvider. Yu will generally have higher cpays when yu btain care frm ut-f-netwrk prviders. If yur cst-sharing is a cinsurance (a percentage f the ttal charges), then yu never pay mre than that percentage. Hwever, yur cst depends n which type f prvider yu see: If yu btain cvered services frm a netwrk prvider, yu pay the cinsurance percent age multiplied by the plan s reimbursement rate (as determined in the cntract between the prvider and the plan). If yu btain cvered services frm an ut-f-netwrk prvider wh participates with Medicare, yu pay the cinsurance percentage multiplied by the Medicare payment rate fr participating prviders. If yu btain cvered services frm an ut-f-netwrk prvider wh des nt participate with Medicare, then yu pay the cinsurance amunt multiplied by the Medicare payment rate fr nn-participating prviders. If yu believe a prvider has balance billed yu, call yur Health Cncierge (phne numbers are printed n the back cver f this bklet). SECTION 2 Use the Medical Benefits Chart t find ut what is cvered fr yu and hw much yu will pay Sectin 2.1 Yur medical benefits and csts as a member f the plan The Medical Benefits Chart n the fllwing pages lists the services HealthTeam Advantage Plan I cvers and what yu pay ut-f-pcket fr each service. The services listed in the Medical Benefits Chart are cvered nly when the fllwing cverage requirements are met:

57 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 55 Yur Medicare cvered services must be prvided accrding t the cverage guidelines established by Medicare. Yur services (including medical care, services, supplies, and equipment) must be medically necessary. Medically necessary means that the services, supplies, r drugs are needed fr the preventin, diagnsis, r treatment f yur medical cnditin and meet accepted standards f medical practice. Sme f the services listed in the Medical Benefits Chart are cvered as in-netwrk services nly if yur dctr r ther netwrk prvider gets apprval in advance (smetimes called prir authrizatin ) frm HealthTeam Advantage Plan I. Cvered services that need apprval in advance t be cvered as in-netwrk services are marked by a ntatin in the Medical Benefits Chart. While yu dn t need apprval in advance fr ut-f-netwrk services, yu r yur dctr can ask us t make a cverage decisin in advance. Other imprtant things t knw abut ur cverage: Fr benefits where yur cst-sharing is a cinsurance percentage, the amunt yu pay depends n what type f prvider yu receive the services frm: If yu receive the cvered services frm a netwrk prvider, yu pay the cinsurance percentage multiplied by the plan s reimbursement rate (as determined in the cntract between the prvider and the plan) If yu receive the cvered services frm an ut-f-netwrk prvider wh participates with Medicare, yu pay the cinsurance percentage multiplied by the Medicare payment rate fr participating prviders, If yu receive the cvered services frm an ut-f-netwrk prvider wh des nt participate with Medicare, yu pay the cinsurance percentage multiplied by the Medicare payment rate fr nn-participating prviders. Like all Medicare health plans, we cver everything that Original Medicare cvers. Fr sme f these benefits, yu pay mre in ur plan than yu wuld in Original Medicare. Fr thers, yu pay less. (If yu want t knw mre abut the cverage and csts f Original Medicare, lk in yur Medicare & Yu 2018 Handbk. View it nline at r ask fr a cpy by calling MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call ) Fr all preventive services that are cvered at n cst under Original Medicare, we als cver the service at n cst t yu. Hwever, if yu als are treated r mnitred fr an existing medical cnditin during the visit when yu receive the preventive service, a cpayment will apply fr the care received fr the existing medical cnditin. Smetimes, Medicare adds cverage under Original Medicare fr new services during the year. If Medicare adds cverage fr any services during 2018, either Medicare r ur plan will cver thse services. Yu will see this apple next t the preventive services in the benefits chart.

58 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 56 Medical Benefits Chart Services that are cvered fr yu What yu must pay when yu get these services Abdminal artic aneurysm screening A ne-time screening ultrasund fr peple at risk. The plan nly cvers this screening if yu have certain risk factrs and if yu get a referral fr it frm yur physician, physician assistant, nurse practitiner, r clinical nurse specialist. In-Netwrk There is n cinsur ance, cpayment, r deductible fr members eligible fr this preven tive screening. Out-Of-Netwrk $30 Cpay fr members eligible fr this preventive screening. Ambulance services Cvered ambulance services include fixed wing, rtary wing, and grund ambulance services, t the nearest apprpriate facility that can prvide care if they are furnished t a member whse medical cnditin is such that ther means f transprtatin culd endanger the persn s health r if authrized by the plan. Nn-emergency transprtatin by ambulance is appr priate if it is dcumented that the member s cnditin is such that ther means f transprtatin culd en danger the persn s health and that transprtatin by ambulance is medically required. Annual Physical (Rutine) In additin t the Medicare-cvered annual wellness visit, plan cvers ne cmprehensive preventive medical exam inatin per year. In-Netwrk $225 cpay fr Medicare-cvered ambulance benefits per ne-way trip. Out-Of-Netwrk $225 cpay fr Medicare-cvered ambulance benefits per ne-way trip. Prir Authrizatin is required fr Nn- Emergency transprtatin In-Netwrk Out-Of-Netwrk $ 0 Cpay $20 Cpay Annual wellness visit If yu ve had Part B fr lnger than 12 mnths, yu can get an annual wellness visit t develp r update a persnal ized preventin plan based n yur current health and risk factrs. This is cvered nce every 12 mnths. Nte: Yur first annual wellness visit can t take place with in 12 mnths f yur Welcme t Medicare preventive visit. Hwever, yu dn t need t have had a Welcme t Medicare visit t be cvered fr annual wellness visits after yu ve had Part B fr 12 mnths. Bne mass measurement Fr qualified individuals (generally, this means peple at risk f lsing bne mass r at risk f steprsis), the fllwing services are cvered every 24 mnths r mre frequently if medically necessary: prcedures t identify bne mass, detect bne lss, r determine bne quality, including a physician s interpretatin f the results. In-Netwrk There is n cinsurance, cpay ment, r deductible fr the annual wellness visit. In-Netwrk There is n cinsurance, cpay ment, r deductible fr Medicare-cvered bne mass measurement. Out-Of-Netwrk $30 Cpay fr the annual wellness visit. Out-Of-Netwrk $30 Cpay fr Medicare-cvered bne mass measurement.

59 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 57 Services that are cvered fr yu What yu must pay when yu get these services Breast cancer screening (mammgrams) Cvered services include: One baseline mammgram between the ages f 35 and 39 One screening mammgram every 12 mnths fr wmen age 40 and lder Clinical breast exams nce every 24 mnths Cardiac rehabilitatin services Cmprehensive prgrams f cardiac rehabilitatin ser vices that include exercise, educatin, and cunseling are cvered fr members wh meet certain cnditins with a dctr s referral. The plan als cvers intensive cardiac rehabilitatin prgrams that are typically mre rigrus r mre intense than cardiac rehabilitatin prgrams. Cardivascular disease risk reductin visit (therapy fr cardivascular disease) We cver ne visit per year with yur primary care dctr t help lwer yur risk fr cardivascular disease. During this visit, yur dctr may discuss aspirin use (if apprpriate), check yur bld pressure, and give yu tips t make sure yu re eating well. Cardivascular disease testing Bld tests fr the detectin f cardivascular disease (r abnrmalities assciated with an elevated risk f cardivascular disease) nce every 5 years (60 mnths). Cervical and vaginal cancer screening Cvered services include: Fr all wmen: Pap tests and pelvic exams are cvered nce every 24 mnths If yu are at high risk f cervical r vaginal cancer r yu are f childbearing age and have had an abnrmal Pap test within the past 3 years: ne Pap test every 12 mnths. In-Netwrk There is n cinsurance, cpay ment, r deductible fr cvered screening mammgrams. In-Netwrk $15 Cpay fr Medicare-cvered Cardiac Rehabilitatin services r Medicare cvered intensive Cardiac Rehabilitatin services In-Netwrk There is n cinsurance, cpayment, r deductible fr the intensive behaviral therapy cardivascular disease preventive benefit. In-Netwrk There is n cinsurance, cpay ment, r deductible fr cardivascular disease testing that is cvered nce every 5 years. In-Netwrk There is n cinsurance, cpay ment, r deductible fr Medicare-cvered preventive Pap and pelvic exams. Out-Of-Netwrk $30 Cpay Out-Of-Netwrk $25 Cpay fr Medicare-cvered Cardiac Rehabilitatin services r Medicare cvered intensive Cardiac Rehabilitatin services Out-Of-Netwrk $30 Cpay Out-Of-Netwrk $30 Cpay Out-Of-Netwrk $30 Cpay

60 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 58 Services that are cvered fr yu What yu must pay when yu get these services Chirpractic services Cvered services include: We cver nly manual manipulatin f the spine t crrect subluxatin (adjustments f the spine) Clrectal cancer screening Fr peple 50 and lder, the fllwing are cvered: Flexible sigmidscpy (r screening barium enema as an alternative) every 48 mnths One f the fllwing every 12 mnths: Guaiac-based fecal ccult bld test (gfobt) Fecal immunchemical test (FIT) DNA based clrectal screening every 3 years Fr peple at high risk f clrectal cancer, we cver: Screening clnscpy (r screening barium enema as an alternative) every 24 mnths Fr peple nt at high risk f clrectal cancer, we cver: Screening clnscpy every 10 years (120 mnths), but nt within 48 mnths f a screening sigmidscpy In-Netwrk $15 Cpay In-Netwrk There is n cinsurance, cpayment, r deductible fr a Medicarecvered clrectal cancer screening exam. Out-Of-Netwrk $20 Cpay Out-Of-Netwrk $30 Cpay fr a Medicare-cvered clrectal cancer screening exam. Dental services In general, preventive dental services (such as cleaning, rutine dental exams, and dental x-rays) are nt cvered by Original Medicare. We cver: Medicare cvered dental prcedures t recn struct the jaw fllwing accidental injury r fr extractin dne in preparatin fr radiatin treatment fr neplastic diseases invlving the jaw. Limited dental services (this des nt include services in cnnectin with care, treatment, filling, remval, r replacement f teeth): In-Netwrk $35 cpay fr Medicare Apprved Dental Services Out-Of-Netwrk $50 cpay fr Medicare Apprved Dental Services

61 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 59 Services that are cvered fr yu What yu must pay when yu get these services Depressin screening We cver ne screening fr depressin per year. The screening must be dne in a primary care setting that can prvide fllw-up treatment and referrals. In-Netwrk There is n cinsurance, cpayment, r deductible fr an annual depressin screening visit. Out-Of-Netwrk $30 Cpay fr an annual depressin screening visit. Diabetes screening We cver this screening (includes fasting glucse tests) if yu have any f the fllwing risk factrs: high bld pressure (hypertensin), histry f abnrmal chlesterl and triglyceride levels (dyslipidemia), besity, r a histry f high bld sugar (glucse). Tests may als be cvered if yu meet ther requirements, like being verweight and having a family histry f diabetes. Based n the results f these tests, yu may be eligible fr up t tw diabetes screenings every 12 mnths. In-Netwrk There is n cinsurance, cpay ment, r deductible fr the Medicare cvered diabetes screening tests. Out-Of-Netwrk $30 Cpay fr the Medicare cvered diabetes screening tests. Diabetes self-management training, diabetic services and supplies Fr all peple wh have diabetes (insulin and nn-insulin users). Cvered services include: Supplies t mnitr yur bld glucse: Bld glucse mnitr, bld glucse test strips, lancet devices and lancets, and glucse-cntrl slutins fr checking the accuracy f test strips and mnitrs. (Mnitring devices and supplies cvered are limited t Freestyle, Precisin and One-Tuch) Fr peple with diabetes wh have severe diabetic ft disease: One pair per calendar year f therapeutic custm-mlded shes (including inserts prvided with such shes) and tw additinal pairs f inserts, r ne pair f depth shes and three pairs f inserts (nt in cluding the nn-custmized remvable inserts prvided with such shes). Cverage includes fitting. Diabetes self-management training is cvered under certain cnditins. In-Netwrk $0 Cpay fr each Medicare cvered diabetes mnitring supply. $0 Cpay fr ne pair f Medicare- Cvered therapeutic shes and up t tw pairs f inserts. $0 cpay fr diabetes self-management training. Out-Of-Netwrk 20% f the cst fr each Medicare cvered diabetes mnitring supply. 20% f the cst fr ne pair f Medicare- Cvered therapeutic shes and up t tw pairs f inserts. 20% f the cst fr diabetes self-management training.

62 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 60 Services that are cvered fr yu Durable medical equipment (DME) and related supplies (Fr a definitin f durable medical equipment, see Chapter 12 f this bklet.) Cvered items include, but are nt limited t: wheelchairs, crutches, pwered mattress systems, diabetic supplies, hspital bed rdered by a prvider fr use in the hme, IV infusin pump, speech generating devices, xygen equip ment, nebulizers, and walkers. What yu must pay when yu get these services Services require prir authrizatin. In-Netwrk 20% f the cst Out-Of-Netwrk 30% f the cst We cver all medically necessary durable medical equip ment cvered by Original Medicare. If ur supplier in yur area des nt carry a particular brand r manufacturer, yu may ask them if they can special rder it fr yu. The mst recent list f suppliers is available n ur website at Emergency care Emergency care refers t services that are: Furnished by a prvider qualified t furnish emergency services, and Needed t evaluate r stabilize an emergency medical cnditin. A medical emergency is when yu, r any ther prudent laypersn with an average knwledge f health and medi cine, believe that yu have medical symptms that require immediate medical attentin t prevent lss f life, lss f a limb, r lss f functin f a limb. The medical symp tms may be an illness, injury, severe pain, r a medical cnditin that is quickly getting wrse. Cst sharing fr necessary emergency services furnished ut-f-netwrk is the same as fr such services furnished in-netwrk. Emergency services are cvered utside the service area anywhere in the wrld.* In-Netwrk $100 cpay Out-Of-Netwrk $100 cpay If yu are admitted t the hspital within 3 days fr the same cnditin, yu d nt have t pay yur share f the cst fr emergency care. See the Inpatient Hspital Care sectin f this bklet fr ther csts. If yu receive emergency care at an ut-f-net wrk hspital and need inpatient care after yur emergency cnditin is stabilized, yu must return t a netwrk hspital in rder fr yur care t cntinue t be cvered OR yu must have yur inpatient care at the ut-f-netwrk hspital authrized by the plan and yur cst is the cst-sharing yu wuld pay at a netwrk hspital. $0 cpay fr Emergency Services fr Wrldwide cverage. *Cverage limited t $50,000 fr supplemental emergency services utside the United States.

63 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 61 Services that are cvered fr yu What yu must pay when yu get these services Health and wellness educatin prgrams Fitness Facility Membership/Exercise Classes thrugh yur Silver & Fit Exercise and Healthy Aging Prgram Hearing services There is n cpay fr an unlimited number f visits t a Silver & Fit participating fitness facility. Yu can switch fitness facilities nce per mnth. In-Netwrk Out-Of-Netwrk Diagnstic hearing and balance evaluatins perfrmed by yur PCP t determine if yu need medical treatment are cvered as utpatient care when furnished by a physician, audilgist, r ther qualified prvider. $35 Cpay fr Medicare Cvered diagnstic hearing exam $50 Cpay fr Medicare Cvered diagnstic hearing exam Additinal hearing benefit includes: Rutine Hearing Exam (up t ne per year) HIV screening Fr peple wh ask fr an HIV screening test r wh are at increased risk fr HIV infectin, we cver: One screening exam every 12 mnths Fr wmen wh are pregnant, we cver: Up t three screening exams during a pregnancy Hme health agency care Prir t receiving hme health services, a dctr must certify that yu need hme health services and will rder hme health services t be prvided by a hme health agency. Yu must be hmebund, which means leaving hme is a majr effrt. Cvered services include, but are nt limited t: Part-time r intermittent skilled nursing and hme health aide services (T be cvered under the hme health care benefit, yur skilled nursing and hme health aide services cmbined must ttal fewer than 8 hurs per day and 35 hurs per week) Physical therapy, ccupatinal therapy, and speech therapy Medical and scial services Medical equipment and supplies $5 cpay fr ne rutine hearing exam per year In-Netwrk $30 cpay fr ne rutine hearing exam per year Out-Of-Netwrk There is n cinsur $30 Cpay fr ance, cpayment, r beneficiaries eligible fr Medicare- deductible fr bene ficiaries eligible fr cvered preventive Medicare-cvered pre HIV screening. ventive HIV screening. Services require prir authrizatin. In-Netwrk $25 Cpay Out-Of-Netwrk $45 Cpay

64 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 62 Services that are cvered fr yu Hspice care Yu may receive care frm any Medicare-certified hspice prgram. Yu are eligible fr the hspice benefit when yur dctr and the hspice medical directr have given yu a terminal prgnsis certifying that yu re terminally ill and have 6 mnths r less t live if yur illness runs its nrmal curse. Yur hspice dctr can be a netwrk prvider r an ut-f-netwrk prvider. Cvered services include: Drugs fr symptm cntrl and pain relief Shrt-term respite care Hme care Fr hspice services and fr services that are cvered by Medicare Part A r B and are related t yur terminal prgnsis: Original Medicare (rather than ur plan) will pay fr yur hspice services and any Part A and Part B services related t yur terminal prgnsis. While yu are in the hspice prgram, yur hspice prvider will bill Original Medicare fr the services that Original Medicare pays fr. Fr services that are cvered by Medicare Part A r B and are nt related t yur terminal prgnsis: If yu need nn-emergency, nn-urgently needed services that are cvered under Medicare Part A r B and that are nt related t yur terminal prgnsis, yur cst fr these services depends n whether yu use a prvider in ur plan s netwrk: If yu btain the cvered services frm a netwrk prvider, yu nly pay the plan cst-sharing amunt fr in-netwrk services If yu btain the cvered services frm an ut-f-net wrk prvider, yu pay the cst-sharing under Fee-fr- Service Medicare (Original Medicare) Fr services that are cvered by HealthTeam Advantage Plan I (PPO) but are nt cvered by Medicare Part A r B: HealthTeam Advantage Plan I (PPO) will cntinue t cver plan-cvered services that are nt cvered under Part A r B whether r nt they are related t yur terminal prgnsis. Yu pay yur plan cst-sharing amunt fr these services. What yu must pay when yu get these services When yu enrll in a Medicare-certified hspice prgram, yur hspice services and yur Part A and Part B services related t yur terminal prgnsis are paid fr by Original Medicare, nt HealthTeam Advantage Plan I (PPO). Yu pay nthing fr hspice care frm a Medicare-certified hspice prgram. Yu may have t pay part f the cst fr drugs and respite care.

65 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 63 Services that are cvered fr yu What yu must pay when yu get these services Hspice care (cntinued) Fr drugs that may be cvered by the plan s Part D benefit: Drugs are never cvered by bth hspice and ur plan at the same time. Fr mre infrmatin, please see Chapter 5, Sectin 9.4 (What if yu re in Medicare-certified hspice). Nte: If yu need nn-hspice care (care that is nt related t yur terminal prgnsis), yu shuld cntact us t arrange the services. Getting yur nn-hspice care thrugh ur netwrk prviders will lwer yur share f the csts fr the services. Immunizatins Cvered Medicare Part B services include: Pneumnia vaccine Flu shts, nce a year in the fall r winter Hepatitis B vaccine if yu are at high r intermediate risk f getting Hepatitis B Other vaccines if yu are at risk and they meet Medi care Part B cverage rules We als cver sme vaccines under ur Part D prescriptin drug benefit. Inpatient hspital care Includes inpatient acute, inpatient rehabilitatin, lng-term care hspitals and ther types f inpatient hspital services. Inpatient hspital care starts the day yu are frmally ad mitted t the hspital with a dctr s rder. The day befre yu are discharged is yur last inpatient day. Cvered services include but are nt limited t: Semi-private rm (r a private rm if medically necessary) Meals including special diets Regular nursing services Csts f special care units (such as intensive care r crnary care units) Drugs and medicatins Lab tests X-rays and ther radilgy services Necessary surgical and medical supplies In-Netwrk Out-Of-Netwrk There is n cinsur $30 Cpay fr the ance, cpayment, r pneumnia, deductible fr the pneu influenza, and mnia, influenza, and Hepatitis B vaccines. Hepatitis B vaccines. $30 cpayment fr all $0 cpayment fr all ther Medicare-cvered Immunizatins ther Medicare Part B cvered Immunizatins. Fr Part D cvered Part D cvered Immu immunizatins, see nizatins will prcess Chapter 5, Sectin 2.5 at the Tier identified in fr details. the frmulary. Services may require prir authrizatin. In-Netwrk Out-Of-Netwrk $250 cpay per day fr days 1 thrugh 6 $0 cpay per day fr days 7 thrugh 90 $400 cpay per day fr days 1 thrugh 7 $0 cpay per day fr days 8 thrugh 90 If yu get authrized inpatient care at an ut-fnetwrk hspital after yur emergency cnditin is stabilized, yur cst is the cst-sharing yu wuld pay at a netwrk hspital.

66 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 64 Services that are cvered fr yu What yu must pay when yu get these services Inpatient hspital care (cntinued) Use f appliances, such as wheelchairs Operating and recvery rm csts Physical, ccupatinal, and speech language therapy Inpatient substance abuse services Under certain cnditins, the fllwing types f trans plants are cvered: crneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bne marrw, stem cell, and intestinal/multivisceral. If yu need a transplant, we will arrange t have yur case reviewed by a Medicare-apprved transplant center that will decide whether yu are a candidate fr a transplant. Transplant prviders may be lcal r utside f the service area. If ur in-netwrk transplant services are utside the cmmunity pattern f care, yu may chse t g lcal ly as lng as the lcal transplant prviders are willing t accept the Original Medicare rate. If HealthTeam Advatnage Plan I (PPO) prvides transplant services at a lcatin utside the pattern f care fr transplants in yur cmmunity and yu chse t btain transplants at this distant lcatin, we will arrange r pay fr appr priate ldging and transprtatin csts fr yu and a cmpanin. Bld - including strage and administratin. Cverage f whle bld and packed red cells begins nly with the furth pint f bld that yu need - yu must either pay the csts fr the first 3 pints f bld yu get in a calendar year r have the bld dnated by yu r smene else. All ther cmpnents f bld are cv ered beginning with the first pint used. Physician services Nte: T be an inpatient, yur prvider must write an rder t admit yu frmally as an inpatient f the hspital. Even if yu stay in the hspital vernight, yu might still be cnsidered an utpatient. If yu are nt sure if yu are an inpatient r an utpatient, yu shuld ask the hspital staff. Yu can als find mre infrmatin in a Medicare fact sheet called Are Yu a Hspital Inpatient r Outpatient? If Yu Have Medicare Ask! This fact sheet is available n the 2 at pdf/11435.pdf r by calling MEDICARE ( ). TTY users call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Service infrmatin, including requirements and cpay infrmatin is listed n previus page.

67 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 65 Services that are cvered fr yu Inpatient mental health care Cvered services include mental health care services that require a hspital stay. Our plan cvers up t 190 days in a lifetime fr inpatient mental health care in a psychiatric hspital. The inpatient hspital care limit des nt apply t inpatient mental ser vices prvided in a general hspital. Inpatient stay: Cvered services received in a hspital f SNF during a nn-cvered inpatient stay What yu must pay when yu get these services Services require prir authrizatin. In-Netwrk Out-Of-Netwrk Inpatient visit: $350 cpay per day Inpatient Visit: fr days 1 thrugh 5 35% f the cst $0 cpay per day fr days 6 thrugh 90 In-Netwrk Out-Of-Netwrk If yu have exhausted yur inpatient benefits r if the inpa tient stay is nt reasnable and necessary, we will nt cver yur inpatient stay. Hwever, in sme cases, we will cver certain services yu receive while yu are in the hspital r the skilled nursing facility (SNF). Cvered services in clude, but are nt limited t: Physician services Diagnstic tests (like lab tests) X-ray, radium, and istpe therapy including technician materials and services Surgical dressings Splints, casts and ther devices used t reduce fractures and dislcatins Prsthetics and rthtics devices (ther than dental) that replace all r part f an internal bdy rgan (including cntiguus tissue), r all r part f the functin f a permanently inperative r malfunctining internal bdy rgan, including replacement r repairs f such devices Leg, arm, back, and neck braces; trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because f breakage, wear, lss, r a change in the patient s physical cnditin Physical therapy, speech therapy, and ccupatinal therapy $10 fr Primary Care Physician $20 fr Specialist $5 cpay fr diagnstic tests $10 cpay fr lab tests $5 cpay 20% f the cst 20% f the cst 20% f the cst 20% f the cst $15 Cpay $45 fr Primary Care Physician $50 fr Specialist $25 cpay fr diagnstic tests $25 cpay fr lab tests $25 cpay 30% f the cst 30% f the cst 30% f the cst 30% f the cst $40 Cpay

68 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 66 Services that are cvered fr yu What yu must pay when yu get these services Medical nutritin therapy This benefit is fr peple with diabetes, renal (kidney) dis ease (but nt n dialysis), r after a kidney transplant when referred by yur dctr. We cver 3 hurs f ne-n-ne cunseling services during yur first year that yu receive medical nutritin therapy services under Medicare (this includes ur plan, any ther Medicare Advantage plan, r Original Medicare), and 2 hurs each year after that. If yur cnditin, treatment, r diagnsis changes, yu may be able t receive mre hurs f treatment with a physician s referral. A physician must prescribe these services and renew their referral yearly if yur treatment is needed int the next calendar year. In-Netwrk There is n cinsurance, cpayment, r deductible fr members eligible fr Medicare- cvered medical nutritin therapy services. Out-Of-Netwrk $30 Cpay fr members eligible fr Medicare-cvered medical nutritin therapy services. Medicare Diabetes Preventin Prgram (MDPP) MDPP services will be cvered fr eligible Medicare beneficiaries under all Medicare health plans. MDPP is a structured health behavir change interventin that prvides practical training in lng-term dietary change, increased physical activity, and prblem-slving strategies fr vercming challenges t sustaining weight lss and a healthy lifestyle. In-Netwrk There is n cinsur ance, cpayment f deductible fr the MDPP benefit. Out-Of-Netwrk $30 Cpay fr the MDPP benefit.

69 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 67 Services that are cvered fr yu What yu must pay when yu get these services Medicare Part B prescriptin drugs Prir Authrizatin may be required. These drugs are cvered under Part B f Original Medi care. Members f ur plan receive cverage fr these drugs thrugh ur plan. Cvered drugs include: Drugs that usually aren t self-administered by the patient and are injected r infused while yu are getting physician, hspital utpatient, r ambulatry surgical center services Drugs yu take using durable medical equipment (such as nebulizers) that were authrized by the plan Cltting factrs yu give yurself by injectin if yu have hemphilia Immunsuppressive Drugs, if yu were enrlled in Medicare Part A at the time f the rgan transplant Injectable steprsis drugs, if yu are hmebund, have a bne fracture that a dctr certifies was related t pst-menpausal steprsis, and cannt self-ad minister the drug Antigens Certain ral anti-cancer drugs and anti-nausea drugs Certain drugs fr hme dialysis, including heparin, the antidte fr heparin when medically necessary, tpical anesthetics, and erythrpiesis-stimulating agents (such as Epgen, Prcrit, Epetin Alfa, Aranesp, r Darbepetin Alfa) Intravenus Immune Glbulin fr the hme treatment f primary immune deficiency diseases Chapter 5 explains the Part D prescriptin drug benefit, including rules yu must fllw t have prescriptins cvered. What yu pay fr yur Part D prescriptin drugs thrugh ur plan is explained in Chapter 6. In-Netwrk Fr Part B drugs such as chemtherapy drugs: 20% f the cst Other Part B drugs: 20% f the cst Out-Of-Netwrk Fr Part B drugs such as chemtherapy drugs: 30% f the cst Other Part B drugs: 30% f the cst

70 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 68 Services that are cvered fr yu What yu must pay when yu get these services Obesity screening and therapy t prmte sustained weight lss If yu have a bdy mass index f 30 r mre, we cver intensive cunseling t help yu lse weight. This cunseling is cvered if yu get it in a primary care setting, where it can be crdinated with yur cmprehensive preventin plan. Talk t yur primary care dctr r practitiner t find ut mre. In-Netwrk There is n cinsurance, cpayment, r deductible fr preventive besity screening and therapy. Out-Of-Netwrk $30 Cpay fr preventive besity screening and therapy. Outpatient diagnstic tests and therapeutic services and supplies Cvered services include, but are nt limited t: X-rays - included with a physician visit - at an utpatient facility Radiatin (radium and istpe) therapy including tech nician materials and supplies - Echcardigraphy with an apprved amunt frm $1 t $ Echcardigraphy with an apprved amunt ver $ Ultrasund - CT-Scan, MRI, MRA, PET, Nuclear Stress Testing and Other Services - Therapeutic Radilgy Services (such as radiatin treatment fr cancer) Surgical supplies, such as dressings Splints, casts and ther devices used t reduce fractures and dislcatins Services may require prir authrizatin. In-Netwrk Out-Of-Netwrk $5 Cpay $10 Cpay $5 Cpay $25 Cpay $50 Cpay $75 Cpay $150 Cpay $175 Cpay $75 Cpay $125 Cpay $200 Cpay $250 Cpay 20% f the cst 30% f the cst 20% f the cst 30% f the cst 20% f the cst 30% f the cst

71 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 69 Services that are cvered fr yu What yu must pay when yu get these services Outpatient diagnstic tests and therapeutic services and supplies (cntinued) In-Netwrk Out-Of-Netwrk Labratry tests Bld - including strage and administratin. Cverage f whle bld and packed red cells begins nly with the furth pint f bld that yu need - yu must either pay the csts fr the first 3 pints f bld yu get in a calendar year r have the bld dnated by yu r smene else. All ther cmpnents f bld are cvered beginning with the first pint used. Other utpatient diagnstic tests $0 cpay at labratry facility $10 cpay at utpatient hspital facility $0 cpay fr bld after the first 3 pints $0 cpay at labratry facility $5 cpay at utpatient hspital facility $10 cpay at labratry facility $25 cpay at utpatient hspital facility 30% f the cst fr bld after the first 3 pints $10 cpay at labratry facility $25 cpay at utpatient hspital facility Outpatient hspital services Services may require prir authrizatin. We cver medically-necessary services yu get in the utpatient department f a hspital fr diagnsis r treatment f an illness r injury. Cvered services include, but are nt limited t: In-Netwrk Out-Of-Netwrk Services in an emergency department r utpatient clinic, $190 Cpay $300 Cpay such as bservatin services r utpatient surgery Labratry and diagnstic tests billed by the hspital $5 Cpay fr $25 Cpy fr Mental health care, including care in a partial-hspi talizatin prgram, if a dctr certifies that inpatient treatment wuld be required withut it diagnstic tests $10 Cpay fr lab tests $55 Cpay fr Partial Hspitalizatin $40 Cpay fr Outpatient Grup Therapy Visit $40 Cpay fr Outpatient Individual Therapy Visit diagnstic tests $25 Cpay fr lab tests $150 Cpay fr Partial Hspitalizatin $60 Cpay fr Outpatient Grup Therapy Visit $60 Cpay fr Outpatient Individual Therapy Visit

72 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 70 Services that are cvered fr yu What yu must pay when yu get these services Outpatient hspital services (cntinued) X-rays and ther radilgy services billed by the hspital - X-Rays - Echcardigraphy with an apprved amunt frm $1 t $ Echcardigraphy with an apprved amunt ver $ Ultrasund - CT-Scan, MRI, MRA, PET, Nuclear Stress Testing and Other Services - Therapeutic Radilgy Services (such as radiatin treatment fr cancer) In-Netwrk $5 Cpay $50 Cpay $150 Cpay $75 Cpay $200 Cpay 20% f the cst Out-Of-Netwrk $25 Cpay $75 Cpay $175 Cpay $125 Cpay $250 Cpay 30% f the cst Medical supplies such as splints and casts 20% f the cst 30% f the cst Certain screenings and preventive services $0 Cpay $30 Cpay Certain drugs and bilgicals that yu can t give yur self 20% f the cst 30% f the cst Nte: Unless the prvider has written an rder t admit yu as an inpatient t the hspital, yu are an utpatient and pay the cst-sharing amunts fr utpatient hspital services. Even if yu stay in the hspital vernight, yu might still be cnsidered an utpatient. If yu are nt sure if yu are an utpatient, yu shuld ask the hspital staff. Yu can als find mre infrmatin in a Medicare fact sheet called Are Yu a Hspital Inpatient r Outpatient? If Yu Have Medicare Ask! This fact sheet is available n the Web at r by calling MEDICARE ( ). TTY users call Yu can call these numbers fr free, 24 hurs a day, 7 days a week.

73 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 71 Services that are cvered fr yu Outpatient mental health care Cvered services include: Mental health services prvided by a state-licensed psychi atrist r dctr, clinical psychlgist, clinical scial wrker, clinical nurse specialist, nurse practitiner, physician assistant, r ther Medicare-qualified mental health care prfessinal as allwed under applicable state laws. Outpatient rehabilitatin services Cvered services include: physical therapy, ccupatinal therapy, and speech language therapy. Outpatient rehabilitatin services are prvided in varius utpatient settings, such as hspital utpatient departments, independent therapist ffices, and Cmprehensive Outpa tient Rehabilitatin Facilities (CORFs). Outpatient substance abuse services Cvered services include grup and individual sessins fr substance abuse treatment. Outpatient surgery, including services prvided at hspital utpatient facilities and ambulatry surgical centers Nte: If yu are having surgery in a hspital facility, yu shuld check with yur prvider abut whether yu will be an inpatient r utpatient. Unless the prvider writes an rder t admit yu as an inpatient t the hspital, yu are an utpatient and pay the cst-sharing amunts fr utpa tient surgery. Even if yu stay in the hspital vernight, yu might still be cnsidered an utpatient. Partial hspitalizatin services Partial hspitalizatin is a structured prgram f active psychiatric treatment prvided as a hspital utpatient ser vice r by a cmmunity mental health center, that is mre intense than the care received in yur dctr s r therapist s ffice and is an alternative t inpatient hspitalizatin. What yu must pay when yu get these services Services require prir authrizatin. In-Netwrk $40 Cpay fr Outpatient Grup Therapy Visit $40 Cpay fr Outpatient Individual Therapy Visit In-Netwrk $15 Cpay fr Occupatinal Therapy Visit $15 Cpay fr Physical therapy and speech and language therapy visit In-Netwrk $45 Cpay fr Grup Sessin $45 Cpay fr Individual Sessin Out-Of-Netwrk $60 Cpay fr Outpatient Grup Therapy Visit $60 Cpay fr Outpatient Individual Therapy Visit Out-Of-Netwrk $40 Cpay fr Occupatinal Therapy Visit $40 Cpay fr Physical therapy and speech and language therapy visit Out-Of-Netwrk $60 Cpay fr Grup Sessin $60 Cpay fr Individual Sessin Services require prir authrizatin. In-Netwrk $175 Cpay per day Ambulatry Surgicial Center $190 Cpay per day Outpatient Hspital Facility Out-Of-Netwrk $225 Cpay per day Ambulatry Surgicial Center $300 Cpay per day Outpatient Hspital Facility Services require prir authrizatin. In-Netwrk $55 cpay Out-Of-Netwrk $150 cpay

74 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 72 Services that are cvered fr yu Physician/Practitiner services, including dctr s ffice visits Cvered services include: Medically-necessary medical care r surgery services furnished in a physician s ffice, certified ambulatry surgical center, hspital utpatient department, r any ther lcatin Cnsultatin, diagnsis, and treatment by a specialist Basic hearing and balance exams perfrmed by yur PCP, if yur dctr rders it t see if yu need medical treatment Secnd pinin prir t surgery Nn-rutine dental care (cvered services are limited t surgery f the jaw r related structures, setting fractures f the jaw r facial bnes, extractin f teeth t prepare the jaw fr radiatin treatments f neplastic cancer disease, r services that wuld be cvered when prvided by a physician) Pdiatry services Cvered services include: Diagnsis and the medical r surgical treatment f injuries and diseases f the feet (such as hammer te r heel spurs). Rutine ft care fr members with certain medical cnditins affecting the lwer limbs Prstate cancer screening exams Fr men age 50 and lder, cvered services include the fllwing - nce every 12 mnths: Digital rectal exam Prstate Specific Antigen (PSA) test Prsthetic devices and related supplies Devices (ther than dental) that replace all r part f a bdy part r functin. These include, but are nt limited t: clstmy bags and supplies directly related t clstmy care, pacemakers, braces, prsthetic shes, artificial limbs, and breast prstheses (including a surgical brassiere after a mastectmy). Includes certain supplies related t prsthetic devices, and repair and/r replacement f prsthetic devices. Als includes sme cverage fllwing cataract remval r cataract surgery see Visin Care later in this sectin fr mre detail. What yu must pay when yu get these services In-Netwrk $10 Cpay fr Primary Care Physician visit $20 Cpay fr Specialist visit Fr services prvided by physicians in ambulatry surgical center r utpatient hspital facility, see Outpatient Surgery n previus page In-Netwrk $35 cpay In-Netwrk There is n cinsurance, cpay ment, r deductible fr an annual PSA test. Out-Of-Netwrk $45 Cpay fr Primary Care Physician visit $50 Cpay fr Specialist visit Fr services prvided by physicians in ambulatry surgical center r utpatient hspital facility, see Outpatient Surgery n previus page Out-Of-Netwrk $60 cpay Out-Of-Netwrk $30 Cpay fr an annual PSA test. Services require prir authrizatin. In-Netwrk Prsthetic devices and related medical supplies: 20% f the cst Out-Of-Netwrk Prsthetic devices and related medical supplies: 30% f the cst

75 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 73 Services that are cvered fr yu What yu must pay when yu get these services Pulmnary rehabilitatin services Cmprehensive prgrams f pulmnary rehabilitatin are cvered fr members wh have mderate t very severe chrnic bstructive pulmnary disease (COPD) and a referral fr pulmnary rehabilitatin frm the dctr treating the chrnic respiratry disease. In-Netwrk Pulmnary rehab services: $15 cpay Out-Of-Netwrk Pulmnary rehab services: $25 cpay Screening and cunseling t reduce alchl misuse We cver ne alchl misuse screening fr adults with Medicare (including pregnant wmen) wh misuse alchl, but aren t alchl dependent. If yu screen psitive fr alchl misuse, yu can get up t 4 brief face-t-face cunseling sessins per year (if yu re cmpetent and alert during cunseling) prvided by a qual ified primary care dctr r practitiner in a primary care setting. In-Netwrk There is n cinsurance, cpay ment, r deductible fr the Medicare-cvered screening and cunseling t reduce alchl misuse preventive benefit. Out-Of-Netwrk $30 Cpay fr the Medicare-cvered screening and cunseling t reduce alchl misuse preventive benefit. Screening fr lung cancer with lw dse cmputed tmgraphy (LDCT) Fr qualified individuals, a LDCT is cvered every 12 mnths. Eligible enrllees are: peple aged years wh have n signs r symptms f lung cances, but wh have a his try f tbacc smking f at least 30 pack-years r wh currently smke r have quit smking within the last 15 years, wh receive a written rder fr LDCT during a lung cancer screening cunseling and shared decisin making visit that meets the Medicare criteria fr such visits and be furnished by a physician f qualified nn-physician practi tiner. Services may require a referral frm yur dctr. In-Netwrk There is n cinsur ance, cpayment, r deductible fr the Medicare-cvered cunseling and shared decisin making visit r fr the LDCT. Out-Of-Netwrk $30 Cpay fr the Medicare-cvered cunseling and shared decisin making visit r fr the LDCT. Fr LDCT lung cancer screenings after the initial LDCT screening: the enrllee must receive a written rder fr LDCT lung cancer screening, which may be furnished during any apprpriate visit with a physician ir qualified nn-physician practitiner. If a physician r qualified nn-physician practitiner elects t prvide a lung cancer screening cunseling and shared decisin making visit fr subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria fr such visits.

76 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 74 Services that are cvered fr yu What yu must pay when yu get these services Screening fr sexually transmitted infectins (STIs) and cunseling t prevent STIs We cver sexually transmitted infectin (STI) screenings fr chlamydia, gnrrhea, syphilis, and Hepatitis B. These screenings are cvered fr pregnant wmen and fr certain peple wh are at increased risk fr an STI when the tests are rdered by a primary care prvider. We cver these tests nce every 12 mnths r at certain times during pregnancy. We als cver up t 2 individual 20 t 30 minute, face-tface high-intensity behaviral cunseling sessins each year fr sexually active adults at increased risk fr STIs. We will nly cver these cunseling sessins as a preven tive service if they are prvided by a primary care prvider and take place in a primary care setting, such as a dctr s ffice. Services t treat kidney disease and cnditins Cvered services include: Kidney disease educatin services t teach kidney care and help members make infrmed decisins abut their care. Fr members with stage IV chrnic kidney disease when referred by their dctr, we cver up t six sessins f kidney disease educatin services per lifetime. In-Netwrk There is n cinsurance, cpay ment, r deductible fr the Medicare-cvered screening fr STIs and cunseling fr STIs preventive benefit. In-Netwrk There is n cinsur ance, cpayment, r deductible fr Medi care cvered kidney disease educatin services. Out-Of-Netwrk $30 Cpay fr the Medicare-cvered screening fr STIs and cunseling fr STIs preventive benefit. Out-Of-Netwrk 20% f the cst fr Medicare cvered kidney disease educatin services. Outpatient dialysis treatments (including dialysis $30 cpay fr $60 cpay fr treatments when temprarily ut f the service area, as Medicare-cvered Medicare-cvered explained in Chapter 3) renal dialysis treatmentments renal dialysis treat- Inpatient dialysis treatments (if yu are admitted as an inpatient t a hspital fr special care) Self-dialysis training (includes training fr yu and $0 Cpay fr Self- 20% f the cst fr anyne helping yu with yur hme dialysis treat Dialysis Training Self-Dialysis Training ments) Hme dialysis equipment and supplies 20% f the cst fr 30% f the cst fr hme dialysis equipment hme dialysis equip- and supplies ment and supplies

77 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 75 Services that are cvered fr yu Services t treat kidney disease and cnditins (cntinued) Certain hme supprt services (such as, when necessary, visits by trained dialysis wrkers t check n yur hme dialysis, t help in emergencies, and check yur dialysis equipment and water supply) Certain drugs fr dialysis are cvered under yur Medicare Part B drug benefit. Fr infrmatin abut cverage fr Part B Drugs, please g t the sectin, Medicare Part B prescriptin drugs. Skilled nursing facility (SNF) care (Fr a definitin f skilled nursing facility care, see Chapter 12 f this bklet. Skilled nursing facilities are smetimes called SNFs. ) Cvered services include but are nt limited t: Semiprivate rm (r a private rm if medically necessary) Meals, including special diets Skilled nursing services Physical therapy, ccupatinal therapy, and speech therapy Drugs administered t yu as part f yur plan f care (This includes substances that are naturally present in the bdy, such as bld cltting factrs.) Bld - including strage and administratin. Cverage f whle bld and packed red cells begins nly with the furth pint f bld that yu need - yu must either pay the csts fr the first 3 pints f bld yu get in a calendar year r have the bld dnated by yu r smene else. All ther cmpnents f bld are cvered beginning with the first pint used. Medical and surgical supplies rdinarily prvided by SNFs Labratry tests rdinarily prvided by SNFs X-rays and ther radilgy services rdinarily prvided by SNFs Use f appliances such as wheelchairs rdinarily prvided by SNFs Physician/Practitiner services What yu must pay when yu get these services In-Netwrk $25 cpay fr hme supprt services 20% f the cst fr Medicare Part B Drugs Out-Of-Netwrk $45 cpay fr hme supprt services 30% f the cst fr Medicare Part B Drugs Services require prir authrizatin. In-Netwrk Our Plan cvers up t 100 days in a SNF $0 Cpay per day fr Days 1 thrugh 20 $150 Cpay per day fr Days 21 thrugh 100 Out-Of-Netwrk Our Plan cvers up t 100 days in a SNF $40 Cpay per day fr Days 1 thrugh 20 $160 Cpay per day fr Days 21 thrugh 100

78 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 76 Services that are cvered fr yu Skilled nursing facility (SNF) care (cntinued) Generally, yu will get yur SNF care frm netwrk facilities. Hwever, under certain cnditins listed belw, yu may be able t pay in-netwrk cst-sharing fr a facility that isn t a netwrk prvider, if the facility accepts ur plan s amunts fr payment. A nursing hme r cntinuing care retirement cmmunity where yu were living right befre yu went t the hspital (as lng as it prvides skilled nursing facility care). A SNF where yur spuse is living at the time yu leave the hspital. What yu must pay when yu get these services Service infrmatin, including requirements and cpay infrmatin is listed n previus page. Smking and tbacc use cessatin (cunseling t stp smking r tbacc use) If yu use tbacc, but d nt have signs r symptms f tbacc-related disease: We cver tw cunseling quit attempts within a 12-mnth perid as a preventive service with n cst t yu. Each cunseling attempt includes up t fur face-t-face visits. If yu use tbacc and have been diagnsed with a tbacc-related disease r are taking medicine that may be affected by tbacc: We cver cessatin cunseling services. We cver tw cunseling quit attempts within a 12-mnth perid, hwever, yu will pay the applicable cst-sharing. Each cunseling attempt includes up t fur face-t-face visits. Urgently needed services Urgently needed services are prvided t treat a nn-emergency, unfreseen medical illness, injury, r cnditin that requires immediate medical care. Urgently needed services may be furnished by netwrk prviders r by ut-f-netwrk prviders when netwrk prviders are temprarily unavailable r inaccessible. Cst sharing fr necessary urgently needed services furnished ut-f-netwrk is the same as fr such services furnished in-netwrk. In-Netwrk There is n cinsurance, cpay- ment, r deductible fr the Medicare-cvered smking and tbacc use cessatin preven- tive benefits. In-Netwrk $30 cpay fr Urgently needed services Out-Of-Netwrk $30 Cpay fr the Medicare-cvered smking and tbacc use cessatin preventive benefits. Out-Of-Netwrk $30 cpay fr Urgently needed services Cvered nly within the United States.

79 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 77 Services that are cvered fr yu What yu must pay when yu get these services Visin care Cvered services include: Outpatient physician services fr the diagnsis and treatment f diseases and injuries f the eye, including treatment fr age-related macular degeneratin. Original Medicare desn t cver rutine eye exams (eye refractins) fr eyeglasses/cntacts. Fr peple wh are at high risk f glaucma, we will cver ne glaucma screening per year. Peple at high risk f glaucma include: peple with a family histry f glaucma, peple with diabetes, and African-Ameri cans wh are age 50 and lder, and Hispanic Americans wh are 65 r lder. Fr peple with diabetes, screening fr diabetic reti npathy is cvered nce per year. One pair f eyeglasses r cntact lenses after each cataract surgery that includes insertin f an intracu lar lens. (If yu have tw separate cataract peratins, yu cannt reserve the benefit after the first surgery and purchase tw eyeglasses after the secnd surgery.) Crrective lenses/frames (and replacements) needed after a cataract remval withut a lens implant. Rutine Eye Exam - This benefit des nt include cv erage fr eye refractins In-Netwrk $35 cpay fr each Medicare cvered visin exam. There is n cinsurance, cpayment, r deductible fr the Medicare-cvered glaucma screening $0 Cpay fr Medicare-cvered eyeglasses r cntact lenses after cataract surgery $5 Cpay fr up t ne rutine eye exam per year Out-Of-Netwrk $50 cpay fr each Medicare cvered visin exam. $30 cpay fr Medicare Cvered glaucma screening. 50% f the cst fr Medicare-cvered eyeglasses r cntact lenses after cataract surgery $30 Cpay fr up t ne rutine eye exam per year Welcme t Medicare Preventive Visit The plan cvers the ne-time Welcme t Medicare preventive visit. The visit includes a review f yur health, as well as educatin and cunseling abut the preventive services yu need (including certain screenings and shts), and referrals fr ther care if needed. Imprtant: We cver the Welcme t Medicare pre ventive visit nly within the first 12 mnths yu have Medicare Part B. When yu make yur appintment, let yur dctr s ffice knw yu wuld like t schedule yur Welcme t Medicare preventive visit. In-Netwrk There is n cinsurance, cpayment, r deductible fr the Welcme t Medicare preventive visit. Out-Of-Netwrk $30 Cpay fr the Welcme t Medicare preventive visit.

80 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 78 Sectin 2.2 Extra ptinal supplemental benefits yu can buy Our plan ffers sme extra benefits that are nt cvered by Original Medicare and nt included in yur benefits package as a plan member. These extra benefits are called Optinal Supplemental Benefits. If yu want these ptinal supplemental benefits, yu must sign up fr them. The ptinal supplemental benefits described in this sectin are subject t the same appeals prcess as any ther benefits. Services that are cvered fr yu Optinal Supplemental Package #1 HealthTeam Advantage Dental Rider $25 mnthly premium, in additin t yur mnthly plan premium and the mnthly Medicare Part B premium, fr the ptinal benefits shwn. Out-f-Pcket csts fr this ptinal supplemental benefit package d nt apply t Maximum Out-f-Pcket (MOOP). What yu must pay when yu get these services Preventive Services Cde Service Descriptin Cpay Limitatins D0120 Recall Exam $0 Up t 2 per year D0150 Cmprehensive Exam $0 1 per year; new patients nly; Limited t 1 every 3 years D1110 Rutine Cleaning $0 2 per year D0270/ D0272/ D0273/ D0274 Chse ne f the fllwing per year Bitewing X-Rays $0 1 set per year D0210 Full Muth X- Rays $0 1 set per year; Allwed nce every 3 years

81 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 79 Services that are cvered fr yu Optinal Supplemental Package #1 (Cntinued) What yu must pay when yu get these services Cmprehensive Services Cde Service Descriptin Cpay Limitatins Out-f-Netwrk: Member reimbursed accrd ing t the current ut-f-net wrk fee schedule reimburse ment rate. Member must submit bill shwing paid in full t pr vider. Fr mre infrmatin cntact the plan. D2140 Amalgam Filling 1 surface $35 D2150 Amalgam Filling 2 surfaces $45 D2160 Amalgam Filling 3 surfaces $55 D2330 D2331 Resin-based Cmpsite Filling Anterir (1 surface) Resin-based Cmpsite Filling Anterir (2 surfaces) $50 $65 Up t 4 ttal fillings per year D2332 Resin-based Cmpsite Filling Anterir (3 surfaces) $80 D4341 Scaling and Rt Planing (per quadrant) $50 cpay per quadrant Up t 2 quads per year D5410/ D5411 Denture Adjustment $0 Ttal f 2 per year D7140 Extractin, Erupted Tth $40 D7210 Extractin, Surgical $75 Up t 2 per year D2751 Crwn - Prcelain Fused t Base Metal $305 D2752 D2791 Crwn - Prcelain Fused t Nble Metal Crwn - Full Cast Base Metal $320 $307 Ttal f 2 per year. Crwns have a 6 mnth waiting perid. D2792 Crwn - Full Cast Nble Metal Out-f-Netwrk $305 Member reimbursed accrding t the current ut-f-netwrk fee schedule reimbursement rate. Member must submit bill shwing paid in full t prvider. Fr mre infrmatin cntact the plan

82 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 80 Services that are cvered fr yu Optinal Supplemental Package #2 HealthTeam Advantage CmbinatinRider (Dental, Hearing and Visin) $40 mnthly premium, in additin t yur mnth ly plan premium and the mnthly Medicare Part B premium, fr the ptinal benefits shwn. Out-f-Pcket csts fr this ptinal supplemental benefit package d nt apply t Maximum Out-f-Pcket (MOOP). Out-f-Netwrk: Member reimbursed accrd ing t the current ut-f-net wrk fee schedule reimburse ment rate. Member must submit bill shwing paid in full t pr vider. Fr mre infrmatin cntact the plan. What yu must pay when yu get these services Preventive Services Cde Service Descriptin Cpay Limitatins D0120 Recall Exam $0 Up t 2 per year D0150 Cmprehensive Exam $0 1 per year; new patients nly; Limited t 1 every 3 years D1110 Rutine Cleaning $0 2 per year D0270/ D0272/ D0273/ D0274 Chse ne f the fllwing per year Bitewing X-Rays $0 1 set per year D0210 Full Muth X- Rays $0 Cmprehensive Services 1 set per year; Allwed nce every 3 years Cde Service Descriptin Cpay Limitatins D2140 Amalgam Filling 1 surface $35 D2150 Amalgam Filling 2 surfaces $45 D2160 Amalgam Filling 3 surfaces $55 D2330 D2331 Resin-based Cmpsite Filling Anterir (1 surface) Resin-based Cmpsite Filling Anterir (2 surfaces) $50 $65 Up t 4 ttal fillings per year D2332 Resin-based Cmpsite Filling Anterir (3 surfaces) $80 D4341 Scaling and Rt Planing (per quadrant) $50 cpay per quadrant Up t 2 quads per year D5410/ D5411 Denture Adjustment $0 Ttal f 2 per year

83 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 81 Services that are cvered fr yu Optinal Supplemental Package #2 (Cntinued) What yu must pay when yu get these services Cde Service Descriptin Cpay Limitatins D7140 Extractin, Erupted Tth $40 Up t 2 per year D7210 Extractin, Surgical $75 D2751 Crwn - Prcelain Fused t Base Metal $305 D2752 D2791 Crwn - Prcelain Fused t Nble Metal Crwn - Full Cast Base Metal $320 $307 Ttal f 2 per year. Crwns have a 6 mnth waiting perid. D2792 Crwn - Full Cast Nble Metal $305 Hearing Services Service Descriptin Cpay Limitatins Rutine Hearing Screening Test $0 1 per year Hearing Aid Fitting Evaluatin $0 Up t 1 every 3 years Hearing Aid $0 $800 cverage limit every three years fr bth ears Visin Services Service Descriptin Cpay Limitatins Rutine Eye Exam $0 1 per year Frames & Lenses OR Cntacts (excludes in-stre r in-ffice prvider specials) $0 $200 cverage limit per year Out-f-Netwrk Member reimbursed accrding t the current ut-f-netwrk fee schedule reimbursement rate. Member must submit bill shwing paid in full t prvider. Fr mre infrmatin cntact the plan.

84 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 82 SECTION 3 What services are nt cvered by the plan? Sectin 3.1 Services we d nt cver (exclusins) This sectin tells yu what services are excluded frm Medicare cverage and therefre, are nt cvered by this plan. If a service is excluded, it means that this plan desn t cver the service. The chart belw lists services and items that either are nt cvered under any cnditin r are cvered nly under specific cnditins. If yu get services that are excluded (nt cvered), yu must pay fr them yurself. We wn t pay fr the excluded medical services listed in the chart belw except under the specific cnditins listed. The nly exceptin: we will pay if a service in the chart belw is fund upn appeal t be a medical service that we shuld have paid fr r cvered because f yur specific situatin. (Fr infrmatin abut appealing a decisin we have made t nt cver a medical service, g t Chapter 9, Sectin 5.3 in this bklet.) All exclusins r limitatins n services are described in the Benefits Chart r in the chart belw. Even if yu receive the excluded services at an emergency facility, the excluded services are still nt cvered and ur plan will nt pay fr them. Services nt cvered by Medicare Services cnsidered nt reasn able and necessary, accrding t the standards f Original Medicare Experimental medical and surgical prcedures, equipment and medicatins. Experimental prcedures and items are thse items and prcedures determined by ur plan and Original Medicare t nt be generally accepted by the medical cmmunity. Nt cvered under any cnditin Cvered nly under specific cnditins Unless these services are listed by ur plan as cvered services May be cvered by Original Medicare under a Medicare-apprved clinical research study r by ur plan. (See Chapter 3, Sectin 5 fr mre infrmatin n clinical research studies.) Private rm in a hspital. Cvered nly when medically necessary.

85 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 83 Services nt cvered by Medicare Persnal items in yur rm at a hspital r a skilled nursing facility, such as a telephne r a televisin. Full-time nursing care in yur hme. *Custdial care is care prvided in a nursing hme, hspice, r ther facility setting when yu d nt require skilled medical care r skilled nursing care. Hmemaker services include basic husehld assistance, including light husekeeping r light meal preparatin. Fees charged fr care by yur immediate relatives r members f yur husehld. Nt cvered under any cnditin Cvered nly under specific cnditins Csmetic surgery r prcedures Rutine dental care, such as cleanings, fillings r dentures. Nn-rutine dental care. Cvered in cases f an accidental injury r fr imprvement f the functining f a malfrmed bdy member. Cvered fr all stages f recnstructin fr a breast after a mastectmy, as well as fr the unaffected breast t prduce a symmetrical appearance. Cvered up t limitatins nted in Dental Services previusly listed in Chapter 4 fr Plan I nly. Dental care required t treat illness r injury may be cvered as inpatient r utpatient care.

86 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 84 Services nt cvered by Medicare Rutine chirpractic care Rutine ft care Hme-delivered meals Orthpedic shes Supprtive devices fr the feet Rutine hearing exams, hearing aids, r exams t fit hearing aids. Rutine eye examinatins, eyeglasses, radial kerattmy, LASIK surgery, visin therapy and ther lw visin aids. Reversal f sterilizatin prcedures and r nn-prescriptin cntraceptive supplies. Acupuncture Nt cvered under any cnditin Cvered nly under specific cnditins Manual manipulatin f the spine t crrect a subluxatin is cvered. Sme limited cverage prvided accrding t Medicare guidelines, e.g., if yu have diabetes. If shes are part f a leg brace and are included in the cst f the brace, r the shes are fr a persn with diabetic ft disease. Orthpedic r therapeutic shes fr peple with diabetic ft disease. Cvered up t limitatins nted in Hearing Services previusly listed in Chapter 4 fr Plan I nly. Eye exam and ne pair f eyeglasses (r cntact lenses) are cvered fr peple after cataract surgery. Rutine services cvered up t limitatins previusly listed in Visin Services in Chapter 4 fr Plan I and Plan II nly.

87 Chapter 4. Medical Benefits Chart (what is cvered and what yu pay) 85 Services nt cvered by Medicare Naturpath services (uses natural r alternative treatments). Nt cvered under any cnditin Cvered nly under specific cnditins *Custdial care is persnal care that des nt require the cntinuing attentin f trained medical r paramedical persnnel, such as care that helps yu with activities f daily living, such as bathing r dressing.

88 CHAPTER 5 Using the plan s cverage fr yur Part D prescriptin drugs

89 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 87 Chapter 5. SECTION 1 Sectin 1.1 Sectin 1.2 SECTION 2 Sectin 2.1 Sectin 2.2 Sectin 2.3 Sectin 2.4 Sectin 2.5 SECTION 3 Sectin 3.1 Sectin 3.2 Sectin 3.3 SECTION 4 Sectin 4.1 Sectin 4.2 Sectin 4.3 SECTION 5 Sectin 5.1 Sectin 5.2 Sectin 5.3 SECTION 6 Sectin 6.1 Sectin 6.2 SECTION 7 Sectin 7.1 Using the plan s cverage fr yur Part D prescriptin drugs Intrductin...89 This chapter describes yur cverage fr Part D drugs Basic rules fr the plan s Part D drug cverage Fill yur prescriptin at a netwrk pharmacy r thrugh the plan s mail-rder service...90 T have yur prescriptin cvered, use a netwrk pharmacy Finding netwrk pharmacies Using the plan s mail-rder services Hw can yu get a lng-term supply f drugs? When can yu use a pharmacy that is nt in the plan s netwrk? Yur drugs need t be n the plan s Drug List...94 The Drug List tells which Part D drugs are cvered There are five cst-sharing tiers fr drugs n the Drug List Hw can yu find ut if a specific drug is n the Drug List? There are restrictins n cverage fr sme drugs...95 Why d sme drugs have restrictins? What kinds f restrictins? D any f these restrictins apply t yur drugs? What if ne f yur drugs is nt cvered in the way yu d like it t be cvered?...97 There are things yu can d if yur drug is nt cvered in the way yu d like it t be cvered What can yu d if yur drug is nt n the Drug List r if the drug is restricted in sme way? What can yu d if yur drug is in a cst-sharing tier yu think is t high? What if yur cverage changes fr ne f yur drugs? The Drug List can change during the year What happens if cverage changes fr a drug yu are taking? What types f drugs are nt cvered by the plan? Types f drugs we d nt cver

90 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 88 SECTION 8 Shw yur plan membership card when yu fill a prescriptin.103 Sectin 8.1 Sectin 8.2 SECTION 9 Sectin 9.1 Sectin 9.2 Sectin 9.3 Sectin 9.4 SECTION 10 Sectin 10.1 Sectin 10.2 Shw yur membership card What if yu dn t have yur membership card with yu? Part D drug cverage in special situatins What if yu re in a hspital r a skilled nursing facility fr a stay that is cvered by the plan? What if yu re a resident in a lng-term care (LTC) facility? What if yu re als getting drug cverage frm an emplyer r retiree grup plan? What if yu re in Medicare-certified hspice? Prgrams n drug safety and managing medicatins Prgrams t help members use drugs safely Medicatin Therapy Management (MTM) prgram t help members manage their medicatins

91 questin mark Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 89 Did yu knw there are prgrams t help peple pay fr their drugs? There are prgrams t help peple with limited resurces pay fr their drugs. These include Extra Help and State Pharmaceutical Assistance Prgrams. Fr mre infrmatin, see Chapter 2, Sectin 7. Are yu currently getting help t pay fr yur drugs? If yu are in a prgram that helps pay fr yur drugs, sme infrmatin in this Evidence f Cverage abut the csts fr Part D prescriptin drugs may nt apply t yu. We send yu a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescrip tin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call yur Healthcare Cncierge and ask fr the LIS Rider. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) SECTION 1 Intrductin Sectin 1.1 This chapter describes yur cverage fr Part D drugs This chapter explains rules fr using yur cverage fr Part D drugs. The next chapter tells what yu pay fr Part D drugs (Chapter 6, What yu pay fr yur Part D prescriptin drugs). In additin t yur cverage fr Part D drugs, HealthTeam Advantage Plan I als cvers sme drugs under the plan s medical benefits. Thrugh its cverage f Medicare Part A benefits, ur plan generally cvers drugs yu are given during cvered stays in the hspital r in a skilled nursing facility. Thrugh its cverage f Medicare Part B benefits, ur plan cvers drugs including certain chemtherapy drugs, certain drug injectins yu are given during an ffice visit, and drugs yu are given at a dialysis facility. Chapter 4 (Medical Benefits Chart, what is cvered and what yu pay) tells abut the benefits and csts fr drugs during a cvered hspital r skilled nursing facility stay, as well as yur benefits and csts fr Part B drugs. Yur drugs may be cvered by Original Medicare if yu are in Medicare hspice. Our plan nly cvers Medicare Parts A, B, and D services and drugs that are unrelated t yur terminal prgnsis and related cnditins and therefre nt cvered under the Medicare hspice benefit. Fr mre infrmatin, please see Sectin 9.4 (What if yu re in Medicare-certified hspice). Fr infrmatin n hspice cverage and Part C, see the hspice sectin f Chapter 4 (Medical Benefits Chart, what is cvered and what yu pay). The fllwing sectins discuss cverage f yur drugs under the plan s Part D benefit rules. Sectin 9, Part D drug cverage in special situatins includes mre infrmatin n yur Part D cverage and Original Medicare. Sectin 1.2 Basic rules fr the plan s Part D drug cverage The plan will generally cver yur drugs as lng as yu fllw these basic rules: Yu must have a prvider (a dctr, dentist r ther prescriber) write yur prescriptin.

92 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 90 Yur prescriber must either accept Medicare r file dcumentatin with CMS shwing that he r she is qualified t write prescriptins, r yur Part D claim will be denied. Yu shuld ask yur prescribers the next time yu call r visit if they meet this cnditin. If nt, please be aware it takes time fr yur prescriber t submit the necessary paperwrk t be prcessed. Yu generally must use a netwrk pharmacy t fill yur prescriptin. (See Sectin 2, Fill yur prescriptins at a netwrk pharmacy r thrugh the plan s mail-rder service.) Yur drug must be n the plan s List f Cvered Drugs (Frmulary) (we call it the Drug List fr shrt). (See Sectin 3, Yur drugs need t be n the plan s Drug List. ) Yur drug must be used fr a medically accepted indicatin. A medically accepted indicatin is a use f the drug that is either apprved by the Fd and Drug Administratin r supprted by certain reference bks. (See Sectin 3 fr mre infrmatin abut a medically accepted indicatin.) SECTION 2 Fill yur prescriptin at a netwrk pharmacy r thrugh the plan s mail-rder service Sectin 2.1 T have yur prescriptin cvered, use a netwrk pharmacy In mst cases, yur prescriptins are cvered nly if they are filled at the plan s netwrk pharmacies. (See Sectin 2.5 fr infrmatin abut when we wuld cver prescriptins filled at ut-f-netwrk pharmacies.) A netwrk pharmacy is a pharmacy that has a cntract with the plan t prvide yur cvered prescriptin drugs. The term cvered drugs means all f the Part D prescriptin drugs that are cvered n the plan s Drug List. Sectin 2.2 Finding netwrk pharmacies Hw d yu find a netwrk pharmacy in yur area? T find a netwrk pharmacy, yu can lk in yur Prvider/Pharmacy Directry, visit ur website ( r call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu may g t any f ur netwrk pharmacies. If yu switch frm ne netwrk pharmacy t anther, and yu need a refill f a drug yu have been taking, yu can ask either t have a new prescriptin written by a prvider r t have yur prescriptin transferred t yur new netwrk pharmacy. What if the pharmacy yu have been using leaves the netwrk? If the pharmacy yu have been using leaves the plan s netwrk, yu will have t find a new pharmacy that is in the netwrk. T find anther netwrk pharmacy in yur area, yu can get help frm yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) r use the Prvider/ Pharmacy Directry. Yu can als find infrmatin n ur website at

93 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 91 What if yu need a specialized pharmacy? Smetimes prescriptins must be filled at a specialized pharmacy. Specialized pharmacies include: Pharmacies that supply drugs fr hme infusin therapy. Pharmacies that supply drugs fr residents f a lng-term care (LTC) facility. Usually, a lng-term care facility (such as a nursing hme) has its wn pharmacy. If yu are in an LTC facility, we must ensure that yu are able t rutinely receive yur Part D benefits thrugh ur netwrk f LTC pharmacies, which is typically the pharmacy that the LTC facility uses. If yu have any difficulty accessing yur Part D benefits in an LTC facility, please cntact yur Healthcare Cncierge. Pharmacies that serve the Indian Health Service / Tribal / Urban Indian Health Prgram (nt available in Puert Ric). Except in emergencies, nly Native Americans r Alaska Natives have access t these pharmacies in ur netwrk. Nne available in this cverage area. Pharmacies that dispense drugs that are restricted by the FDA t certain lcatins r that require special handling, prvider crdinatin, r educatin n their use. (Nte: This scenari shuld happen rarely.) T lcate a specialized pharmacy, lk in yur Prvider/Pharmacy Directry r call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Sectin 2.3 Using the plan s mail-rder services Fr certain kinds f drugs, yu can use the plan s netwrk mail-rder services. Generally, the drugs prvided thrugh mail rder are drugs that yu take n a regular basis, fr a chrnic r lng-term medical cnditin. The drugs that are nt available thrugh the plan s mail-rder service are marked with NMO (Nt available thrugh mail rder) in ur Drug List. Our plan s mail-rder service allws yu t rder up t a 90-day supply. T get rder frms and infrmatin abut filling yur prescriptins by mail, cntact yur Healthcare Cncierge at (TTY users shuld call 711), Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. Usually a mail-rder pharmacy rder will get t yu in n mre than 7-10 days. If yur rder is delayed, cntact yur Healthcare Cncierge t see abut getting a temprary supply. New prescriptins the pharmacy receives directly frm yur dctr s ffice. After the pharmacy receives a prescriptin frm a health care prvider, it will cntact yu t see if yu want the medicatin filled immediately r at a later time. This will give yu an pprtunity t make sure that the pharmacy is delivering the crrect drug (including strength, amunt, and frm) and, if needed, allw yu t stp r delay the rder befre yu are billed and it is shipped. It is imprtant that yu respnd each time yu are cntacted by the pharmacy, t let them knw what t d with the new prescriptin and t prevent any delays in shipping.

94 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 92 Refills n mail rder prescriptins. Fr refills, please cntact yur pharmacy 10 days befre yu think the drugs yu have n hand will run ut t make sure yur next rder is shipped t yu in time. S the pharmacy can reach yu t cnfirm yur rder befre shipping, please make sure t let the pharmacy knw the best ways t cntact yu. If yu have further questins after speaking t yur pharmacist, cntact yur Healthcare Cncierge at (TTY users shuld call 711), Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. Sectin 2.4 Hw can yu get a lng-term supply f drugs? When yu get a lng-term supply f drugs, yur cst-sharing may be lwer. The plan ffers tw ways t get a lng-term supply (als called an extended supply ) f maintenance drugs n ur plan s Drug List. (Maintenance drugs are drugs that yu take n a regular basis, fr a chrnic r lng-term medical cnditin.) Yu may rder this supply thrugh mail rder (see Sectin 2.3) r yu may g t a retail pharmacy. 1. Sme retail pharmacies in ur netwrk allw yu t get a lng-term supply f maintenance drugs. Yur Prvider/Pharmacy Directry tells yu which pharmacies in ur netwrk can give yu a lngterm supply f maintenance drugs. Yu can als call yur Healthcare Cncierge fr mre infrmatin (phne numbers are printed n the back cver f this bklet). 2. Fr certain kinds f drugs, yu can use the plan s netwrk mail-rder services. The drugs that are nt available thrugh the plan s mail-rder service are marked with NMO (Nt available thrugh mail rder) in ur Drug List. Our plan s mail-rder service allws yu t rder up t a 90-day supply. See Sectin 2.3 fr mre infrmatin abut using ur mail-rder services. Sectin 2.5 When can yu use a pharmacy that is nt in the plan s netwrk? Yur prescriptin may be cvered in certain situatins Generally, we cver drugs filled at an ut-f-netwrk pharmacy nly when yu are nt able t use a netwrk pharmacy. T help yu, we have netwrk pharmacies utside f ur service area where yu can get yur prescriptins filled as a member f ur plan. If yu cannt use a netwrk pharmacy, here are the circumstances when we wuld cver prescriptins filled at an ut-f-netwrk pharmacy: Travel: (Getting cverage when yu travel r are away frm the plan s service area). If yu take a prescriptin drug n a regular basis and yu are ging n a trip, be sure t check yur supply f the drug befre yu leave. When pssible, take alng all the medicatin yu will need. Yu may be able t rder yur prescriptin drugs, a vacatin supply, ahead f time thrugh ur retail r mail pharmacy netwrk. If yu are traveling within the United States and territries and becme ill, r run ut f yur prescriptin drugs, we will cver prescriptins that are filled at an ut-f-netwrk pharmacy. In this situatin, yu will have t pay the full cst (rather than paying just yur c-payment r cinsurance) when yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share (e.g. the amunt we wuld pay a netwrk pharmacy) f the cst by submitting a reimbursement frm. If yu g t an ut-f-netwrk pharmacy, yu may be respnsible fr paying the difference between what we wuld pay fr a prescriptin filled at

95 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 93 an in-netwrk pharmacy and what the ut-f-netwrk pharmacy charged fr yur prescriptin. T learn hw t submit a reimbursement claim, please call yur Healthcare Cncierge. Yu can als call yur Healthcare Cncierge t find ut if there is a netwrk pharmacy in the area where yu are traveling. We cannt pay fr any prescriptins that are filled by pharmacies utside f the United States and territries, even fr a medical emergency. Medical Emergency: What if I need a prescriptin because f a medical emergency r because I needed urgent care? We will cver prescriptins that are filled at an ut-f-netwrk pharmacy lcated in the United States r ne f the territries if the prescriptins are related t care fr a medical emergency r urgent care. In this situatin, yu will have t pay the full cst (rather than paying just yur c-payment r cinsurance) when yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share f the cst by submitting a reimbursement frm. If yu g t an ut-f-netwrk pharmacy, yu may be respnsible fr paying the difference between what we wuld pay fr a prescriptin filled at an in-netwrk pharmacy and what the ut-f-netwrk pharmacy charged fr yur prescriptin. Additinal Situatins: Other times yu can get yur prescriptin cvered if yu g t an ut-fnetwrk pharmacy. We will cver yur prescriptin at an ut-f-netwrk pharmacy if at least ne f the fllwing applies: If yu are unable t btain a cvered drug in a timely manner within ur service area because there is n netwrk pharmacy, within a reasnable driving distance, that prvides 24-hur service. If yu are trying t fill a prescriptin drug that is nt regularly stcked at an accessible netwrk retail r mail-rder pharmacy (including high cst and unique drugs). If yu are getting a vaccine that is medically necessary but nt cvered by Medicare Part B and sme cvered drugs that are administered in yur dctr s ffice. Fr all f the abve listed situatins, yu may receive up t a 31-day supply f prescriptin drugs. In these situatins, please check first with yur Healthcare Cncierge t see if there is a netwrk pharmacy nearby. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Yu may be required t pay the difference between what yu pay fr the drug at the ut-f-netwrk pharmacy and the cst that we wuld cver at an in-netwrk pharmacy. Hw d yu ask fr reimbursement frm the plan? If yu must use an ut-f-netwrk pharmacy, yu will generally have t pay the full cst (rather than yur nrmal share f the cst) at the time yu fill yur prescriptin. Yu can ask us t reimburse yu fr ur share f the cst. (Chapter 7, Sectin 2.1 explains hw t ask the plan t pay yu back.)

96 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 94 SECTION 3 Yur drugs need t be n the plan s Drug List Sectin 3.1 The Drug List tells which Part D drugs are cvered The plan has a List f Cvered Drugs (Frmulary). In this Evidence f Cverage, we call it the Drug List fr shrt. The drugs n this list are 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 plan s Drug List. The drugs n the Drug List are nly thse cvered under Medicare Part D (earlier in this chapter, Sectin 1.1 explains abut Part D drugs). We will generally cver a drug n the plan s Drug List as lng as yu fllw the ther cverage rules explained in this chapter and the use f the drug is a medically accepted indicatin. A medically accepted indicatin is a use f the drug that is either: Apprved by the Fd and Drug Administratin. (That is, the Fd and Drug Administratin has apprved the drug fr the diagnsis r cnditin fr which it is being prescribed.) -- r -- Supprted by certain reference bks. (These reference bks are the American Hspital Frmulary Service Drug Infrmatin; the DRUGDEX Infrmatin System; and the USPDI r its successr; and, fr cancer, the Natinal Cmprehensive Cancer Netwrk and Clinical Pharmaclgy r their successrs.) The Drug List includes bth brand name and generic drugs A generic drug is a prescriptin drug that has the same active ingredients as the brand name drug. Generally, it wrks just as well as the brand name drug and usually csts less. There are generic drug substitutes available fr many brand name drugs. What is nt n the Drug List? The plan des nt cver all prescriptin drugs. In sme cases, the law des nt allw any Medicare plan t cver certain types f drugs (fr mre abut this, see Sectin 7.1 in this chapter). In ther cases, we have decided nt t include a particular drug n ur Drug List.

97 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 95 Sectin 3.2 There are five cst-sharing tiers fr drugs n the Drug List Every drug n the plan s Drug List is in ne f five cst-sharing tiers. In general, the higher the cst-sharing tier, the higher yur cst fr the drug: Tier 1 - Preferred Generics (Generic drugs that are available at the lwest cst share fr this plan.) Tier 2 Generics (Generic drugs that are available at a higher cst t yu than drugs in Tier 1) Tier 3 Preferred Brands (Generic r brand drugs that are available at a lwer cst t yu than drugs in Tier 4) Tier 4 Nn-Preferred Drugs (Generic r brand drugs that are available at a higher cst t yu than drugs in Tier 3) Tier 5 Specialty Drugs (This is the highest-cst tier. Sme injectables and ther high-cst drugs) T find ut which cst-sharing tier yur drug is in, lk it up in the plan s Drug List. The amunt yu pay fr drugs in each cst-sharing tier is shwn in Chapter 6 (What yu pay fr yur Part D prescriptin drugs). Sectin 3.3 Hw can yu find ut if a specific drug is n the Drug List? Yu have three ways t find ut: 1. Check the mst recent Drug List we sent yu in the mail. 2. Visit the plan s website ( The Drug List n the website is always the mst current. 3. Call yur Healthcare Cncierge t find ut if a particular drug is n the plan s Drug List r t ask fr a cpy f the list. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) SECTION 4 There are restrictins n cverage fr sme drugs Sectin 4.1 Why d sme drugs have restrictins? Fr certain prescriptin drugs, special rules restrict hw and when the plan cvers them. A team f dctrs and pharmacists develped these rules t help ur members use drugs in the mst effective ways. These special rules als help cntrl verall drug csts, which keeps yur drug cverage mre affrdable. In general, ur rules encurage yu t get a drug that wrks fr yur medical cnditin and is safe and effective. Whenever a safe, lwer-cst drug will wrk just as well medically as a higher-cst drug, the plan s rules are designed t encurage yu and yur prvider t use that lwer-cst ptin. We als need t cmply with Medicare s rules and regulatins fr drug cverage and cst-sharing.

98 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 96 If there is a restrictin fr yur drug, it usually means that yu r yur prvider will have t take extra steps in rder fr us t cver the drug. If yu want us t waive the restrictin fr yu, yu will need t use the cverage decisin prcess and ask us t make an exceptin. We may r may nt agree t waive the restrictin fr yu. (See Chapter 9, Sectin 6.2 fr infrmatin abut asking fr exceptins.) Please nte that smetimes a drug may appear mre than nce in ur drug list. This is because different restrictins r cst-sharing may apply based n factrs such as the strength, amunt, r frm f the drug prescribed by yur health care prvider (fr instance, 10 mg versus 100 mg; ne per day versus tw per day; tablet versus liquid). Sectin 4.2 What kinds f restrictins? Our plan uses different types f restrictins t help ur members use drugs in the mst effective ways. The sectins belw tell yu mre abut the types f restrictins we use fr certain drugs. Restricting brand name drugs when a generic versin is available Generally, a generic drug wrks the same as a brand name drug and usually csts less. In mst cases, when a generic versin f a brand name drug is available, ur netwrk pharmacies will prvide yu the generic versin. We usually will nt cver the brand name drug when a generic versin is available. Hwever, if yur prvider has tld us the medical reasn that the generic drug will nt wrk fr yu, then we will cver the brand name drug. (Yur share f the cst may be greater fr the brand name drug than fr the generic drug.) Getting plan apprval in advance Fr certain drugs, yu r yur prvider need t get apprval frm the plan befre we will agree t cver the drug fr yu. This is called prir authrizatin. Smetimes the requirement fr getting apprval in advance helps guide apprpriate use f certain drugs. If yu d nt get this apprval, yur drug might nt be cvered by the plan. Trying a different drug first This requirement encurages yu t try less cstly but just as effective drugs befre the plan cvers anther drug. Fr example, if Drug A and Drug B treat the same medical cnditin, the plan may require yu t try Drug A first. If Drug A des nt wrk fr yu, the plan will then cver Drug B. This requirement t try a different drug first is called step therapy. Quantity limits Fr certain drugs, we limit the amunt f the drug that yu can have by limiting hw much f a drug yu can get each time yu fill yur prescriptin. Fr example, if it is nrmally cnsidered safe t take nly ne pill per day fr a certain drug, we may limit cverage fr yur prescriptin t n mre than ne pill per day. Sectin 4.3 D any f these restrictins apply t yur drugs? The plan s Drug List includes infrmatin abut the restrictins described abve. T find ut if any f these restrictins apply t a drug yu take r want t take, check the Drug List. Fr the mst up-t-date infrmatin, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) r check ur website (

99 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 97 If there is a restrictin fr yur drug, it usually means that yu r yur prvider will have t take extra steps in rder fr us t cver the drug. If there is a restrictin n the drug yu want t take, yu shuld cntact yur Healthcare Cncierge t learn what yu r yur prvider wuld need t d t get cverage fr the drug. If yu want us t waive the restrictin fr yu, yu will need t use the cverage decisin prcess and ask us t make an exceptin. We may r may nt agree t waive the restrictin fr yu. (See Chapter 9, Sectin 6.2 fr infrmatin abut asking fr exceptins.) SECTION 5 What if ne f yur drugs is nt cvered in the way yu d like it t be cvered? Sectin 5.1 There are things yu can d if yur drug is nt cvered in the way yu d like it t be cvered We hpe that yur drug cverage will wrk well fr yu. But it s pssible that there culd be a prescriptin drug yu are currently taking, r ne that yu and yur prvider think yu shuld be taking that is nt n ur frmulary r is n ur frmulary with restrictins. Fr example: The drug might nt be cvered at all. Or maybe a generic versin f the drug is cvered but the brand name versin yu want t take is nt cvered. The drug is cvered, but there are extra rules r restrictins n cverage fr that drug. As explained in Sectin 4, sme f the drugs cvered by the plan have extra rules t restrict their use. Fr ex ample, yu might be required t try a different drug first, t see if it will wrk, befre the drug yu want t take will be cvered fr yu. Or there might be limits n what amunt f the drug (number f pills, etc.) is cvered during a particular time perid. In sme cases, yu may want us t waive the restrictin fr yu. The drug is cvered, but it is in a cst-sharing tier that makes yur cst-sharing mre expensive than yu think it shuld be. The plan puts each cvered drug int ne f five different cst-sharing tiers. Hw much yu pay fr yur prescriptin depends in part n which cst-sharing tier yur drug is in. Sectin 5.2 There are things yu can d if yur drug is nt cvered in the way that yu d like it t be cvered. Yur ptins depend n what type f prblem yu have: If yur drug is nt n the Drug List r if yur drug is restricted, g t Sectin 5.2 t learn what yu can d. If yur drug is in a cst-sharing tier that makes yur cst mre expensive than yu think it shuld be, g t Sectin 5.3 t learn what yu can d. What can yu d if yur drug is nt n the Drug List r if the drug is restricted in sme way? If yur drug is nt n the Drug List r is restricted, here are things yu can d: Yu may be able t get a temprary supply f the drug (nly members in certain situatins can get a temprary supply). This will give yu and yur prvider time t change t anther drug r t file a request t have the drug cvered.

100 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 98 Yu can change t anther drug. Yu can request an exceptin and ask the plan t cver the drug r remve restrictins frm the drug. Yu may be able t get a temprary supply Under certain circumstances, the plan can ffer a temprary supply f a drug t yu when yur drug is nt n the Drug List r when it is restricted in sme way. Ding this gives yu time t talk with yur prvider abut the change in cverage and figure ut what t d. T be eligible fr a temprary supply, yu must meet the tw requirements belw: 1. The change t yur drug cverage must be ne f the fllwing types f changes: The drug yu have been taking is n lnger n the plan s Drug List. -- r -- the drug yu have been taking is nw restricted in sme way (Sectin 4 in this chapter tells abut restrictins). 2. Yu must be in ne f the situatins described belw: Fr thse members wh are new r wh were in the plan last year and aren t in a lng-term care (LTC) facility: We will cver a temprary supply f yur drug during the first 90 days f yur membership in the plan if yu were new and the first 90 days f the calendar year if yu were in the plan last year. This temprary supply will be fr a maximum f a 30-day supply. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f a 30-day supply f medicatin. The prescriptin must be filled at a netwrk pharmacy. Fr thse members wh are new r wh were in the plan last year and reside in a lng-term care (LTC) facility: We will cver a temprary supply f yur drug during the first 90 days f yur membership in the plan if yu are new and during the first 90 days f the calendar year if yu were in the plan last year. The ttal supply will be fr a maximum f a 91 t 98-day supply depending n the dispensing increment. If yur prescriptin is written fr fewer days, we will allw multiple fills t prvide up t a maximum f a 91 t 98-day supply f medicatin. (Please nte that the lng-term care pharmacy may prvide the drug in smaller amunts at a time t prevent waste.) Fr thse members wh have been in the plan fr mre than 90 days and reside in a lng-term care (LTC) facility and need a supply right away: We will cver ne 31-day supply f a particular drug, r less if yur prescriptin is written fr fewer days. This is in additin t the abve lng-term care transitin supply. Fr members wh are utside their transitin perid, and experience a change in the level f care when changing frm ne treatment setting t anther (example:lng-term care facility t hspital, hspital t lng-term care facility, hspital t hme, hme t lng-term care facility,

101 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 99 hspice t lng-term care facility, hspice t hme): We will allw an early refill fr a 30-day supply f medicatin in the retail setting and up t a 31- day supply in the lng-term care setting fr frmulary medicatins and an emergency transitin fill fr nn-frmulary medicatins (including thse medicatins that are n frmulary but require prir authrizatin, step therapy, r are subject t quantity limit restrictins). This des nt apply fr shrt-term leaves f absences (i.e. hlidays r vacatins) frm LTC r hspital facilities. If yu are utside f yur 90-day transitin perid, we will still prvide an emergency 30-day supply in the retail setting r up t a 31-day supply in the lng-term care setting f Part D cvered nn-frmulary medicatins (including Part D cvered drugs that are n ur frmulary that wuld therwise require prir authrizatin, step therapy, r quantity limit restrictins), n a case by case basis, while an exceptin is being prcessed. T ask fr a temprary supply, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). During the time when yu are getting a temprary supply f a drug, yu shuld talk with yur prvider t decide what t d when yur temprary supply runs ut. Yu can either switch t a different drug cvered by the plan r ask the plan t make an exceptin fr yu and cver yur current drug. The sectins belw tell yu mre abut these ptins. Yu can change t anther drug Start by talking with yur prvider. Perhaps there is a different drug cvered by the plan that might wrk just as well fr yu. Yu can call yur Healthcare Cncierge t ask fr a list f cvered drugs that treat the same medical cnditin. This list can help yur prvider find a cvered drug that might wrk fr yu. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Yu can ask fr an exceptin Yu and yur prvider can ask the plan t make an exceptin fr yu and cver the drug in the way yu wuld like it t be cvered. If yur prvider says that yu have medical reasns that justify asking us fr an exceptin, yur prvider can help yu request an exceptin t the rule. Fr example, yu can ask the plan t cver a drug even thugh it is nt n the plan s Drug List. Or yu can ask the plan t make an exceptin and cver the drug withut restrictins. If yu are a current member and a drug yu are taking will be remved frm the frmulary r restricted in sme way fr next year, we will allw yu t request a frmulary exceptin in advance fr next year. We will tell yu abut any change in the cverage fr yur drug fr next year. Yu can ask fr an exceptin befre next year and we will give yu an answer within 72 hurs after we receive yur request (r yur prescriber s supprting statement). If we apprve yur request, we will authrize the cverage befre the change takes effect. If yu and yur prvider want t ask fr an exceptin, Chapter 9, Sectin 6.4 tells what t d. It explains the prcedures and deadlines that have been set by Medicare t make sure yur request is handled prmptly and fairly.

102 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 100 Sectin 5.3 What can yu d if yur drug is in a cst-sharing tier yu think is t high? If yur drug is in a cst-sharing tier yu think is t high, here are things yu can d: Yu can change t anther drug If yur drug is in a cst-sharing tier yu think is t high, start by talking with yur prvider. Perhaps there is a different drug in a lwer cst-sharing tier that might wrk just as well fr yu. Yu can call yur Healthcare Cncierge t ask fr a list f cvered drugs that treat the same medical cnditin. This list can help yur prvider find a cvered drug that might wrk fr yu. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Yu can ask fr an exceptin Fr drugs in Tier 4 and Tier 2, yu and yur prvider can ask the plan t make an exceptin in the cst-sharing tier fr the drug s that yu pay less fr it. If yur prvider says that yu have medical reasns that justify asking us fr an exceptin, yur prvider can help yu request an exceptin t the rule. If yu and yur prvider want t ask fr an exceptin, Chapter 9, Sectin 6.4 tells what t d. It explains the prcedures and deadlines that have been set by Medicare t make sure yur request is handled prmptly and fairly. Drugs in Tier 5 are nt eligible fr this type f exceptin. We d nt lwer the cst-sharing amunt fr drugs in this Tier. SECTION 6 What if yur cverage changes fr ne f yur drugs? Sectin 6.1 The Drug List can change during the year Mst f the changes in drug cverage happen at the beginning f each year (January 1). Hwever, during the year, the plan might make changes t the Drug List. Fr example, the plan might: Add r remve drugs frm the Drug List. New drugs becme available, including new generic drugs. Perhaps the gvernment has given apprval t a new use fr an existing drug. Smetimes, a drug gets recalled and we decide nt t cver it. Or we might remve a drug frm the list because it has been fund t be ineffective. Mve a drug t a higher r lwer cst-sharing tier. Add r remve a restrictin n cverage fr a drug (fr mre infrmatin abut restrictins t cverage, see Sectin 4 in this chapter). Replace a brand name drug with a generic drug. In almst all cases, we must get apprval frm Medicare fr changes we make t the plan s Drug List.

103 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 101 Sectin 6.2 What happens if cverage changes fr a drug yu are taking? Hw will yu find ut if yur drug s cverage has been changed? If there is a change t cverage fr a drug yu are taking, the plan will send yu a ntice t tell yu. Nrmally, we will let yu knw at least 60 days ahead f time. Once in a while, a drug is suddenly recalled because it s been fund t be unsafe r fr ther reasns. If this happens, the plan will immediately remve the drug frm the Drug List. We will let yu knw f this change right away. Yur prvider will als knw abut this change, and can wrk with yu t find anther drug fr yur cnditin. D changes t yur drug cverage affect yu right away? If any f the fllwing types f changes affect a drug yu are taking, the change will nt affect yu until January 1 f the next year if yu stay in the plan: If we mve yur drug int a higher cst-sharing tier. If we put a new restrictin n yur use f the drug. If we remve yur drug frm the Drug List, but nt because f a sudden recall r because a new generic drug has replaced it. If any f these changes happens fr a drug yu are taking, then the change wn t affect yur use r what yu pay as yur share f the cst until January 1 f the next year. Until that date, yu prbably wn t see any increase in yur payments r any added restrictin t yur use f the drug. Hwever, n January 1 f the next year, the changes will affect yu. In sme cases, yu will be affected by the cverage change befre January 1: If a brand name drug yu are taking is replaced by a new generic drug, the plan must give yu at least 60 days ntice r give yu a 60-day refill f yur brand name drug at a netwrk pharmacy. During this 60-day perid, yu shuld be wrking with yur prvider t switch t the generic r t a different drug that we cver. Or yu and yur prvider can ask the plan t make an exceptin and cntinue t cver the brand name drug fr yu. Fr infrmatin n hw t ask fr an exceptin, see Chapter 9 (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). Again, if a drug is suddenly recalled because it s been fund t be unsafe r fr ther reasns, the plan will immediately remve the drug frm the Drug List. We will let yu knw f this change right away. Yur prvider will als knw abut this change, and can wrk with yu t find anther drug fr yur cnditin.

104 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 102 SECTION 7 What types f drugs are nt cvered by the plan? Sectin 7.1 Types f drugs we d nt cver This sectin tells yu what kinds f prescriptin drugs are excluded. This means Medicare des nt pay fr these drugs. If yu get drugs that are excluded, yu must pay fr them yurself. We wn t pay fr the drugs that are listed in this sectin. The nly exceptin: If the requested drug is fund upn appeal t be a drug that is nt excluded under Part D and we shuld have paid fr r cvered it because f yur specific situatin. (Fr infrmatin abut appealing a decisin we have made t nt cver a drug, g t Chapter 9, Sectin 6.5 in this bklet.) Here are three general rules abut drugs that Medicare drug plans will nt cver under Part D: Our plan s Part D drug cverage cannt cver a drug that wuld be cvered under Medicare Part A r Part B. Our plan cannt cver a drug purchased utside the United States and its territries. Our plan usually cannt cver ff-label use. Off-label use is any use f the drug ther than thse indicated n a drug s label as apprved by the Fd and Drug Administratin. Generally, cverage fr ff-label use is allwed nly when the use is supprted by certain reference bks. These reference bks are the American Hspital Frmulary Service Drug Infrmatin, the DRUGDEX Infrmatin System; and fr cancer, the Natinal Cmprehensive Cancer Netwrk and Clinical Pharmaclgy, r their successrs. If the use is nt supprted by any f these reference bks, then ur plan cannt cver its ff-label use. Als, by law, these categries f drugs are nt cvered by Medicare drug plans: Nn-prescriptin drugs (als called ver-the-cunter drugs). Drugs when used t prmte fertility. Drugs when used fr the relief f cugh r cld symptms. Drugs when used fr csmetic purpses r t prmte hair grwth. Prescriptin vitamins and mineral prducts, except prenatal vitamins and fluride preparatins. Drugs when used fr the treatment f sexual r erectile dysfunctin, such as Viagra, Cialis, Levitra, and Caverject. Drugs when used fr treatment f anrexia, weight lss, r weight gain. Outpatient drugs fr which the manufacturer seeks t require that assciated tests r mnitring services be purchased exclusively frm the manufacturer as a cnditin f sale. The amunt yu pay when yu fill a prescriptin fr these drugs des nt cunt tward qualifying yu fr the Catastrphic Cverage Stage. (The Catastrphic Cverage Stage is described in Chapter 6, Sectin 7 f this bklet.)

105 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 103 If yu receive Extra Help paying fr yur drugs, yur state Medicaid prgram may cver sme prescriptin drugs nt nrmally cvered in a Medicare drug plan. Please cntact yur state Medicaid prgram t determine what drug cverage may be available t yu. (Yu can find phne numbers and cntact infrmatin fr Medicaid in Chapter 2, Sectin 6.) SECTION 8 Shw yur plan membership card when yu fill a prescriptin Sectin 8.1 Shw yur membership card T fill yur prescriptin, shw yur plan membership card at the netwrk pharmacy yu chse. When yu shw yur plan membership card, the netwrk pharmacy will autmatically bill the plan fr ur share f yur cvered prescriptin drug cst. Yu will need t pay the pharmacy yur share f the cst when yu pick up yur prescriptin. Sectin 8.2 What if yu dn t have yur membership card with yu? If yu dn t have yur plan membership card with yu when yu fill yur prescriptin, ask the pharmacy t call the plan t get the necessary infrmatin. If the pharmacy is nt able t get the necessary infrmatin, yu may have t pay the full cst f the prescriptin when yu pick it up. (Yu can then ask us t reimburse yu fr ur share. See Chapter 7, Sectin 2.1 fr infrmatin abut hw t ask the plan fr reimbursement.) SECTION 9 Part D drug cverage in special situatins Sectin 9.1 What if yu re in a hspital r a skilled nursing facility fr a stay that is cvered by the plan? If yu are admitted t a hspital r t a skilled nursing facility fr a stay cvered by the plan, we will generally cver the cst f yur prescriptin drugs during yur stay. Once yu leave the hspital r skilled nursing facility, the plan will cver yur drugs as lng as the drugs meet all f ur rules fr cverage. See the previus parts f this sectin that tell abut the rules fr getting drug cverage. Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut drug cverage and what yu pay. Please Nte: When yu enter, live in, r leave a skilled nursing facility, yu are entitled t a Special Enrllment Perid. During this time perid, yu can switch plans r change yur cverage. (Chapter 10, Ending yur membership in the plan, tells when yu can leave ur plan and jin a different Medicare plan.) Sectin 9.2 What if yu re a resident in a lng-term care (LTC) facility? Usually, a lng-term care facility (LTC) (such as a nursing hme) has its wn pharmacy, r a pharmacy that supplies drugs fr all f its residents. If yu are a resident f a lng-term care facility, yu may get yur prescriptin drugs thrugh the facility s pharmacy as lng as it is part f ur netwrk. Check yur Prvider/Pharmacy Directry t find ut if yur lng-term care facility s pharmacy is part f ur netwrk. If it isn t, r if yu need mre infrmatin, please cntact yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet).

106 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 104 What if yu re a resident in a lng-term care (LTC) facility and becme a new member f the plan? If yu need a drug that is nt n ur Drug List r is restricted in sme way, the plan will cver a temprary supply f yur drug during the first 90 days f yur membership. The ttal supply will be fr a max imum f 91 t 98-day supply depending n the dispensing increment, r less if yur prescriptin is written fr fewer days. (Please nte that the lng-term care pharmacy may prvide the drug in smaller amunts at a time t prevent waste.) If yu have been a member f the plan fr mre than 90 days and need a drug that is nt n ur Drug List r if the plan has any restrictin n the drug s cverage, we will cver ne 31-day supply, r less if yur prescriptin is written fr fewer days. During the time when yu are getting a temprary supply f a drug, yu shuld talk with yur prvider t decide what t d when yur temprary supply runs ut. Perhaps there is a different drug cvered by the plan that might wrk just as well fr yu. Or yu and yur prvider can ask the plan t make an exceptin fr yu and cver the drug in the way yu wuld like it t be cvered. If yu and yur prvider want t ask fr an exceptin, Chapter 9, Sectin 6.4 tells what t d. Sectin 9.3 What if yu re als getting drug cverage frm an emplyer r retiree grup plan? D yu currently have ther prescriptin drug cverage thrugh yur (r yur spuse s) emplyer r retiree grup? If s, please cntact that grup s benefits administratr. He r she can help yu determine hw yur current prescriptin drug cverage will wrk with ur plan. In general, if yu are currently emplyed, the prescriptin drug cverage yu get frm us will be secndary t yur emplyer r retiree grup cverage. That means yur grup cverage wuld pay first. Special nte abut creditable cverage : Each year yur emplyer r retiree grup shuld send yu a ntice that tells if yur prescriptin drug cverage fr the next calendar year is creditable and the chices yu have fr drug cverage. If the cverage frm the grup plan is creditable, it means that the plan has drug cverage that is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. Keep these ntices abut creditable cverage, because yu may need them later. If yu enrll in a Medicare plan that includes Part D drug cverage, yu may need these ntices t shw that yu have maintained creditable cverage. If yu didn t get a ntice abut creditable cverage frm yur emplyer r retiree grup plan, yu can get a cpy frm the emplyer r retiree grup s benefits administratr r the emplyer r unin. Sectin 9.4 What if yu re in Medicare-certified hspice? Drugs are never cvered by bth hspice and ur plan at the same time. If yu are enrlled in Medicare hspice and require an anti-nausea, laxative, pain medicatin r antianxiety drug that is nt cvered by yur hspice because it is unrelated t yur terminal illness and related cnditins, ur plan must receive ntificatin frm either the prescriber r yur hspice prvider that the drug is unrelated befre ur plan can cver the drug. T prevent delays in receiving any unrelated drugs that shuld be cvered by ur plan, yu can ask yur hspice prvider r prescriber t make sure we have the ntificatin that the drug is unrelated befre yu ask a pharmacy t fill yur prescriptin.

107 Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 105 In the event yu either revke yur hspice electin r are discharged frm hspice ur plan shuld cver all yur drugs. T prevent any delays at a pharmacy when yur Medicare hspice benefit ends, yu shuld bring dcumentatin t the pharmacy t verify yur revcatin r discharge. See the previus parts f this sectin that tell abut the rules fr getting drug cverage under Part D Chapter 6 (What yu pay fr yur Part D prescriptin drugs) gives mre infrmatin abut drug cverage and what yu pay. SECTION 10 Prgrams n drug safety and managing medicatins Sectin 10.1 Prgrams t help members use drugs safely We cnduct drug use reviews fr ur members t help make sure that they are getting safe and apprpriate care. These reviews are especially imprtant fr members wh have mre than ne prvider wh prescribes their drugs. We d a review each time yu fill a prescriptin. We als review ur recrds n a regular basis. During these reviews, we lk fr ptential prblems such as: Pssible medicatin errrs Drugs that may nt be necessary because yu are taking anther drug t treat the same medical cnditin Drugs that may nt be safe r apprpriate because f yur age r gender Certain cmbinatins f drugs that culd harm yu if taken at the same time Prescriptins written fr drugs that have ingredients yu are allergic t Pssible errrs in the amunt (dsage) f a drug yu are taking. If we see a pssible prblem in yur use f medicatins, we will wrk with yur prvider t crrect the prblem. Sectin 10.2 Medicatin Therapy Management (MTM) prgram t help members manage their medicatins We have a prgram that can help ur members with cmplex health needs. Fr example, sme members have several medical cnditins, take different drugs at the same time, and have high drug csts. This prgram is vluntary and free t members. A team f pharmacists and dctrs develped the prgram fr us. This prgram can help make sure that ur members get the mst benefit frm the drugs they take. Our prgram is called a Medicatin Therapy Management (MTM) prgram. Sme members wh take several medicatins fr different medical cnditins may be able t get services thrugh an MTM prgram. A pharmacist r ther health prfessinal will give yu a cmprehensive review f all yur medicatins. Yu can talk abut hw best t take yur medicatins, yur csts, r any prblems yu re having. Yu ll get a written summary f this discussin. The summary has a medicatin actin plan that recmmends what yu can d t make the best use f yur medicatins, with space fr yu t take ntes r write dwn any fllw-up questins. Yu ll als get a persnal medicatin list that will include all the medicatins yu re taking and why yu take them.

108 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 5. Using the plan s cverage fr yur Part D prescriptin drugs 106 It s a gd idea t have yur medicatin review befre yur yearly Wellness visit, s yu can talk t yur dctr abut yur actin plan and medicatin list. Bring yur actin plan and medicatin list with yu t yur visit r anytime yu talk with yur dctrs, pharmacists, and ther health care prviders. Als, keep yur medicatin list with yu (fr example, with yur ID) in case yu g t the hspital r emergency rm. If we have a prgram that fits yur needs, we will autmatically enrll yu in the prgram and send yu infrmatin. If yu decide nt t participate, please ntify us and we will withdraw yu frm the pr gram. If yu have any questins abut these prgrams, please cntact yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet).

109 CHAPTER 6 What yu pay fr yur Part D prescriptin drugs

110 Chapter 6. What yu pay fr yur Part D prescriptin drugs 108 Chapter 6. SECTION 1 Sectin 1.1 Sectin 1.2 SECTION 2 Sectin 2.1 SECTION 3 Sectin 3.1 Sectin 3.2 SECTION 4 Sectin 4.1 SECTION 5 Sectin 5.1 Sectin 5.2 Sectin 5.3 Sectin 5.4 Sectin 5.5 SECTION 6 Sectin 6.1 Sectin 6.2 What yu pay fr yur Part D prescriptin drugs Intrductin Use this chapter tgether with ther materials that explain yur drug cverage Types f ut-f-pcket csts yu may pay fr cvered drugs What yu pay fr a drug depends n which drug payment stage yu are in when yu get the drug What are the drug payment stages fr HealthTeam Advantage Plan I members? We send yu reprts that explain payments fr yur drugs and which payment stage yu are in We send yu a mnthly reprt called the Part D Explanatin f Benefits (the Part D EOB ) Help us keep ur infrmatin abut yur drug payments up t date There is n deductible fr HealthTeam Advantage Plan I Yu d nt pay a deductible fr yur Part D drugs During the Initial Cverage Stage, the plan pays its share f yur drug csts and yu pay yur share What yu pay fr a drug depends n the drug and where yu fill yur prescriptin A table that shws yur csts fr a ne-mnth supply f a drug If yur dctr prescribes less than a full mnth s supply, yu may nt have t pay the cst f the entire mnth s supply A table that shws yur csts fr a lng-term (up t a 90 day) supply f a drug Yu stay in the Initial Cverage Stage until yur ttal drug csts fr the year reach $3, During the Cverage Gap Stage, the plan prvides sme drug cverage Yu stay in the Cverage Gap Stage until yur ut-f-pcket csts reach $5, Hw Medicare calculates yur ut-f-pcket csts fr prescriptin drugs..119

111 Chapter 6. What yu pay fr yur Part D prescriptin drugs 109 SECTION 7 Sectin 7.1 SECTION 8 Sectin 8.1 Sectin 8.2 During the Catastrphic Cverage Stage, the plan pays mst f the cst fr yur drugs Once yu are in the Catastrphic Cverage Stage, yu will stay in this stage fr the rest f the year What yu pay fr vaccinatins cvered by Part D depends n hw and where yu get them Our plan may have separate cverage fr the Part D vaccine medicatin itself and fr the cst f giving yu the vaccine Yu may want t call us at yur Healthcare Cncierge befre yu get a vaccinatin

112 questin mark Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 6. What yu pay fr yur Part D prescriptin drugs 110 Did yu knw there are prgrams t help peple pay fr their drugs? There are prgrams t help peple with limited resurces pay fr their drugs. These include Extra Help and State Pharmaceutical Assistance Prgrams. Fr mre infrmatin, see Chapter 2, Sectin 7. Are yu currently getting help t pay fr yur drugs? If yu are in a prgram that helps pay fr yur drugs, sme infrmatin in this Evidence f Cverage abut the csts fr Part D prescriptin drugs may nt apply t yu. We send yu a separate insert, called the Evidence f Cverage Rider fr Peple Wh Get Extra Help Paying fr Prescrip tin Drugs (als knwn as the Lw Incme Subsidy Rider r the LIS Rider ), which tells yu abut yur drug cverage. If yu dn t have this insert, please call yur Healthcare Cncierge and ask fr the LIS Rider. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) SECTION 1 Sectin 1.1 Intrductin Use this chapter tgether with ther materials that explain yur drug cverage This chapter fcuses n what yu pay fr yur Part D prescriptin drugs. T keep things simple, we use drug in this chapter t mean a Part D prescriptin drug. As explained in Chapter 5, nt all drugs are Part D drugs sme drugs are cvered under Medicare Part A r Part B and ther drugs are excluded frm Medicare cverage by law. T understand the payment infrmatin we give yu in this chapter, yu need t knw the basics f what drugs are cvered, where t fill yur prescriptins, and what rules t fllw when yu get yur cvered drugs. Here are materials that explain these basics: The plan s List f Cvered Drugs (Frmulary). T keep things simple, we call this the Drug List. This Drug List tells which drugs are cvered fr yu. It als tells which f the five cst-sharing tiers the drug is in and whether there are any restrictins n yur cverage fr the drug. If yu need a cpy f the Drug List, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can als find the Drug List n ur website at The Drug List n the website is always the mst current. Chapter 5 f this bklet. Chapter 5 gives the details abut yur prescriptin drug cverage, including rules yu need t fllw when yu get yur cvered drugs. Chapter 5 als tells which types f prescriptin drugs are nt cvered by ur plan. The plan s Prvider/Pharmacy Directry. In mst situatins yu must use a netwrk pharmacy t

113 Chapter 6. What yu pay fr yur Part D prescriptin drugs 111 get yur cvered drugs (see Chapter 5 fr the details). The Prvider/Pharmacy Directry has a list f pharmacies in the plan s netwrk. It als tells yu which pharmacies in ur netwrk can give yu a lng-term supply f a drug (such as filling a prescriptin fr a three-mnth s supply). Sectin 1.2 Types f ut-f-pcket csts yu may pay fr cvered drugs T understand the payment infrmatin we give yu in this chapter, yu need t knw abut the types f ut-f-pcket csts yu may pay fr yur cvered services. The amunt that yu pay fr a drug is called cst-sharing, and there are three ways yu may be asked t pay. The deductible is the amunt yu must pay fr drugs befre ur plan begins t pay its share. Cpayment means that yu pay a fixed amunt each time yu fill a prescriptin. Cinsurance means that yu pay a percent f the ttal cst f the drug each time yu fill a prescriptin.

114 Chapter 6. What yu pay fr yur Part D prescriptin drugs 112 SECTION 2 Sectin 2.1 What yu pay fr a drug depends n which drug payment stage yu are in when yu get the drug What are the drug payment stages fr HealthTeam Advantage Plan I members? As shwn in the table belw, there are drug payment stages fr yur prescriptin drug cverage under HealthTeam Advantage Plan I. Hw much yu pay fr a drug depends n which f these stages yu are in at the time yu get a prescriptin filled r refilled. Stage 1 Stage 2 Stage 3 Stage 4 Yearly Deductible Stage Because there is n deductible fr the plan, this payment stage des nt apply t yu. Initial Cverage Stage Yu begin in this stage when yu fill yur first prescriptin f the year. During this stage, the plan pays its share f the cst f yur drugs and yu pay yur share f the cst. Cverage Gap Stage Fr Tier 1 generic drugs, yu pay either yur Tier 1 cpayment r 44% f the csts, whichever is lwer. Fr all ther cvered generic drugs, yu pay 44% f the csts. Fr cvered brand name drugs, yu pay 35% f the price (plus a prtin f the dispensing fee). Catastrphic Cverage Stage During this stage, the plan will pay mst f the cst f yur drugs fr the rest f the calendar year (thrugh December 31, 2018). (Details are in Sectin 7 f this chapter.) Yu stay in this stage until yur year-t-date ttal drug csts (yur payments plus any Part D plan s payments) ttal $3,750. (Details are in Sectin 5 f this chapter.) Yu stay in this stage until yur year-t-date utf-pcket csts (yur payments) reach a ttal f $5,000. This amunt and rules fr cunting csts tward this amunt have been set by Medicare. (Details are in Sectin 6 f this chapter.) SECTION 3 We send yu reprts that explain payments fr yur drugs and which payment stage yu are in Sectin 3.1 We send yu a mnthly reprt called the Part D Explanatin f Benefits (the Part D EOB ) Our plan keeps track f the csts f yur prescriptin drugs and the payments yu have made when yu get yur prescriptins filled r refilled at the pharmacy. This way, we can tell yu when yu have mved frm ne drug payment stage t the next. In particular, there are tw types f csts we keep track f:

115 Chapter 6. What yu pay fr yur Part D prescriptin drugs 113 We keep track f hw much yu have paid. This is called yur ut-f-pcket cst. We keep track f yur ttal drug csts. This is the amunt yu pay ut-f-pcket r thers pay n yur behalf plus the amunt paid by the plan. Our plan will prepare a written reprt called the Part D Explanatin f Benefits (it is smetimes called the Part D EOB ) when yu have had ne r mre prescriptins filled thrugh the plan during the previus mnth. It includes: Infrmatin fr that mnth. This reprt gives the payment details abut the prescriptins yu have filled during the previus mnth. It shws the ttal drugs csts, what the plan paid, and what yu and thers n yur behalf paid. Ttals fr the year since January 1. This is called year-t-date infrmatin. It shws yu the ttal drug csts and ttal payments fr yur drugs since the year began. Sectin 3.2 Help us keep ur infrmatin abut yur drug payments up t date T keep track f yur drug csts and the payments yu make fr drugs, we use recrds we get frm pharmacies. Here is hw yu can help us keep yur infrmatin crrect and up t date: Shw yur membership card when yu get a prescriptin filled. T make sure we knw abut the prescriptins yu are filling and what yu are paying, shw yur plan membership card every time yu get a prescriptin filled. Make sure we have the infrmatin we need. There are times yu may pay fr prescriptin drugs when we will nt autmatically get the infrmatin we need t keep track f yur ut-f-pcket csts. T help us keep track f yur ut-f-pcket csts, yu may give us cpies f receipts fr drugs that yu have purchased. (If yu are billed fr a cvered drug, yu can ask ur plan t pay ur share f the cst. Fr instructins n hw t d this, g t Chapter 7, Sectin 2 f this bklet.) Here are sme types f situatins when yu may want t give us cpies f yur drug receipts t be sure we have a cmplete recrd f what yu have spent fr yur drugs: When yu purchase a cvered drug at a netwrk pharmacy at a special price r using a dis cunt card that is nt part f ur plan s benefit. When yu made a cpayment fr drugs that are prvided under a drug manufacturer patient assistance prgram. Any time yu have purchased cvered drugs at ut-f-netwrk pharmacies r ther times yu have paid the full price fr a cvered drug under special circumstances. Send us infrmatin abut the payments thers have made fr yu. Payments made by certain ther individuals and rganizatins als cunt tward yur ut-f-pcket csts and help qualify yu fr catastrphic cverage. Fr example, payments made by a State Pharmaceutical Assistance Prgram, an AIDS drug assistance prgram (ADAP), the Indian Health Service, and mst charities cunt tward yur ut-f-pcket csts. Yu shuld keep a recrd f these payments and send them t us s we can track yur csts.

116 Chapter 6. What yu pay fr yur Part D prescriptin drugs 114 Check the written reprt we send yu. When yu receive a Part D Explanatin f Benefits (a Part D EOB) in the mail, please lk it ver t be sure the infrmatin is cmplete and crrect. If yu think smething is missing frm the reprt, r yu have any questins, please call us at yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Be sure t keep these reprts. They are an imprtant recrd f yur drug expenses. SECTION 4 There is n deductible fr HealthTeam Advantage Plan I Sectin 4.1 Yu d nt pay a deductible fr yur Part D drugs There is n deductible fr HealthTeam Advantage Plan I. Yu begin in the Initial Cverage Stage when yu fill yur first prescriptin f the year. See Sectin 5 fr infrmatin abut yur cverage in the Initial Cverage Stage. SECTION 5 During the Initial Cverage Stage, the plan pays its share f yur drug csts and yu pay yur share Sectin 5.1 What yu pay fr a drug depends n the drug and where yu fill yur prescriptin During the Initial Cverage Stage, the plan pays its share f the cst f yur cvered prescriptin drugs, and yu pay yur share (yur cpayment r cinsurance amunt). Yur share f the cst will vary depending n the drug and where yu fill yur prescriptin. The plan has five cst-sharing tiers Every drug n the plan s Drug List is in ne f five cst-sharing tiers. In general, the higher the cst-sharing tier number, the higher yur cst fr the drug: Tier 1 Preferred Generics (This is the lwest cst tier. Generic drugs that are available at the lwest cst share fr this plan.) Tier 2 Generics (Generic drugs that are available at a higher cst t yu than drugs in Tier 1). Tier 3 Preferred Brands (Generic r brand drugs that are available at a lwer cst t yu than drugs in Tier 4) Tier 4 Nn-Preferred Drugs (Generic r brand drugs that are available at a higher cst t yu than drugs in Tier 3) Tier 5 Specialty Drugs (This is the highest-cst tier. Sme injectables and ther high-cst drugs) T find ut which cst-sharing tier yur drug is in, lk it up in the plan s Drug List.

117 Chapter 6. What yu pay fr yur Part D prescriptin drugs 115 Yur pharmacy chices Hw much yu pay fr a drug depends n whether yu get the drug frm: A retail pharmacy that is in ur plan s netwrk A pharmacy that is nt in the plan s netwrk The plan s mail-rder pharmacy Fr mre infrmatin abut these pharmacy chices and filling yur prescriptins, see Chapter 5 in this bklet and the plan s Prvider/Pharmacy Directry. Sectin 5.2 A table that shws yur csts fr a ne-mnth supply f a drug During the Initial Cverage Stage, yur share f the cst f a cvered drug will be either a cpayment r cinsurance. Cpayment means that yu pay a fixed amunt each time yu fill a prescriptin. Cinsurance means that yu pay a percent f the ttal cst f the drug each time yu fill a prescriptin. As shwn in the table belw, the amunt f the cpayment r cinsurance depends n which cst-sharing tier yur drug is in. Please nte: If yur cvered drug csts less than the cpayment amunt listed in the chart, yu will pay that lwer price fr the drug. Yu pay either the full price f the drug r the cpayment amunt, whichever is lwer. We cver prescriptins filled at ut-f-netwrk pharmacies in nly limited situatins. Please see Chapter 5, Sectin 2.5 fr infrmatin abut when we will cver a prescriptin filled at an ut-fnetwrk pharmacy.

118 Chapter 6. What yu pay fr yur Part D prescriptin drugs 116 Yur share f the cst when yu get a ne-mnth supply f a cvered Part D prescriptin drug: Tier Cst-Sharing Tier 1 (Preferred Generics) Cst-Sharing Tier 2 (Generics) Cst-Sharing Tier 3 (Preferred Brands) Cst-Sharing Tier 4 (Nn-Preferred Drugs) Cst-Sharing Tier 5 (Specialty Tier Drugs) Standard retail cst-sharing (in-netwrk) (up t a 30-day supply) Mail Order cst-sharing (up t a 30-day supply) Lng-term care (LTC) cst-sharing (up t a 31-day supply) Out-f-netwrk cst-sharing (Cverage is limited t certain situatins; see Chapter 5 fr details.) (up t a 29-day supply) $5 cpay $5 cpay $5 cpay $5 cpay $15 cpay $15 cpay $15 cpay $15 cpay $45 cpay $45 cpay $45 cpay $45 cpay $85 cpay $85 cpay $85 cpay $85 cpay 33% cinsurance 33% cinsurance 33% cinsurance 33% cinsurance Sectin 5.3 If yur dctr prescribes less than a full mnth s supply, yu may nt have t pay the cst f the entire mnth s supply Typically, the amunt yu pay fr a prescriptin drug cvers yu a full mnth s supply f a cvered drug. Hwever yur dctr can prescribe less than a mnth s supply f drugs. There may be times when yu want t ask yur dctr abut prescribing less than a mnth s supply f a drug (fr example, when yu are trying a medicatin fr the first time that is knwn t have serius side effects). If yur dctr prescribes less than a full mnth s supply, yu will nt have t pay fr the full mnth s supply fr certain drugs. The amunt yu pay when yu get less than a full mnth s supply will depend n whether yu are respnsible fr paying cinsurance (a percentage f the ttal cst) r a cpayment (a flat dllar amunt). If yu are respnsible fr cinsurance, yu pay a percentage f the ttal cst f the drug. Yu pay the same percentage regardless f whether the prescriptin is fr a full mnth s supply r fr fewer days. Hwever, because the entire drug cst will be lwer if yu get less than a full mnth s supply,

119 Chapter 6. What yu pay fr yur Part D prescriptin drugs 117 the amunt yu pay will be less. If yu are respnsible fr a cpayment fr the drug, yur cpay will be based n the number f days f the drug that yu receive. We will calculate the amunt yu pay per day fr yur drug (the daily cst-sharing rate ) and multiply it by the number f days f the drug yu receive. Here s an example: Let s say the cpay fr yur drug fr a full mnth s supply (a 30-day supply) is $30. This means that the amunt yu pay per day fr yur drug is $1. If yu receive a 7 days supply f the drug, yur payment will be $1 per day multiplied by 7 days, fr a ttal payment f $7. Daily cst-sharing allws yu t make sure a drug wrks fr yu befre yu have t pay fr an entire mnth s supply. Yu can als ask yur dctr t prescribe, and yur pharmacist t dispense, less than a full mnth s supply f a drug r drugs if this will help yu better plan refill dates fr different prescriptins s that yu can take fewer trips t the pharmacy. The amunt yu pay will depend upn the days supply yu receive. Sectin 5.4 A table that shws yur csts fr a lng-term (up t a 90-day) supply f a drug Fr sme drugs, yu can get a lng-term supply (als called an extended supply ) when yu fill yur prescriptin. A lng-term supply is up t a 90-day supply. (Fr details n where and hw t get a lng-term supply f a drug, see Chapter 5, Sectin 2.4.) The table belw shws what yu pay when yu get a lng-term (up t a 90-day) supply f a drug. Please nte: If yur cvered drug csts less than the cpayment amunt listed in the chart, yu will pay that lwer price fr the drug. Yu pay either the full price f the drug r the cpayment amunt, whichever is lwer. Yur share f the cst when yu get a lng-term supply f a cvered Part D prescriptin drug: Tier Cst-Sharing Tier 1 (Preferred Generics) Cst-Sharing Tier 2 (Nn-Preferred Generics) Cst-Sharing Tier 3 (Preferred Brands) Cst-Sharing Tier 4 (Nn-Preferred Drugs) Cst-Sharing Tier 5 (Specialty Tier Drugs) Standard retail cst-sharing (in-netwrk) (up t a 90-day supply) Mail-rder cst-sharing (up t a 90-day supply) $10 cpay $10 cpay $30 cpay $30 cpay $90 cpay $90 cpay $170 cpay $170 cpay 33% cinsurance 33% cinsurance

120 Chapter 6. What yu pay fr yur Part D prescriptin drugs 118 Sectin 5.5 Yu stay in the Initial Cverage Stage until yur ttal drug csts fr the year reach $3,750 Yu stay in the Initial Cverage Stage until the ttal amunt fr the prescriptin drugs yu have filled and refilled reaches the $3,750 limit fr the Initial Cverage Stage. Yur ttal drug cst is based n adding tgether what yu have paid and what any Part D plan has paid: What yu have paid fr all the cvered drugs yu have gtten since yu started with yur first drug purchase f the year. (See Sectin 6.2 fr mre infrmatin abut hw Medicare calculates yur ut-f-pcket csts.) This includes: The ttal yu paid as yur share f the cst fr yur drugs during the Initial Cverage Stage. What the plan has paid as its share f the cst fr yur drugs during the Initial Cverage Stage. (If yu were enrlled in a different Part D plan at any time during 2018, the amunt that plan paid during the Initial Cverage Stage als cunts tward yur ttal drug csts.) The Part D Explanatin f Benefits (Part D EOB) that we send t yu will help yu keep track f hw much yu and the plan, as well as any third parties, have spent n yur behalf fr yur drugs during the year. Many peple d nt reach the $3,750 limit in a year. We will let yu knw if yu reach this $3,750 amunt. If yu d reach this amunt, yu will leave the Initial Cverage Stage and mve n t the Cverage Gap Stage. SECTION 6 During the Cverage Gap Stage, the plan prvides sme drug cverage Sectin 6.1 Yu stay in the Cverage Gap Stage until yur ut-f-pcket csts reach $5,000 When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 35% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mves yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Fr Tier 1 generic drugs, yu pay either yur Tier 1 cpayment r 44% f the csts, whichever is lwer. Fr all ther cvered generic drugs, yu pay n mre than 44% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (56%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. Yu cntinue paying the discunted price fr brand name drugs and n mre than 44% f the csts f generic drugs until yur yearly ut-f-pcket payments reach a maximum amunt that Medicare has set. In 2018, that amunt is $5,000. Medicare has rules abut what cunts and what des nt cunt as yur ut-f-pcket csts. When yu reach an ut-f-pcket limit f $5,000, yu leave the Cverage Gap Stage and mve n t the Catastrphic Cverage Stage.

121 Chapter 6. What yu pay fr yur Part D prescriptin drugs 119 Sectin 6.2 Hw Medicare calculates yur ut-f-pcket csts fr prescriptin drugs Here are Medicare s rules that we must fllw when we keep track f yur ut-f-pcket csts fr yur drugs. These payments are included in yur ut-f-pcket csts When yu add up yur ut-f-pcket csts, yu can include the payments listed belw (as lng as they are fr Part D cvered drugs and yu fllwed the rules fr drug cverage that are explained in Chapter 5 f this bklet): The amunt yu pay fr drugs when yu are in any f the fllwing drug payment stages: The Initial Cverage Stage. The Cverage Gap Stage. Any payments yu made during this calendar year as a member f a different Medicare prescriptin drug plan befre yu jined ur plan. It matters wh pays: If yu make these payments yurself, they are included in yur ut-f-pcket csts. These payments are als included if they are made n yur behalf by certain ther individuals r rganizatins. This includes payments fr yur drugs made by a friend r relative, by mst charities, by AIDS drug assistance prgrams, by a State Pharmaceutical Assistance Prgram that is qualified by Medicare, r by the Indian Health Service. Payments made by Medicare s Extra Help Prgram are als included. Sme f the payments made by the Medicare Cverage Gap Discunt Prgram are included. The amunt the manufacturer pays fr yur brand name drugs is included. But the amunt the plan pays fr yur generic drugs is nt included. Mving n t the Catastrphic Cverage Stage: When yu (r thse paying n yur behalf) have spent a ttal f $5,000 in ut-f-pcket csts within the calendar year, yu will mve frm the Cverage Gap Stage t the Catastrphic Cverage Stage.

122 Chapter 6. What yu pay fr yur Part D prescriptin drugs 120 These payments are nt included in yur ut-f-pcket csts When yu add up yur ut-f-pcket csts, yu are nt allwed t include any f these types f pay ments fr prescriptin drugs: Drugs yu buy utside the United States and its territries. Drugs that are nt cvered by ur plan. Drugs yu get at an ut-f-netwrk pharmacy that d nt meet the plan s requirements fr ut-fnetwrk cverage. Nn-Part D drugs, including prescriptin drugs cvered by Part A r Part B and ther drugs excluded frm Part D cverage by Medicare. Payments made by the plan fr yur brand r generic drugs while in the Cverage Gap. Payments fr yur drugs that are made by grup health plans including emplyer health plans. Payments fr yur drugs that are made by certain insurance plans and gvernment-funded health prgrams such as TRICARE and the Veterans Affairs. Payments fr yur drugs made by a third-party with a legal bligatin t pay fr prescriptin csts (fr example, Wrkers Cmpensatin). Reminder: If any ther rganizatin such as the nes listed abve pays part r all f yur ut-fpcket csts fr drugs, yu are required t tell ur plan. Call yur Healthcare Cncierge t let us knw (phne numbers are printed n the back cver f this bklet). Hw can yu keep track f yur ut-f-pcket ttal? We will help yu. The Part D Explanatin f Benefits (Part D EOB) reprt we send t yu includes the current amunt f yur ut-f-pcket csts (Sectin 3 in this chapter tells abut this reprt). When yu reach a ttal f $5,000 in ut-f-pcket csts fr the year, this reprt will tell yu that yu have left the Cverage Gap Stage and have mved n t the Catastrphic Cverage Stage. Make sure we have the infrmatin we need. Sectin 3.2 tells what yu can d t help make sure that ur recrds f what yu have spent are cmplete and up t date. SECTION 7 Sectin 7.1 During the Catastrphic Cverage Stage, the plan pays mst f the cst fr yur drugs Once yu are in the Catastrphic Cverage Stage, yu will stay in this stage fr the rest f the year Yu qualify fr the Catastrphic Cverage Stage when yur ut-f-pcket csts have reached the $5,000 limit fr the calendar year. Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year.

123 Chapter 6. What yu pay fr yur Part D prescriptin drugs 121 During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.35 fr a generic drug r a drug that is treated like a generic and $8.35 fr all ther drugs. Our plan pays the rest f the cst. SECTION 8 What yu pay fr vaccinatins cvered by Part D depends n hw and where yu get them Sectin 8.1 Our plan may have separate cverage fr the Part D vaccine medicatin itself and fr the cst f giving yu the vaccine Our plan prvides cverage fr a number f Part D vaccines. We als cver vaccines that are cnsidered medical benefits. Yu can find ut abut cverage f these vaccines by ging t the Medical Benefits Chart in Chapter 4, Sectin 2.1. There are tw parts t ur cverage f Part D vaccinatins: The first part f cverage is the cst f the vaccine medicatin itself. The vaccine is a prescriptin medicatin. The secnd part f cverage is fr the cst f giving yu the vaccine. (This is smetimes called the administratin f the vaccine.) What d yu pay fr a Part D vaccinatin? What yu pay fr a Part D vaccinatin depends n three things: 1. The type f vaccine (what yu are being vaccinated fr). Sme vaccines are cnsidered medical benefits. Yu can find ut abut yur cverage f these vaccines by ging t Chapter 4, Medical Benefits Chart (what is cvered and what yu pay). Other vaccines are cnsidered Part D drugs. Yu can find these vaccines listed in the plan s List f Cvered Drugs (Frmulary). 2. Where yu get the vaccine medicatin. 3. Wh gives yu the vaccine.

124 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 6. What yu pay fr yur Part D prescriptin drugs 122 What yu pay at the time yu get the Part D vaccinatin can vary depending n the circumstances. Fr example: Smetimes when yu get yur vaccine, yu will have t pay the entire cst fr bth the vaccine medicatin and fr getting the vaccine. Yu can ask ur plan t pay yu back fr ur share f the cst. Other times, when yu get the vaccine medicatin r the vaccine, yu will pay nly yur share f the cst. T shw hw this wrks, here are three cmmn ways yu might get a Part D vaccine. Remember yu are respnsible fr all f the csts assciated with vaccines (including their administratin) during the Cver age Gap Stage f yur benefit. Situatin 1: Situatin 2: Situatin 3: Yu buy the Part D vaccine at the pharmacy and yu get yur vaccine at the netwrk pharmacy. (Whether yu have this chice depends n where yu live. Sme states d nt allw pharmacies t administer a vaccinatin.) Yu will have t pay the pharmacy the amunt f yur cinsurance r cpayment fr the vaccine and the cst f giving yu the vaccine. Our plan will pay the remainder f the csts. Yu get the Part D vaccinatin at yur dctr s ffice. When yu get the vaccinatin, yu will pay fr the entire cst f the vaccine and its administratin. Yu can then ask ur plan t pay ur share f the cst by using the prcedures that are described in Chapter 7 f this bklet (Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs). Yu will be reimbursed the amunt yu paid less yur nrmal cinsurance r cpayment fr the vaccine (including administratin) Yu buy the Part D vaccine at yur pharmacy, and then take it t yur dctr s ffice where they give yu the vaccine. Yu will have t pay the pharmacy the amunt f yur cinsurance r cpayment fr the vaccine itself. When yur dctr gives yu the vaccine, yu will pay the entire cst fr this service. Yu can then ask ur plan t pay ur share f the cst by using the prcedures described in Chapter 7 f this bklet. Yu will be reimbursed the amunt charged by the dctr fr administering the vaccine.

125 Chapter 6. What yu pay fr yur Part D prescriptin drugs 123 Sectin 8.2 Yu may want t call us at yur Healthcare Cncierge befre yu get a vaccinatin The rules fr cverage f vaccinatins are cmplicated. We are here t help. We recmmend that yu call us first at yur Healthcare Cncierge whenever yu are planning t get a vaccinatin. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) We can tell yu abut hw yur vaccinatin is cvered by ur plan and explain yur share f the cst. We can tell yu hw t keep yur wn cst dwn by using prviders and pharmacies in ur netwrk. If yu are nt able t use a netwrk prvider and pharmacy, we can tell yu what yu need t d t get payment frm us fr ur share f the cst.

126 CHAPTER 7 Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs

127 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 125 Chapter 7. SECTION 1 Sectin 1.1 SECTION 2 Sectin 2.1 SECTION 3 Sectin 3.1 Sectin 3.2 SECTION 4 Sectin 4.1 Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs Situatins in which yu shuld ask us t pay ur share f the cst f yur cvered services r drugs If yu pay ur plan s share f the cst f yur cvered services r drugs, r if yu receive a bill, yu can ask us fr payment Hw t ask us t pay yu back r t pay a bill yu have received Hw and where t send us yur request fr payment We will cnsider yur request fr payment and say yes r n We check t see whether we shuld cver the service r drug and hw much we we If we tell yu that we will nt pay fr all r part f the medical care r drug, yu can make an appeal Other situatins in which yu shuld save yur receipts and send cpies t us In sme cases, yu shuld send cpies f yur receipts t us t help us track yur ut-f-pcket drug csts

128 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 126 SECTION 1 Situatins in which yu shuld ask us t pay ur share f the cst f yur cvered services r drugs Sectin 1.1 If yu pay ur plan s share f the cst f yur cvered services r drugs, r if yu receive a bill, yu can ask us fr payment Smetimes when yu get medical care r a prescriptin drug, yu may need t pay the full cst right away. Other times, yu may find that yu have paid mre than yu expected under the cverage rules f the plan. In either case, yu can ask ur plan t pay yu back (paying yu back is ften called reimburs ing yu). It is yur right t be paid back by ur plan whenever yu ve paid mre than yur share f the cst fr medical services r drugs that are cvered by ur plan. There may als be times when yu get a bill frm a prvider fr the full cst f medical care yu have received. In many cases, yu shuld send this bill t us instead f paying it. We will lk at the bill and decide whether the services shuld be cvered. If we decide they shuld be cvered, we will pay the prvider directly. Here are examples f situatins in which yu may need t ask ur plan t pay yu back r t pay a bill yu have received: 1. When yu ve received medical care frm a prvider wh is nt in ur plan s netwrk When yu received care frm a prvider wh is nt part f ur netwrk, yu are nly respnsible fr paying yur share f the cst, nt fr the entire cst. (Yur share f the cst may be higher fr an utf-netwrk prvider than fr a netwrk prvider.) Yu shuld ask the prvider t bill the plan fr ur share f the cst. If yu pay the entire amunt yurself at the time yu receive the care, yu need t ask us t pay yu back fr ur share f the cst. Send us the bill, alng with dcumentatin f any payments yu have made. At times yu may get a bill frm the prvider asking fr payment that yu think yu d nt we. Send us this bill, alng with dcumentatin f any payments yu have already made. If the prvider is wed anything, we will pay the prvider directly. If yu have already paid mre than yur share f the cst f the service, we will determine hw much yu wed and pay yu back fr ur share f the cst. Please nte: While yu can get yur care frm an ut-f-netwrk prvider, the prvider must be eligible t participate in Medicare. Except fr emergency care, we cannt pay a prvider wh is nt eligible t participate in Medicare. If the prvider is nt eligible t participate in Medicare, yu will be respnsible fr the full cst f the services yu receive. 2. When a netwrk prvider sends yu a bill yu think yu shuld nt pay Netwrk prviders shuld always bill the plan directly, and ask yu nly fr yur share f the cst. But smetimes they make mistakes, and ask yu t pay mre than yur share.

129 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 127 Yu nly have t pay yur cst-sharing amunt when yu get services cvered by ur plan. We d nt allw prviders t add additinal separate charges, called balance billing. This prtectin (that yu never pay mre than yur cst-sharing amunt) applies even if we pay the prvider less than the prvider charges fr a service and even if there is a dispute and we dn t pay certain prvider charges. Fr mre infrmatin abut balance billing, g t Chapter 4, Sectin 1.6. Whenever yu get a bill frm a netwrk prvider that yu think is mre than yu shuld pay, send us the bill. We will cntact the prvider directly and reslve the billing prblem. If yu have already paid a bill t a netwrk prvider, but yu feel that yu paid t much, send us the bill alng with dcumentatin f any payment yu have made and ask us t pay yu back the difference between the amunt yu paid and the amunt yu wed under the plan. 3. If yu are retractively enrlled in ur plan Smetimes a persn s enrllment in the plan is retractive. (Retractive means that the first day f their enrllment has already passed. The enrllment date may even have ccurred last year.) If yu were retractively enrlled in ur plan and yu paid ut-f-pcket fr any f yur cvered services r drugs after yur enrllment date, yu can ask us t pay yu back fr ur share f the csts. Yu will need t submit paperwrk fr us t handle the reimbursement. Please call yur Healthcare Cncierge fr additinal infrmatin abut hw t ask us t pay yu back and deadlines fr making yur request. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) 4. When yu use an ut-f-netwrk pharmacy t get a prescriptin filled If yu g t an ut-f-netwrk pharmacy and try t use yur membership card t fill a prescriptin, the pharmacy may nt be able t submit the claim directly t us. When that happens, yu will have t pay the full cst f yur prescriptin. (We cver prescriptins filled at ut-f-netwrk pharmacies nly in a few special situatins. Please g t Chapter 5, Sectin 2.5 t learn mre.) Save yur receipt and send a cpy t us when yu ask us t pay yu back fr ur share f the cst. 5. When yu pay the full cst fr a prescriptin because yu dn t have yur plan mem- bership card with yu If yu d nt have yur plan membership card with yu, yu can ask the pharmacy t call the plan r t lk up yur plan enrllment infrmatin. Hwever, if the pharmacy cannt get the enrllment infrmatin they need right away, yu may need t pay the full cst f the prescriptin yurself. Save yur receipt and send a cpy t us when yu ask us t pay yu back fr ur share f the cst. 6. When yu pay the full cst fr a prescriptin in ther situatins Yu may pay the full cst f the prescriptin because yu find that the drug is nt cvered fr sme reasn.

130 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 128 Fr example, the drug may nt be n the plan s List f Cvered Drugs (Frmulary); r it culd have a requirement r restrictin that yu didn t knw abut r dn t think shuld apply t yu. If yu decide t get the drug immediately, yu may need t pay the full cst fr it. Save yur receipt and send a cpy t us when yu ask us t pay yu back. In sme situatins, we may need t get mre infrmatin frm yur dctr in rder t pay yu back fr ur share f the cst. All f the examples abve are types f cverage decisins. This means that if we deny yur request fr payment, yu can appeal ur decisin. Chapter 9 f this bklet (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)) has infrmatin abut hw t make an appeal. SECTION 2 Hw t ask us t pay yu back r t pay a bill yu have received Sectin 2.1 Hw and where t send us yur request fr payment Send us yur request fr payment, alng with yur bill and dcumentatin f any payment yu have made. It s a gd idea t make a cpy f yur bill and receipts fr yur recrds. T make sure yu are giving us all the infrmatin we need t make a decisin, yu can fill ut ur claim frm t make yur request fr payment. Yu dn t have t use the frm, but it will help us prcess the infrmatin faster. Either dwnlad a cpy f the frm frm ur website r call yur Healthcare Cncierge and ask fr the frm. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) Yu must submit yur claim t us within 60 days f the date yu received the service, item, r drug. Mail yur request fr payment tgether with any bills r receipts t us at this address: HealthTeam Advantage Attn: Organizatinal Determinatins 7800 McClud Rad, Suite 100 Greensbr, NC Fr Part D Reimbursements: EnvisinRx Optins Attn: DMR Department 2181 East Aurra Rad, Suite 201 Twinsburg, OH Cntact yur Healthcare Cncierge if yu have any questins (phne numbers are printed n the back cver f this bklet). If yu dn t knw what yu shuld have paid, r yu receive bills and yu dn t knw what t d abut thse bills, we can help. Yu can als call if yu want t give us mre infrmatin abut a request fr payment yu have already sent t us.

131 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 129 SECTION 3 We will cnsider yur request fr payment and say yes r n Sectin 3.1 We check t see whether we shuld cver the service r drug and hw much we we When we receive yur request fr payment, we will let yu knw if we need any additinal infrmatin frm yu. Otherwise, we will cnsider yur request and make a cverage decisin. If we decide that the medical care r drug is cvered and yu fllwed all the rules fr getting the care r drug, we will pay fr ur share f the cst. If yu have already paid fr the service r drug, we will mail yur reimbursement f ur share f the cst t yu. If yu have nt paid fr the service r drug yet, we will mail the payment directly t the prvider. (Chapter 3 explains the rules yu need t fllw fr getting yur medical services cvered. Chapter 5 explains the rules yu need t fllw fr getting yur Part D prescriptin drugs cvered.) If we decide that the medical care r drug is nt cvered, r yu did nt fllw all the rules, we will nt pay fr ur share f the cst. Instead, we will send yu a letter that explains the reasns why we are nt sending the payment yu have requested and yur rights t appeal that decisin. Sectin 3.2 If we tell yu that we will nt pay fr all r part f the medical care r drug, yu can make an appeal If yu think we have made a mistake in turning dwn yur request fr payment r yu dn t agree with the amunt we are paying, yu can make an appeal. If yu make an appeal, it means yu are asking us t change the decisin we made when we turned dwn yur request fr payment. Fr the details n hw t make this appeal, g t Chapter 9 f this bklet (What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)). The appeals prcess is a frmal prcess with detailed prcedures and imprtant deadlines. If making an appeal is new t yu, yu will find it helpful t start by reading Sectin 4 f Chapter 9. Sectin 4 is an intrductry sectin that explains the prcess fr cverage decisins and appeals and gives definitins f terms such as appeal. Then after yu have read Sectin 4, yu can g t the sectin in Chapter 9 that tells what t d fr yur situatin: If yu want t make an appeal abut getting paid back fr a medical service, g t Sectin 5.3 in Chapter 9. If yu want t make an appeal abut getting paid back fr a drug, g t Sectin 6.5 f Chapter 9. SECTION 4 Sectin 4.1 Other situatins in which yu shuld save yur receipts and send cpies t us In sme cases, yu shuld send cpies f yur receipts t us t help us track yur ut-f-pcket drug csts There are sme situatins when yu shuld let us knw abut payments yu have made fr yur drugs. In these cases, yu are nt asking us fr payment. Instead, yu are telling us abut yur payments s that we can calculate yur ut-f-pcket csts crrectly. This may help yu t qualify fr the Catastrphic Cver

132 Chapter 7. Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs 130 age Stage mre quickly. Here are tw situatins when yu shuld send us cpies f receipts t let us knw abut payments yu have made fr yur drugs: 1. When yu buy the drug fr a price that is lwer than ur price Smetimes when yu are in the Cverage Gap Stage yu can buy yur drug at a netwrk pharmacy fr a price that is lwer than ur price. Fr example, a pharmacy might ffer a special price n the drug. Or yu may have a discunt card that is utside ur benefit that ffers a lwer price. Unless special cnditins apply, yu must use a netwrk pharmacy in these situatins and yur drug must be n ur Drug List. Save yur receipt and send a cpy t us s that we can have yur ut-f-pcket expenses cunt tward qualifying yu fr the Catastrphic Cverage Stage. Please nte: If yu are in the Cverage Gap Stage, we may nt pay fr any share f these drug csts. But sending a cpy f the receipt allws us t calculate yur ut-f-pcket csts crrectly and may help yu qualify fr the Catastrphic Cverage Stage mre quickly. 2. When yu get a drug thrugh a patient assistance prgram ffered by a drug manufacturer Sme members are enrlled in a patient assistance prgram ffered by a drug manufacturer that is utside the plan benefits. If yu get any drugs thrugh a prgram ffered by a drug manufacturer, yu may pay a cpayment t the patient assistance prgram. Save yur receipt and send a cpy t us s that we can have yur ut-f-pcket expenses cunt tward qualifying yu fr the Catastrphic Cverage Stage. Please nte: Because yu are getting yur drug thrugh the patient assistance prgram and nt thrugh the plan s benefits, we will nt pay fr any share f these drug csts. But sending a cpy f the receipt allws us t calculate yur ut-f-pcket csts crrectly and may help yu qualify fr the Catastrphic Cverage Stage mre quickly. Since yu are nt asking fr payment in the tw cases described abve, these situatins are nt cnsidered cverage decisins. Therefre, yu cannt make an appeal if yu disagree with ur decisin.

133 CHAPTER 8 Yur rights and respnsibilities

134 Chapter 8. Yur rights and respnsibilities 132 Chapter 8. SECTION 1 Sectin 1.1 Sectin 1.2 Sectin 1.3 Sectin 1.4 Sectin 1.5 Sectin 1.6 Sectin 1.7 Sectin 1.8 Sectin 1.9 SECTION 2 Sectin 2.1 Yur rights and respnsibilities Our plan must hnr yur rights as a member f the plan We must prvide infrmatin in a way that wrks fr yu (in languages ther than English, in large print, r ther alternate frmats, etc.) We must treat yu with fairness and respect at all times We must ensure that yu get timely access t yur cvered services and drugs We must prtect the privacy f yur persnal health infrmatin We must give yu infrmatin abut the plan, its netwrk f prviders, and yur cvered services We must supprt yur right t make decisins abut yur care Yu have the right t make cmplaints and t ask us t recnsider decisins we have made What can yu d if yu believe yu are being treated unfairly r yur rights are nt being respected? Hw t get mre infrmatin abut yur rights Yu have sme respnsibilities as a member f the plan What are yur respnsibilities?

135 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 8. Yur rights and respnsibilities 133 SECTION 1 Our plan must hnr yur rights as a member f the plan Sectin 1.1 We must prvide infrmatin in a way that wrks fr yu (in languages ther than English, in large print, r ther alternate frmats, etc.) T get infrmatin frm us in a way that wrks fr yu, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Our plan has peple and free interpreter services available t answer questins frm disabled and nn-en glish speaking members. We can als give yu infrmatin in Braille, in large print r ther alternate frmats at n cst if yu need it. We are required t give yu infrmatin abut the plan s benefits in a frmat that is accessible and apprpriate fr yu. T get infrmatin frm us in a way that wrks fr yu, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) r cntact the Nrth Carlina Office f Administrative Hearings. If yu have any truble getting infrmatin frm ur plan in a frmat that is accessible and apprpriate fr yu, please call t file a grievance with Healthteam Advantage. Yu may als file a cmplaint with Medi care by calling MEDICARE ( ), r directly with the Office fr Civil Rights. Cntact infrmatin is included in this Evidence f Cverage r with this mailing, r yu may cntact yur Health care Cncierge fr additinal infrmatin. Sectin 1.2 We must treat yu with fairness and respect at all times Our plan must bey laws that prtect yu frm discriminatin r unfair treatment. We d nt discriminate based n a persn s race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, health status, claims experience, medical histry, genetic infrmatin, evidence f insurability, r gegraphic lcatin within the service area. If yu want mre infrmatin r have cncerns abut discriminatin r unfair treatment, please call the De partment f Health and Human Services Office fr Civil Rights (TTY ) r yur lcal Office fr Civil Rights. If yu have a disability and need help with access t care, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). If yu have a cmplaint, such as a prblem with wheelchair access, yur Healthcare Cncierge can help. Sectin 1.3 We must ensure that yu get timely access t yur cvered services and drugs Yu have the right t chse a prvider in the plan s netwrk. Call yur Healthcare Cncierge t learn which dctrs are accepting new patients (phne numbers are printed n the back cver f this bklet). Yu als have the right t g t a wmen s health specialist (such as a gyneclgist) withut a referral and still pay the in-netwrk cst-sharing amunt. As a plan member, yu have the right t get appintments and cvered services frm yur prviders within a reasnable amunt f time. This includes the right t get timely services frm specialists when yu need that care. Yu als have the right t get yur prescriptins filled r refilled at any f ur netwrk pharmacies withut lng delays. If yu think that yu are nt getting yur medical care r Part D drugs within a reasnable amunt f time,

136 Chapter 8. Yur rights and respnsibilities 134 Chapter 9, Sectin 10 f this bklet tells what yu can d. (If we have denied cverage fr yur medical care r drugs and yu dn t agree with ur decisin, Chapter 9, Sectin 4 tells what yu can d.) Sectin 1.4 We must prtect the privacy f yur persnal health infrmatin Federal and state laws prtect the privacy f yur medical recrds and persnal health infrmatin. We prtect yur persnal health infrmatin as required by these laws. Yur persnal health infrmatin includes the persnal infrmatin yu gave us when yu enrlled in this plan as well as yur medical recrds and ther medical and health infrmatin. The laws that prtect yur privacy give yu rights related t getting infrmatin and cntrlling hw yur health infrmatin is used. We give yu a written ntice, called a Ntice f Privacy Practice, that tells abut these rights and explains hw we prtect the privacy f yur health infrmatin. Hw d we prtect the privacy f yur health infrmatin? We make sure that unauthrized peple dn t see r change yur recrds. In mst situatins, if we give yur health infrmatin t anyne wh isn t prviding yur care r paying fr yur care, we are required t get written permissin frm yu first. Written permissin can be given by yu r by smene yu have given legal pwer t make decisins fr yu. There are certain exceptins that d nt require us t get yur written permissin first. These exceptins are allwed r required by law. Fr example, we are required t release health infrmatin t gvernment agencies that are checking n quality f care. Because yu are a member f ur plan thrugh Medicare, we are required t give Medicare yur health infrmatin including infrmatin abut yur Part D prescriptin drugs. If Medicare releases yur infrmatin fr research r ther uses, this will be dne accrding t Federal statutes and regulatins. Yu can see the infrmatin in yur recrds and knw hw it has been shared with thers Yu have the right t lk at yur medical recrds held at the plan, and t get a cpy f yur recrds. We are allwed t charge yu a fee fr making cpies. Yu als have the right t ask us t make additins r crrectins t yur medical recrds. If yu ask us t d this, we will wrk with yur health care prvider t decide whether the changes shuld be made. Yu have the right t knw hw yur health infrmatin has been shared with thers fr any purpses that are nt rutine. If yu have questins r cncerns abut the privacy f yur persnal health infrmatin, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can either dwnlad a cpy f the Privacy Practices frm ur website at cm r call yur Healthcare Cncierge and ask fr them, (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.)

137 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 8. Yur rights and respnsibilities 135 Sectin 1.5 We must give yu infrmatin abut the plan, its netwrk f prviders, and yur cvered services As a member f HealthTeam Advantage Plan I, yu have the right t get several kinds f infrmatin frm us. (As explained abve in Sectin 1.1, yu have the right t get infrmatin frm us in a way that wrks fr yu. This includes getting the infrmatin in languages ther than English and in large print r ther alternate frmats.) If yu want any f the fllwing kinds f infrmatin, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet): Infrmatin abut ur plan. This includes, fr example, infrmatin abut the plan s financial cnditin. It als includes infrmatin abut the number f appeals made by members and the plan s perfrmance ratings, including hw it has been rated by plan members and hw it cmpares t ther Medicare health plans. Infrmatin abut ur netwrk prviders including ur netwrk pharmacies. Fr example, yu have the right t get infrmatin frm us abut the qualificatins f the prviders and pharmacies in ur netwrk and hw we pay the prviders in ur netwrk. Fr a list f the pharmacies in the plan s netwrk, see the Prvider/Pharmacy Directry. Fr mre detailed infrmatin abut ur prviders r pharmacies, yu can call yur Health care Cncierge (phne numbers are printed n the back cver f this bklet) r visit ur website at Infrmatin abut yur cverage and the rules yu must fllw when using yur cverage. In Chapters 3 and 4 f this bklet, we explain what medical services are cvered fr yu, any restrictins t yur cverage, and what rules yu must fllw t get yur cvered medical services. T get the details n yur Part D prescriptin drug cverage, see Chapters 5 and 6 f this bklet plus the plan s List f Cvered Drugs (Frmulary). These chapters, tgether with the List f Cvered Drugs (Frmulary), tell yu what drugs are cvered and explain the rules yu must fllw and the restrictins t yur cverage fr certain drugs. If yu have questins abut the rules r restrictins, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Infrmatin abut why smething is nt cvered and what yu can d abut it. If a medical service r Part D drug is nt cvered fr yu, r if yur cverage is restricted in sme way, yu can ask us fr a written explanatin. Yu have the right t this explanatin even if yu received the medical service r drug frm an ut-f-netwrk prvider r pharmacy. If yu are nt happy r if yu disagree with a decisin we make abut what medical care r Part D drug is cvered fr yu, yu have the right t ask us t change the decisin. Yu

138 Chapter 8. Yur rights and respnsibilities 136 can ask us t change the decisin by making an appeal. Fr details n what t d if smething is nt cvered fr yu in the way yu think it shuld be cvered, see Chapter 9 f this bklet. It gives yu the details abut hw t make an appeal if yu want us t change ur decisin. (Chapter 9 als tells abut hw t make a cmplaint abut quality f care, waiting times, and ther cncerns.) If yu want t ask ur plan t pay ur share f a bill yu have received fr medical care r a Part D prescriptin drug, see Chapter 7 f this bklet. Sectin 1.6 We must supprt yur right t make decisins abut yur care Yu have the right t knw yur treatment ptins and participate in decisins abut yur health care Yu have the right t get full infrmatin frm yur dctrs and ther health care prviders when yu g fr medical care. Yur prviders must explain yur medical cnditin and yur treatment chices in a way that yu can understand. Yu als have the right t participate fully in decisins abut yur health care. T help yu make decisins with yur dctrs abut what treatment is best fr yu, yur rights include the fllwing: T knw abut all f yur chices. This means that yu have the right t be tld abut all f the treatment ptins that are recmmended fr yur cnditin, n matter what they cst r whether they are cvered by ur plan. It als includes being tld abut prgrams ur plan ffers t help members manage their medicatins and use drugs safely. T knw abut the risks. Yu have the right t be tld abut any risks invlved in yur care. Yu must be tld in advance if any prpsed medical care r treatment is part f a research experiment. Yu always have the chice t refuse any experimental treatments. The right t say n. Yu have the right t refuse any recmmended treatment. This includes the right t leave a hspital r ther medical facility, even if yur dctr advises yu nt t leave. Yu als have the right t stp taking yur medicatin. Of curse, if yu refuse treatment r stp taking medicatin, yu accept full respnsibility fr what happens t yur bdy as a result. T receive an explanatin if yu are denied cverage fr care. Yu have the right t receive an explanatin frm us if a prvider has denied care that yu believe yu shuld receive. T receive this explanatin, yu will need t ask us fr a cverage decisin. Chapter 9 f this bklet tells hw t ask the plan fr a cverage decisin. Yu have the right t give instructins abut what is t be dne if yu are nt able t make medical decisins fr yurself Smetimes peple becme unable t make health care decisins fr themselves due t accidents r serius illness. Yu have the right t say what yu want t happen if yu are in this situatin. This means that, if yu want t, yu can: Fill ut a written frm t give smene the legal authrity t make medical decisins fr yu if yu ever becme unable t make decisins fr yurself.

139 Chapter 8. Yur rights and respnsibilities 137 Give yur dctrs written instructins abut hw yu want them t handle yur medical care if yu becme unable t make decisins fr yurself. The legal dcuments that yu can use t give yur directins in advance in these situatins are called advance directives. There are different types f advance directives and different names fr them. Dcuments called living will and pwer f attrney fr health care are examples f advance directives. If yu want t use an advance directive t give yur instructins, here is what t d: Get the frm. If yu want t have an advance directive, yu can get a frm frm yur lawyer, frm a scial wrker, r frm sme ffice supply stres. Yu can smetimes get advance directive frms frm rganizatins that give peple infrmatin abut Medicare. Yu can als cntact yur Healthcare Cncierge t ask fr the frms (phne numbers are printed n the back cver f this bklet). Fill it ut and sign it. Regardless f where yu get this frm, keep in mind that it is a legal dcument. Yu shuld cnsider having a lawyer help yu prepare it. Give cpies t apprpriate peple. Yu shuld give a cpy f the frm t yur dctr and t the persn yu name n the frm as the ne t make decisins fr yu if yu can t. Yu may want t give cpies t clse friends r family members as well. Be sure t keep a cpy at hme. If yu knw ahead f time that yu are ging t be hspitalized, and yu have signed an advance directive, take a cpy with yu t the hspital. If yu are admitted t the hspital, they will ask yu whether yu have signed an advance directive frm and whether yu have it with yu. If yu have nt signed an advance directive frm, the hspital has frms available and will ask if yu want t sign ne. Remember, it is yur chice whether yu want t fill ut an advance directive (including whether yu want t sign ne if yu are in the hspital). Accrding t law, n ne can deny yu care r discriminate against yu based n whether r nt yu have signed an advance directive. What if yur instructins are nt fllwed? If yu have signed an advance directive, and yu believe that a dctr r hspital did nt fllw the in structins in it, yu may file a cmplaint with; Nrth Carlina Department f Aging and Adult Services Cnsumer Rights and Services - Cmplaint Intake Unit 2101 Mail Service Center Raleigh, NC

140 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 8. Yur rights and respnsibilities 138 Sectin 1.7 Yu have the right t make cmplaints and t ask us t recnsider decisins we have made If yu have any prblems r cncerns abut yur cvered services r care, Chapter 9 f this bklet tells what yu can d. It gives the details abut hw t deal with all types f prblems and cmplaints. What yu need t d t fllw up n a prblem r cncern depends n the situatin. Yu might need t ask ur plan t make a cverage decisin fr yu, make an appeal t us t change a cverage decisin, r make a cmplaint. Whatever yu d ask fr a cverage decisin, make an appeal, r make a cmplaint we are required t treat yu fairly. Yu have the right t get a summary f infrmatin abut the appeals and cmplaints that ther mem bers have filed against ur plan in the past. T get this infrmatin, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Sectin 1.8 What can yu d if yu believe yu are being treated unfairly r yur rights are nt being respected? If it is abut discriminatin, call the Office fr Civil Rights If yu believe yu have been treated unfairly r yur rights have nt been respected due t yur race, dis ability, religin, sex, health, ethnicity, creed (beliefs), age, r natinal rigin, yu shuld call the Depart ment f Health and Human Services Office fr Civil Rights at r TTY , r call yur lcal Office fr Civil Rights. Is it abut smething else? If yu believe yu have been treated unfairly r yur rights have nt been respected, and it s nt abut discriminatin, yu can get help dealing with the prblem yu are having: Yu can call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can call the State Health Insurance Assistance Prgram. Fr details abut this rganizatin and hw t cntact it, g t Chapter 2, Sectin 3. Or, yu can call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Sectin 1.9 Hw t get mre infrmatin abut yur rights There are several places where yu can get mre infrmatin abut yur rights: Yu can call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can call the State Health Insurance Assistance Prgram. Fr details abut this rganizatin and hw t cntact it, g t Chapter 2, Sectin 3. Yu can cntact Medicare.

141 Chapter 8. Yur rights and respnsibilities 139 Yu can visit the Medicare website t read r dwnlad the publicatin Yur Medicare Rights & Prtectins. (The publicatin is available at: pdf/11534.pdf.) Or, yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 2 Yu have sme respnsibilities as a member f the plan Sectin 2.1 What are yur respnsibilities? Things yu need t d as a member f the plan are listed belw. If yu have any questins, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). We re here t help. Get familiar with yur cvered services and the rules yu must fllw t get these cvered services. Use this Evidence f Cverage bklet t learn what is cvered fr yu and the rules yu need t fllw t get yur cvered services. Chapters 3 and 4 give the details abut yur medical services, including what is cvered, what is nt cvered, rules t fllw, and what yu pay. Chapters 5 and 6 give the details abut yur cverage fr Part D prescriptin drugs. If yu have any ther health insurance cverage r prescriptin drug cverage in additin t ur plan, yu are required t tell us. Please call yur Healthcare Cncierge t let us knw (phne numbers are printed n the back cver f this bklet). We are required t fllw rules set by Medicare t make sure that yu are using all f yur cverage in cmbinatin when yu get yur cvered services frm ur plan. This is called crdinatin f benefits because it invlves crdinating the health and drug benefits yu get frm ur plan with any ther health and drug benefits available t yu. We ll help yu crdinate yur benefits. (Fr mre infrmatin abut crdinatin f benefits, g t Chapter 1, Sectin 10.) Tell yur dctr and ther health care prviders that yu are enrlled in ur plan. Shw yur plan membership card whenever yu get yur medical care r Part D prescriptin drugs. Help yur dctrs and ther prviders help yu by giving them infrmatin, asking ques- tins, and fllwing thrugh n yur care. T help yur dctrs and ther health prviders give yu the best care, learn as much as yu are able t abut yur health prblems and give them the infrmatin they need abut yu and yur health. Fllw the treatment plans and instructins that yu and yur dctrs agree upn. Make sure yur dctrs knw all f the drugs yu are taking, including ver-the-cunter drugs, vitamins, and supplements.

142 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 8. Yur rights and respnsibilities 140 If yu have any questins, be sure t ask. Yur dctrs and ther health care prviders are suppsed t explain things in a way yu can understand. If yu ask a questin and yu dn t understand the answer yu are given, ask again. Be cnsiderate. We expect all ur members t respect the rights f ther patients. We als expect yu t act in a way that helps the smth running f yur dctr s ffice, hspitals, and ther ffices. Pay what yu we. As a plan member, yu are respnsible fr these payments: Yu must pay yur plan premiums t cntinue being a member f ur plan. In rder t be eligible fr ur plan, yu must have Medicare Part A and Medicare Part B. Fr that reasn, sme plan members must pay a premium fr Medicare Part A and mst plan members must pay a premium fr Medicare Part B t remain a member f the plan. Fr mst f yur medical services r drugs cvered by the plan, yu must pay yur share f the cst when yu get the service r drug. This will be a cpayment (a fixed amunt) OR cinsurance (a percentage f the ttal cst). Chapter 4 tells what yu must pay fr yur medical services. Chapter 6 tells what yu must pay fr yur Part D prescriptin drugs. If yu get any medical services r drugs that are nt cvered by ur plan r by ther insurance yu may have, yu must pay the full cst. If yu disagree with ur decisin t deny cverage fr a service r drug, yu can make an appeal. Please see Chapter 9 f this bklet fr infrmatin abut hw t make an appeal. If yu are required t pay a late enrllment penalty, yu must pay the penalty t keep yur prescriptin drug cverage. If yu are required t pay the extra amunt fr Part D because f yur yearly incme, yu must pay the extra amunt directly t the gvernment t remain a member f the plan. Tell us if yu mve. If yu are ging t mve, it s imprtant t tell us right away. Call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). If yu mve utside f ur plan service area, yu cannt remain a member f ur plan. (Chapter 1 tells abut ur service area.) We can help yu figure ut whether yu are mving utside ur service area. If yu are leaving ur service area, yu will have a Special Enrll ment Perid when yu can jin any Medicare plan available in yur new area. We can let yu knw if we have a plan in yur new area. If yu mve within ur service area, we still need t knw s we can keep yur membership recrd up t date and knw hw t cntact yu. If yu mve, it is als imprtant t tell Scial Security (r the Railrad Retirement Bard). Yu can find phne numbers and cntact infrmatin fr these rganizatins in Chapter 2. Call yur Healthcare Cncierge fr help if yu have questins r cncerns. We als welcme

143 Chapter 8. Yur rights and respnsibilities 141 any suggestins yu may have fr imprving ur plan. Phne numbers and calling hurs fr yur Healthcare Cncierge are printed n the back cver f this bklet. Fr mre infrmatin n hw t reach us, including ur mailing address, please see Chapter 2.

144 CHAPTER 9 What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints)

145 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 143 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) BACKGROUND SECTION 1 Sectin 1.1 Sectin 1.2 SECTION 2 Sectin 2.1 SECTION 3 Sectin 3.1 Intrductin What t d if yu have a prblem r cncern What abut the legal terms? Yu can get help frm gvernment rganizatins that are nt cnnected with us Where t get mre infrmatin and persnalized assistance T deal with yur prblem, which prcess shuld yu use? Shuld yu use the prcess fr cverage decisins and appeals? Or shuld yu use the prcess fr making cmplaints? COVERAGE DECISIONS AND APPEALS SECTION 4 Sectin 4.1 Sectin 4.2 Sectin 4.3 SECTION 5 Sectin 5.1 Sectin 5.2 Sectin 5.3 Sectin 5.4 Sectin 5.5 A guide t the basics f cverage decisins and appeals Asking fr cverage decisins and making appeals: the big picture Hw t get help when yu are asking fr a cverage decisin r making an appeal Which sectin f this chapter gives the details fr yur situatin? Yur medical care: Hw t ask fr a cverage decisin r make an appeal This sectin tells what t d if yu have prblems getting cverage fr medical care r if yu want us t pay yu back fr ur share f the cst f yur care Step-by-step: Hw t ask fr a cverage decisin (hw t ask ur plan t authrize r prvide the medical care cverage yu want) Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a medical care cverage decisin made by ur plan) Step-by-step: Hw a Level 2 Appeal is dne What if yu are asking us t pay yu fr ur share f a bill yu have received fr medical care?

146 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 144 SECTION 6 Sectin 6.1 Sectin 6.2 Sectin 6.3 Sectin 6.4 Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal This sectin tells yu what t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug What is an exceptin? Imprtant things t knw abut asking fr exceptins Step-by-step: Hw t ask fr a cverage decisin, including an exceptin Sectin 6.5 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a cverage decisin made by ur plan) Sectin 6.6 SECTION 7 Step-by-step: Hw t make a Level 2 Appeal Hw t ask us t cver a lnger inpatient hspital stay if yu think the dctr is discharging yu t sn Sectin 7.1 During yur inpatient hspital stay, yu will get a written ntice frm Medicare that tells abut yur rights Sectin 7.2 Step-by-step: Hw t make a Level 1 Appeal t change yur hspital discharge date Sectin 7.3 Step-by-step: Hw t make a Level 2 Appeal t change yur hspital discharge date Sectin 7.4 SECTION 8 Sectin 8.1 Sectin 8.2 What if yu miss the deadline fr making yur Level 1 Appeal? Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn This sectin is abut three services nly: Hme Health care, Skilled Nursing Facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services We will tell yu in advance when yur cverage will be ending Sectin 8.3 Step-by-step: Hw t make a Level 1 Appeal t have ur plan cver yur care fr a lnger time Sectin 8.4 Step-by-step: Hw t make a Level 2 Appeal t have ur plan cver yur care fr a lnger time Sectin 8.5 What if yu miss the deadline fr making yur Level 1 Appeal? SECTION 9 Sectin 9.1 Sectin 9.2 Taking yur appeal t Level 3 and beynd Levels f Appeal 3, 4, and 5 fr Medical Service Appeals Levels f Appeal 3, 4, and 5 fr Part D Drug Appeals

147 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 145 MAKING COMPLAINTS SECTION 10 Sectin 10.1 Sectin 10.2 Sectin 10.3 Sectin 10.4 Sectin 10.5 Hw t make a cmplaint abut quality f care, waiting times, custmer service, r ther cncerns What kinds f prblems are handled by the cmplaint prcess? The frmal name fr making a cmplaint is filing a grievance Step-by-step: Making a cmplaint Yu can als make cmplaints abut quality f care t the Quality Imprvement Organizatin Yu can als tell Medicare abut yur cmplaint

148 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 146 BACKGROUND SECTION 1 Intrductin Sectin 1.1 What t d if yu have a prblem r cncern This chapter explains tw types f prcesses fr handling prblems and cncerns: Fr sme types f prblems, yu need t use the prcess fr cverage decisins and appeals. Fr ther types f prblems, yu need t use the prcess fr making cmplaints. Bth f these prcesses have been apprved by Medicare. T ensure fairness and prmpt handling f yur prblems, each prcess has a set f rules, prcedures, and deadlines that must be fllwed by us and by yu. Which ne d yu use? That depends n the type f prblem yu are having. The guide in Sectin 3 will help yu identify the right prcess t use. Sectin 1.2 What abut the legal terms? There are technical legal terms fr sme f the rules, prcedures, and types f deadlines explained in this chapter. Many f these terms are unfamiliar t mst peple and can be hard t understand. T keep things simple, this chapter explains the legal rules and prcedures using simpler wrds in place f certain legal terms. Fr example, this chapter generally says making a cmplaint rather than filing a grievance, cverage decisin rather than rganizatin determinatin r cverage determinatin, and Independent Review Organizatin instead f Independent Review Entity. It als uses abbrevia tins as little as pssible. Hwever, it can be helpful and smetimes quite imprtant fr yu t knw the crrect legal terms fr the situatin yu are in. Knwing which terms t use will help yu cmmunicate mre clearly and accu rately when yu are dealing with yur prblem and get the right help r infrmatin fr yur situatin. T help yu knw which terms t use, we include legal terms when we give the details fr handling specific types f situatins. SECTION 2 Yu can get help frm gvernment rganizatins that are nt cnnected with us Sectin 2.1 Where t get mre infrmatin and persnalized assistance Smetimes it can be cnfusing t start r fllw thrugh the prcess fr dealing with a prblem. This can be especially true if yu d nt feel well r have limited energy. Other times, yu may nt have the knwledge yu need t take the next step. Get help frm an independent gvernment rganizatin We are always available t help yu. But in sme situatins yu may als want help r guidance frm smene wh is nt cnnected with us. Yu can always cntact yur State Health Insurance Assistance

149 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 147 Prgram (SHIP). This gvernment prgram has trained cunselrs in every state. The prgram is nt cnnected with us r with any insurance cmpany r health plan. The cunselrs at this prgram can help yu understand which prcess yu shuld use t handle a prblem yu are having. They can als answer yur questins, give yu mre infrmatin, and ffer guidance n what t d. The services f SHIP cunselrs are free. Yu will find phne numbers in Chapter 2, Sectin 3 f this bklet. Yu can als get help and infrmatin frm Medicare Fr mre infrmatin and help in handling a prblem, yu can als cntact Medicare. Here are tw ways t get infrmatin directly frm Medicare: Yu can call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can visit the Medicare website ( SECTION 3 T deal with yur prblem, which prcess shuld yu use? Sectin 3.1 Shuld yu use the prcess fr cverage decisins and appeals? Or shuld yu use the prcess fr making cmplaints? If yu have a prblem r cncern, yu nly need t read the parts f this chapter that apply t yur situatin. The guide that fllws will help. T figure ut which part f this chapter will help with yur specific prblem r cncern, START HERE Is yur prblem r cncern abut yur benefits r cverage? (This includes prblems abut whether particular medical care r prescriptin drugs are cvered r nt, the way in which they are cvered, and prblems related t payment fr medical care r prescriptin drugs.) Yes. My prblem is abut benefits r cverage. G n t the next sectin f this chapter, Sectin 4, A guide t the basics f cverage decisins and appeals. N. My prblem is nt abut benefits r cverage. Skip ahead t Sectin 10 at the end f this chapter: Hw t make a cmplaint abut quality f care, waiting times, custmer service r ther cncerns.

150 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 148 COVERAGE DECISIONS AND APPEALS SECTION 4 A guide t the basics f cverage decisins and appeals Sectin 4.1 Asking fr cverage decisins and making appeals: the big picture The prcess fr cverage decisins and appeals deals with prblems related t yur benefits and cverage fr medical services and prescriptin drugs, including prblems related t payment. This is the prcess yu use fr issues such as whether smething is cvered r nt and the way in which smething is cv ered. Asking fr cverage decisins A cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur medical services r drugs. Fr example, yur plan netwrk dctr makes a (favrable) cver age decisin fr yu whenever yu receive medical care frm him r her r if yur netwrk dctr refers yu t a medical specialist. Yu r yur dctr can als cntact us and ask fr a cverage decisin if yur dctr is unsure whether we will cver a particular medical service r refuses t prvide medical care yu think that yu need. In ther wrds, if yu want t knw if we will cver a medical service befre yu receive it, yu can ask us t make a cverage decisin fr yu. We are making a cverage decisin fr yu whenever we decide what is cvered fr yu and hw much we pay. In sme cases we might decide a service r drug is nt cvered r is n lnger cvered by Medicare fr yu. If yu disagree with this cverage decisin, yu can make an appeal. Making an appeal If we make a cverage decisin and yu are nt satisfied with this decisin, yu can appeal the decisin. An appeal is a frmal way f asking us t review and change a cverage decisin we have made. When yu appeal a decisin fr the first time, this is called a Level 1 Appeal. In this appeal, we review the cverage decisin we made t check t see if we were fllwing all f the rules prperly. Yur appeal is handled by different reviewers than thse wh made the riginal unfavrable decisin. When we have cmpleted the review, we give yu ur decisin. Under certain circumstances, which we discuss later, yu can request an expedited r fast cverage decisin r fast appeal f a cverage decisin. If we say n t all r part f yur Level 1 Appeal, yu can g n t a Level 2 Appeal. The Level 2 Appeal is cnducted by an independent rganizatin that is nt cnnected t us. (In sme situatins, yur case will be autmatically sent t the independent rganizatin fr a Level 2 Appeal. If this happens, we will let yu knw. In ther situatins, yu will need t ask fr a Level 2 Appeal.) If yu are nt satisfied with the decisin at the Level 2 Appeal, yu may be able t cntinue thrugh additinal levels f appeal. Sectin 4.2 Hw t get help when yu are asking fr a cverage decisin r making an appeal Wuld yu like sme help? Here are resurces yu may wish t use if yu decide t ask fr any kind f cverage decisin r appeal a decisin:

151 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 149 Yu can call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). T get free help frm an independent rganizatin that is nt cnnected with ur plan, cntact yur State Health Insurance Assistance Prgram (see Sectin 2 f this chapter). Yur dctr can make a request fr yu. Fr medical care, yur dctr can request a cverage decisin r a Level 1 Appeal n yur behalf. If yur appeal is denied at Level 1, it will be autmatically frwarded t Level 2. T request any appeal after Level 2, yur dctr must be appinted as yur representative. Fr Part D prescriptin drugs, yur dctr r ther prescriber can request a cverage decisin r a Level 1 r Level 2 Appeal n yur behalf. T request any appeal after Level 2, yur dctr r ther prescriber must be appinted as yur representative. Yu can ask smene t act n yur behalf. If yu want t, yu can name anther persn t act fr yu as yur representative t ask fr a cverage decisin r make an appeal. There may be smene wh is already legally authrized t act as yur representative under State law. If yu want a friend, relative, yur dctr r ther prvider, r ther persn t be yur rep resentative, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) and ask fr the Appintment f Representative frm. (The frm is als avail able n Medicare s website at r n ur website at The frm gives that persn permis sin t act n yur behalf. It must be signed by yu and by the persn wh yu wuld like t act n yur behalf. Yu must give us a cpy f the signed frm. Yu als have the right t hire a lawyer t act fr yu. Yu may cntact yur wn lawyer, r get the name f a lawyer frm yur lcal bar assciatin r ther referral service. There are als grups that will give yu free legal services if yu qualify. Hwever, yu are nt required t hire a lawyer t ask fr any kind f cverage decisin r appeal a decisin. Sectin 4.3 Which sectin f this chapter gives the details fr yur situatin? There are fur different types f situatins that invlve cverage decisins and appeals. Since each situatin has different rules and deadlines, we give the details fr each ne in a separate sectin: Sectin 5 f this chapter: Yur medical care: Hw t ask fr a cverage decisin r make an appeal Sectin 6 f this chapter: Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal Sectin 7 f this chapter: Hw t ask us t cver a lnger inpatient hspital stay if yu think the dctr is discharging yu t sn

152 questin mark Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 150 Sectin 8 f this chapter: Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn (Applies t these services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services) If yu re nt sure which sectin yu shuld be using, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can als get help r infrmatin frm gvernment rganizatins such as yur State Health Insurance Assistance Prgram (Chapter 2, Sectin 3, f this bklet has the phne numbers fr this prgram). SECTION 5 Yur medical care: Hw t ask fr a cverage decisin r make an appeal Have yu read Sectin 4 f this chapter (A guide t the basics f cverage decisins and appeals)? If nt, yu may want t read it befre yu start this sectin. Sectin 5.1 This sectin tells what t d if yu have prblems getting cverage fr medical care r if yu want us t pay yu back fr ur share f the cst f yur care This sectin is abut yur benefits fr medical care and services. These benefits are described in Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). T keep things simple, we generally refer t medical care cverage r medical care in the rest f this sectin, instead f repeating medical care r treatment r services every time. This sectin tells what yu can d if yu are in any f the five fllwing situatins: 1. Yu are nt getting certain medical care yu want, and yu believe that this care is cvered by ur plan. 2. Our plan will nt apprve the medical care yur dctr r ther medical prvider wants t give yu, and yu believe that this care is cvered by the plan. 3. Yu have received medical care r services that yu believe shuld be cvered by the plan, but we have said we will nt pay fr this care. 4. Yu have received and paid fr medical care r services that yu believe shuld be cvered by the plan, and yu want t ask ur plan t reimburse yu fr this care. 5. Yu are being tld that cverage fr certain medical care yu have been getting that we previusly apprved will be reduced r stpped, and yu believe that reducing r stpping this care culd harm yur health. NOTE: If the cverage that will be stpped is fr hspital care, hme health care, skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services, yu need t read a separate sectin f this chapter because special rules apply t these types f care. Here s what t read in thse situatins:

153 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 151 Chapter 9, Sectin 7: Hw t ask us t cver a lnger inpatient hspital stay if yu think the dctr is discharging yu t sn. Chapter 9, Sectin 8: Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn. This sectin is abut three services nly: hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services. Fr all ther situatins that invlve being tld that medical care yu have been getting will be stpped, use this sectin (Sectin 5) as yur guide fr what t d. Which f these situatins are yu in? If yu are in this situatin: D yu want t find ut whether we will cver the medical care r services yu want? Have we already tld yu that we will nt cver r pay fr a medical service in the way that yu want it t be cvered r paid fr? D yu want t ask us t pay yu back fr medical care r services yu have already received and paid fr? This is what yu can d: Yu can ask us t make a cverage decisin fr yu. G t the next sectin f this chapter, Sectin 5.2. Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 5.3 f this chapter. Yu can send us the bill. Skip ahead t Sectin 5.5 f this chapter. Sectin 5.2 Step-by-step: Hw t ask fr a cverage decisin (hw t ask ur plan t authrize r prvide the medical care cverage yu want) Legal Terms When a cverage decisin invlves yur medical care, it is called an rganizatin determinatin. Step 1: Yu ask ur plan t make a cverage decisin n the medical care yu are requesting. If yur health requires a quick respnse, yu shuld ask us t make a fast cverage decisin. Legal Terms A fast cverage decisin is called an expedited determinatin.

154 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 152 Hw t request cverage fr the medical care yu want Start by calling, writing, r faxing ur plan t make yur request fr us t authrize r prvide cverage fr the medical care yu want. Yu, yur dctr, r yur representative can d this. Fr the details n hw t cntact us, g t Chapter 2, Sectin 1 and lk fr the sectin called, Hw t cntact us when yu are asking fr a cverage decisin abut yur medical care. Generally we use the standard deadlines fr giving yu ur decisin When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard cverage decisin means we will give yu an answer within 14 calendar days after we receive yur request. Hwever, we can take up t 14 mre calendar days if yu ask fr mre time, r if we need infrmatin (such as medical recrds frm ut-f-netwrk prviders) that may benefit yu. If we decide t take extra days t make the decisin, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur deci sin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (The prcess fr making a cmplaint is different frm the prcess fr cverage decisins and appeals. Fr mre infrmatin abut the prcess fr making cm plaints, including fast cmplaints, see Sectin 10 f this chapter.) If yur health requires it, ask us t give yu a fast cverage decisin A fast cverage decisin means we will answer within 72 hurs. Hwever, we can take up t 14 mre calendar days if we find that sme infrmatin that may benefit yu is missing (such as medical recrds frm ut-f-netwrk prviders), r if yu need time t get infrmatin t us fr the review. If we decide t take extra days, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) We will call yu as sn as we make the decisin. T get a fast cverage decisin, yu must meet tw requirements: Yu can get a fast cverage decisin nly if yu are asking fr cverage fr medical care yu have nt yet received. (Yu cannt get a fast cverage decisin if yur request is abut payment fr medical care yu have already received.) Yu can get a fast cverage decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin.

155 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 153 If yur dctr tells us that yur health requires a fast cverage decisin, we will autmatically agree t give yu a fast cverage decisin. If yu ask fr a fast cverage decisin n yur wn, withut yur dctr s supprt, we will decide whether yur health requires that we give yu a fast cverage decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast cverage decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr asks fr the fast cverage decisin, we will autmatically give a fast cverage decisin. The letter will als tell hw yu can file a fast cmplaint abut ur decisin t give yu a standard cverage decisin instead f the fast cverage decisin yu requested. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) Step 2: We cnsider yur request fr medical care cverage and give yu ur answer. Deadlines fr a fast cverage decisin Generally, fr a fast cverage decisin, we will give yu ur answer within 72 hurs. As explained abve, we can take up t 14 mre calendar days under certain circumstances. If we decide t take extra days t make the cverage decisin, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter. If we d nt give yu ur answer within 72 hurs (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the medical care cverage we have agreed t prvide within 72 hurs after we received yur request. If we extended the time needed t make ur cverage decisin, we will authrize r prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a detailed written explanatin as t why we said n. Deadlines fr a standard cverage decisin Generally, fr a standard cverage decisin, we will give yu ur answer within 14 calendar days f receiving yur request.

156 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 154 We can take up t 14 mre calendar days ( an extended time perid ) under certain circumstances. If we decide t take extra days t make the cverage decisin, we will tell yu in writing. If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) If we d nt give yu ur answer within 14 calendar days (r if there is an extended time perid, by the end f that perid), yu have the right t appeal. Sectin 5.3 belw tells hw t make an appeal. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 14 calendar days after we received yur request. If we extended the time needed t make ur cverage decisin, we will authrize r prvide the cverage by the end f that extended perid. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. Step 3: If we say n t yur request fr cverage fr medical care, yu decide if yu want t make an appeal. If we say n, yu have the right t ask us t recnsider and perhaps change this decisin by making an appeal. Making an appeal means making anther try t get the medical care cverage yu want. If yu decide t make an appeal, it means yu are ging n t Level 1 f the appeals prcess (see Sectin 5.3 belw). Sectin 5.3 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a medical care cverage decisin made by ur plan) Legal Terms An appeal t the plan abut a medical care cverage decisin is called a plan recnsideratin. Step 1: Yu cntact us and make yur appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal.

157 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 155 What t d T start an appeal, yu, yur dctr, r yur representative, must cntact us. Fr details n hw t reach us fr any purpse related t yur appeal, g t Chapter 2, Sectin 1 and lk fr sectin called, Hw t cntact us when yu are making an appeal abut yur medical care. If yu are asking fr a standard appeal, make yur standard appeal in writing by submitting a request. If yu have smene appealing ur decisin fr yu ther than yur dctr, yur appeal must include an Appintment f Representative frm authrizing this persn t represent yu. (T get the frm, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) and ask fr the Appintment f Representa tive frm. It is als available n Medicare s website at frms/dwnlads/cms1696.pdf r n ur website at While we can accept an appeal request withut the frm, we cannt begin r cmplete ur review until we receive it. If we d nt receive the frm within 44 calendar days after receiving yur appeal request (ur deadline fr making a decisin n yur ap peal), yur appeal request will be dismissed. If this happens, we will send yu a written ntice explaining yur right t ask the Independent Review Organizatin t review ur decisin t dismiss yur appeal. If yu are asking fr a fast appeal, make yur appeal in writing r call us at the phne number shwn in Chapter 2, Sectin 1 (Hw t cntact us when yu are making an appeal abut yur medical care). Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Examples f gd cause fr missing the deadline may include if yu had a serius illness that prevented yu frm cntacting us r if we prvided yu with incrrect r incmplete infrmatin abut the deadline fr requesting an appeal. Yu can ask fr a cpy f the infrmatin regarding yur medical decisin and add mre infrmatin t supprt yur appeal. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. If yu wish, yu and yur dctr may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal (yu can make a request by calling us) Legal Terms A fast appeal is als called an expedited recnsideratin.

158 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 156 If yu are appealing a decisin we made abut cverage fr care yu have nt yet received, yu and/r yur dctr will need t decide if yu need a fast appeal. The requirements and prcedures fr getting a fast appeal are the same as thse fr getting a fast cverage decisin. T ask fr a fast appeal, fllw the instructins fr asking fr a fast cverage decisin. (These instructins are given earlier in this sectin.) If yur dctr tells us that yur health requires a fast appeal, we will give yu a fast appeal. Step 2: We cnsider yur appeal and we give yu ur answer. When ur plan is reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur request fr cverage f medical care. We check t see if we were fllwing all the rules when we said n t yur request. We will gather mre infrmatin if we need it. We may cntact yu r yur dctr t get mre infrmatin. Deadlines fr a fast appeal When we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires us t d s. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we decide t take extra days t make the decisin, we will tell yu in writing. If we d nt give yu an answer within 72 hurs (r by the end f the extended time perid if we tk extra days), we are required t autmatically send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we tell yu abut this rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 30 calendar days after we receive yur appeal if yur appeal is abut cverage fr services yu have nt yet received. We will give yu ur decisin sner if yur health cnditin requires us t. Hwever, if yu ask fr mre time, r if we need t gather mre infrmatin that may benefit yu, we can take up t 14 mre calendar days. If we decide t take extra days t make the decisin, we will tell yu in writing.

159 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 157 If yu believe we shuld nt take extra days, yu can file a fast cmplaint abut ur decisin t take extra days. When yu file a fast cmplaint, we will give yu an answer t yur cmplaint within 24 hurs. (Fr mre infrmatin abut the prcess fr making cmplaints, including fast cmplaints, see Sectin 10 f this chapter.) If we d nt give yu an answer by the deadline abve (r by the end f the extended time perid if we tk extra days), we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this sectin, we talk abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must authrize r prvide the cverage we have agreed t prvide within 30 calendar days after we receive yur appeal. If ur answer is n t part r all f what yu requested, we will send yu a written denial ntice infrming yu that we have autmatically sent yur appeal t the Independent Review Organizatin fr a Level 2 Appeal. Step 3: If ur plan says n t part r all f yur appeal, yur case will autmatically be sent n t the next level f the appeals prcess. Sectin 5.4 T make sure we were fllwing all the rules when we said n t yur appeal, we are required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yur appeal is ging n t the next level f the appeals prcess, which is Level 2. Step-by-step: Hw a Level 2 Appeal is dne If we say n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the ap peals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews ur decisin fr yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: The Independent Review Organizatin reviews yur appeal. The Independent Review Organizatin is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with us and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Re view Organizatin. Medicare versees its wrk. We will send the infrmatin abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file.

160 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 158 Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. If yu had a fast appeal at Level 1, yu will als have a fast appeal at Level 2 If yu had a fast appeal t ur plan at Level 1, yu will autmatically receive a fast appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. If yu had a standard appeal at Level 1, yu will als have a standard appeal at Level 2 If yu had a standard appeal t ur plan at Level 1, yu will autmatically receive a standard appeal at Level 2. The review rganizatin must give yu an answer t yur Level 2 Appeal within 30 calendar days f when it receives yur appeal. Hwever, if the Independent Review Organizatin needs t gather mre infrmatin that may benefit yu, it can take up t 14 mre calendar days. Step 2: The Independent Review Organizatin gives yu their answer. The Independent Review Organizatin will tell yu its decisin in writing and explain the reasns fr it. If the review rganizatin says yes t part r all f what yu requested, we must authrize the medical care cverage within 72 hurs r prvide the service within 14 calendar days after we receive the decisin frm the review rganizatinfr standard requests r within 72 hurs frm the date the plan receives the decisin frm the review rganizatin fr expedited requests. If this rganizatin says n t part r all f yur appeal, it means they agree with us that yur request (r part f yur request) fr cverage fr medical care shuld nt be apprved. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) If the Independent Review Organizatin uphlds the decisin yu have the right t a Level 3 Appeal. Hwever, t make anther appeal at Level 3, the dllar value f the med ical care cverage yu are requesting must meet a certain minimum. If the dllar value f the cverage yu are requesting is t lw, yu cannt make anther appeal, which means that the decisin at Level 2 is final. The written ntice yu get frm the Independent Review Organizatin will tell yu hw t find ut the dllar amunt t cntinue the appeals prcess. Step 3: If yur case meets the requirements, yu chse whether yu want t take yur

161 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 159 appeal further. Sectin 5.5 There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. The details n hw t d this are in the written ntice yu gt after yur Level 2 Appeal. The Level 3 Appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. What if yu are asking us t pay yu fr ur share f a bill yu have received fr medical care? If yu want t ask us fr payment fr medical care, start by reading Chapter 7 f this bklet: Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs. Chapter 7 describes the situatins in which yu may need t ask fr reimbursement r t pay a bill yu have received frm a prvider. It als tells hw t send us the paperwrk that asks us fr payment. Asking fr reimbursement is asking fr a cverage decisin frm us If yu send us the paperwrk that asks fr reimbursement, yu are asking us t make a cverage decisin (fr mre infrmatin abut cverage decisins, see Sectin 4.1 f this chapter). T make this cverage decisin, we will check t see if the medical care yu paid fr is a cvered service (see Chapter 4: Medical Benefits Chart (what is cvered and what yu pay)). We will als check t see if yu fllwed all the rules fr using yur cverage fr medical care (these rules are given in Chapter 3 f this bklet: Using the plan s cverage fr yur medical services). We will say yes r n t yur request If the medical care yu paid fr is cvered and yu fllwed all the rules, we will send yu the payment fr ur share f the cst f yur medical care within 60 calendar days after we receive yur request. Or, if yu haven t paid fr the services, we will send the payment directly t the prvider. When we send the payment, it s the same as saying yes t yur request fr a cverage decisin.) If the medical care is nt cvered, r yu did nt fllw all the rules, we will nt send payment. Instead, we will send yu a letter that says we will nt pay fr the services and the reasns why in detail. (When we turn dwn yur request fr payment, it s the same as saying n t yur request fr a cverage decisin.) What if yu ask fr payment and we say that we will nt pay? If yu d nt agree with ur decisin t turn yu dwn, yu can make an appeal. If yu make an appeal, it means yu are asking us t change the cverage decisin we made when we turned dwn yur request fr payment. T make this appeal, fllw the prcess fr appeals that we describe in Sectin 5.3. G t this sectin fr step-by-step instructins. When yu are fllwing these instructins, please nte:

162 questin mark Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 160 If yu make an appeal fr reimbursement, we must give yu ur answer within 60 calendar days after we receive yur appeal. (If yu are asking us t pay yu back fr medical care yu have already received and paid fr yurself, yu are nt allwed t ask fr a fast appeal.) If the Independent Review Organizatin reverses ur decisin t deny payment, we must send the payment yu have requested t yu r t the prvider within 30 calendar days. If the answer t yur appeal is yes at any stage f the appeals prcess after Level 2, we must send the payment yu requested t yu r t the prvider within 60 calendar days. SECTION 6 Yur Part D prescriptin drugs: Hw t ask fr a cverage decisin r make an appeal Have yu read Sectin 4 f this chapter (A guide t the basics f cverage decisins and appeals)? If nt, yu may want t read it befre yu start this sectin. Sectin 6.1 This sectin tells yu what t d if yu have prblems getting a Part D drug r yu want us t pay yu back fr a Part D drug Yur benefits as a member f ur plan include cverage fr many prescriptin drugs. Please refer t ur plan s List f Cvered Drugs (Frmulary). T be cvered, the drug must be used fr a medically accepted indicatin. (A medically accepted indicatin is a use f the drug that is either apprved by the Fd and Drug Administratin r supprted by certain reference bks. See Chapter 5, Sectin 3 fr mre infrma tin abut a medically accepted indicatin.) This sectin is abut yur Part D drugs nly. T keep things simple, we generally say drug in the rest f this sectin, instead f repeating cvered utpatient prescriptin drug r Part D drug every time. Fr details abut what we mean by Part D drugs, the List f Cvered Drugs (Frmulary), rules and restrictins n cverage, and cst infrmatin, see Chapter 5 (Using ur plan s cverage fr yur Part D prescriptin drugs) and Chapter 6 (What yu pay fr yur Part D prescriptin drugs). Part D cverage decisins and appeals As discussed in Sectin 4 f this chapter, a cverage decisin is a decisin we make abut yur benefits and cverage r abut the amunt we will pay fr yur drugs. Legal Terms An initial cverage decisin abut yur Part D drugs is called a cverage determinatin. Here are examples f cverage decisins yu ask us t make abut yur Part D drugs: Yu ask us t make an exceptin, including: Asking us t cver a Part D drug that is nt n the plan s List f Cvered Drugs (Frmulary)

163 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 161 Asking us t waive a restrictin n the plan s cverage fr a drug (such as limits n the amunt f the drug yu can get) Asking t pay a lwer cst-sharing amunt fr a cvered drug n a higher cst-sharing tier Yu ask us whether a drug is cvered fr yu and whether yu satisfy any applicable cverage rules. (Fr example, when yur drug is n the plan s List f Cvered Drugs (Frmulary) but we require yu t get apprval frm us befre we will cver it fr yu.) Please nte: If yur pharmacy tells yu that yur prescriptin cannt be filled as written, yu will get a written ntice explaining hw t cntact us t ask fr a cverage decisin. Yu ask us t pay fr a prescriptin drug yu already bught. This is a request fr a cverage decisin abut payment. If yu disagree with a cverage decisin we have made, yu can appeal ur decisin. This sectin tells yu bth hw t ask fr cverage decisins and hw t request an appeal. Use the chart belw t help yu determine which part has infrmatin fr yur situatin: Which f these situatins are yu in? If yu are in this situatin: D yu need a drug that isn t n ur Drug List r need us t waive a rule r restrictin n a drug we cver? D yu want us t cver a drug n ur Drug List and yu believe yu meet any plan rules r restrictins (such as getting apprval in advance) fr the drug yu need? D yu want t ask us t pay yu back fr a drug yu have already received and paid fr? Have we already tld yu that we will nt cver r pay fr a drug in the way that yu want it t be cvered r paid fr? This is what yu can d: Yu can ask us t make an exceptin. (This is a type f cverage decisin.) Start with Sectin 6.2 f this chapter. Yu can ask us fr a cverage decisin. Skip ahead t Sectin 6.4 f this chapter. Yu can ask us t pay yu back. (This is a type f cverage decisin.) Skip ahead t Sectin 6.4 f this chapter. Yu can make an appeal. (This means yu are asking us t recnsider.) Skip ahead t Sectin 6.5 f this chapter. Sectin 6.2 What is an exceptin? If a drug is nt cvered in the way yu wuld like it t be cvered, yu can ask us t make an exceptin. An exceptin is a type f cverage decisin. Similar t ther types f cverage decisins, if we turn dwn yur request fr an exceptin, yu can appeal ur decisin. When yu ask fr an exceptin, yur dctr r ther prescriber will need t explain the medical reasns why yu need the exceptin apprved. We will then cnsider yur request. Here are three examples f exceptins that yu r yur dctr r ther prescriber can ask us t make:

164 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) Cvering a Part D drug fr yu that is nt n ur List f Cvered Drugs (Frmulary). (We call it the Drug List fr shrt.) Legal Terms Asking fr cverage f a drug that is nt n the Drug List is smetimes called asking fr a frmulary exceptin. If we agree t make an exceptin and cver a drug that is nt n the Drug List, yu will need t pay the cst-sharing amunt that applies t drugs in Tier 4. Yu cannt ask fr an exceptin t the cpayment r cinsurance amunt we require yu t pay fr the drug. 2. Remving a restrictin n ur cverage fr a cvered drug. There are extra rules r restrictins that apply t certain drugs n ur List f Cvered Drugs (Frmulary) (fr mre infrmatin, g t Chapter 5 and lk fr Sectin 4). Legal Terms Asking fr remval f a restrictin n cverage fr a drug is smetimes called asking fr a frmulary exceptin. The extra rules and restrictins n cverage fr certain drugs include: Getting plan apprval in advance befre we will agree t cver the drug fr yu. (This is smetimes called prir authrizatin. ) Being required t try a different drug first befre we will agree t cver the drug yu are asking fr. (This is smetimes called step therapy. ) Quantity limits. Fr sme drugs, there are restrictins n the amunt f the drug yu can have. If we agree t make an exceptin and waive a restrictin fr yu, yu can ask fr an exceptin t the cpayment r cinsurance amunt we require yu t pay fr the drug. 3. Changing cverage f a drug t a lwer cst-sharing tier. Every drug n ur Drug List is in ne f five cst-sharing tiers. In general, the lwer the cst-sharing tier number, the less yu will pay as yur share f the cst f the drug. Sectin 6.3 Legal Terms Asking t pay a lwer price fr a cvered nn-preferred drug is smetimes called asking fr a tiering exceptin. Yu cannt ask us t change the cst-sharing tier fr any drug in Tier 5, Specialty Drugs Tier. Imprtant things t knw abut asking fr exceptins Yur dctr must tell us the medical reasns Yur dctr r ther prescriber must give us a statement that explains the medical reasns fr requesting an exceptin. Fr a faster decisin, include this medical infrmatin frm yur dctr r ther prescriber when yu ask fr the exceptin.

165 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 163 Typically, ur Drug List includes mre than ne drug fr treating a particular cnditin. These different pssibilities are called alternative drugs. If an alternative drug wuld be just as effective as the drug yu are requesting and wuld nt cause mre side effects r ther health prblems, we will generally nt apprve yur request fr an exceptin. We can say yes r n t yur request If we apprve yur request fr an exceptin, ur apprval usually is valid until the end f the plan year. This is true as lng as yur dctr cntinues t prescribe the drug fr yu and that drug cntinues t be safe and effective fr treating yur cnditin. If we say n t yur request fr an exceptin, yu can ask fr a review f ur decisin by making an appeal. Sectin 6.5 tells hw t make an appeal if we say n. The next sectin tells yu hw t ask fr a cverage decisin, including an exceptin. Sectin 6.4 Step-by-step: Hw t ask fr a cverage decisin, including an exceptin Step 1: Yu ask us t make a cverage decisin abut the drug(s) r payment yu need. If yur health requires a quick respnse, yu must ask us t make a fast cverage decisin. Yu cannt ask fr a fast cverage decisin if yu are asking us t pay yu back fr a drug yu already bught. What t d Request the type f cverage decisin yu want. Start by calling, writing, r faxing us t make yur request. Yu, yur representative, r yur dctr (r ther prescriber) can d this. Yu can als access the cverage decisin prcess thrugh ur website. Fr the details, g t Chapter 2, Sectin 1 and lk fr the sectin called, Hw t cntact us when yu are asking fr a cverage decisin abut yur Part D prescriptin drugs. Or if yu are asking us t pay yu back fr a drug, g t the sectin called, Where t send a request that asks us t pay fr ur share f the cst fr medical care r a drug yu have received. Yu r yur dctr r smene else wh is acting n yur behalf can ask fr a cverage decisin. Sectin 4 f this chapter tells hw yu can give written permissin t smene else t act as yur representative. Yu can als have a lawyer act n yur behalf. If yu want t ask us t pay yu back fr a drug, start by reading Chapter 7 f this bklet: Asking us t pay ur share f a bill yu have received fr cvered medical services r drugs. Chapter 7 describes the situatins in which yu may need t ask fr reimbursement. It als tells hw t send us the paperwrk that asks us t pay yu back fr ur share f the cst f a drug yu have paid fr. If yu are requesting an exceptin, prvide the supprting statement. Yur dctr r ther prescriber must give us the medical reasns fr the drug exceptin yu are requesting. (We call this the supprting statement. ) Yur dctr r ther prescriber can fax r mail the statement t us. Or yur dctr r ther prescriber can tell us n the phne and fllw up by faxing r mailing a written statement if necessary. See Sectins 6.2 and 6.3 fr mre infr

166 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 164 matin abut exceptin requests. We must accept any written request, including a request submitted n the CMS Mdel Cverage Determinatin Request Frm which is available n ur website. If yur health requires it, ask us t give yu a fast cverage decisin Legal Terms A fast cverage decisin is called an expedited cverage determinatin. When we give yu ur decisin, we will use the standard deadlines unless we have agreed t use the fast deadlines. A standard cverage decisin means we will give yu an answer within 72 hurs after we receive yur dctr s statement. A fast cverage decisin means we will answer within 24 hurs after we receive yur dctr s statement. T get a fast cverage decisin, yu must meet tw requirements: Yu can get a fast cverage decisin nly if yu are asking fr a drug yu have nt yet received. (Yu cannt get a fast cverage decisin if yu are asking us t pay yu back fr a drug yu have already bught.) Yu can get a fast cverage decisin nly if using the standard deadlines culd cause serius harm t yur health r hurt yur ability t functin. If yur dctr r ther prescriber tells us that yur health requires a fast cverage decisin, we will autmatically agree t give yu a fast cverage decisin. If yu ask fr a fast cverage decisin n yur wn (withut yur dctr s r ther prescriber s supprt), we will decide whether yur health requires that we give yu a fast cverage decisin. If we decide that yur medical cnditin des nt meet the requirements fr a fast cverage decisin, we will send yu a letter that says s (and we will use the standard deadlines instead). This letter will tell yu that if yur dctr r ther prescriber asks fr the fast cverage decisin, we will autmatically give a fast cverage decisin. The letter will als tell hw yu can file a cmplaint abut ur decisin t give yu a standard cverage decisin instead f the fast cverage decisin yu requested. It tells hw t file a fast cmplaint, which means yu wuld get ur answer t yur cmplaint within 24 hurs f receiving the cmplaint. (The prcess fr making a cmplaint is dif ferent frm the prcess fr cverage decisins and appeals. Fr mre infrmatin abut the prcess fr making cmplaints, see Sectin 10 f this chapter.)

167 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 165 Step 2: We cnsider yur request and we give yu ur answer. Deadlines fr a fast cverage decisin If we are using the fast deadlines, we must give yu ur answer within 24 hurs. Generally, this means within 24 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 24 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent utside rganizatin. Later in this sectin, we talk abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 24 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. We will als tell yu hw t appeal. Deadlines fr a standard cverage decisin abut a drug yu have nt yet received If we are using the standard deadlines, we must give yu ur answer within 72 hurs. Generally, this means within 72 hurs after we receive yur request. If yu are requesting an exceptin, we will give yu ur answer within 72 hurs after we receive yur dctr s statement supprting yur request. We will give yu ur answer sner if yur health requires us t. If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we talk abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested If we apprve yur request fr cverage, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur request r dctr s statement supprting yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. We will als tell yu hw t appeal. Deadlines fr a standard cverage decisin abut payment fr a drug yu have already bught We must give yu ur answer within 14 calendar days after we receive yur request.

168 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 166 If we d nt meet this deadline, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an independent rganizatin. Later in this sectin, we talk abut this review rganizatin and explain what happens at Appeal Level 2. If ur answer is yes t part r all f what yu requested, we are als required t make payment t yu within 14 calendar days after we receive yur request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n. We will als tell yu hw t appeal. Step 3: If we say n t yur cverage request, yu decide if yu want t make an appeal. If we say n, yu have the right t request an appeal. Requesting an appeal means asking us t recnsider and pssibly change the decisin we made. Sectin 6.5 Step-by-step: Hw t make a Level 1 Appeal (hw t ask fr a review f a cverage decisin made by ur plan) Legal Terms An appeal t the plan abut a Part D drug cverage decisin is called a plan redeterminatin. Step 1: Yu cntact us and make yur Level 1 Appeal. If yur health requires a quick respnse, yu must ask fr a fast appeal. What t d T start yur appeal, yu (r yur representative r yur dctr r ther prescriber) must cntact us. Fr details n hw t reach us by phne, fax, r mail, r n ur website, fr any purpse related t yur appeal, g t Chapter 2, Sectin 1, and lk fr the sectin called, Hw t cntact us when yu are making an appeal abut yur Part D prescriptin drugs. If yu are asking fr a standard appeal, make yur appeal by submitting a written request, r by calling us at the phne number shwn in Chapter 2, Sectin 1 (Hw t cntact the plan when yu are making an appeal abut yur Part D prescriptin drugs). If yu are asking fr a fast appeal, yu may make yur appeal in writing r yu may call us at the phne number shwn in Chapter 2, Sectin 1 (Hw t cntact ur plan when yu are making an appeal abut yur part D prescriptin drugs).

169 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 167 We must accept any written request, including a request submitted n the CMS Mdel Cverage Determinatin Request Frm, which is available n ur website. Yu must make yur appeal request within 60 calendar days frm the date n the written ntice we sent t tell yu ur answer t yur request fr a cverage decisin. If yu miss this deadline and have a gd reasn fr missing it, we may give yu mre time t make yur appeal. Examples f gd cause fr missing the deadline may include if yu had a serius illness that prevented yu frm cntacting us r if we prvided yu with incrrect r incmplete infrmatin abut the deadline fr requesting an appeal. Yu can ask fr a cpy f the infrmatin in yur appeal and add mre infrmatin. Yu have the right t ask us fr a cpy f the infrmatin regarding yur appeal. If yu wish, yu and yur dctr r ther prescriber may give us additinal infrmatin t supprt yur appeal. If yur health requires it, ask fr a fast appeal Legal Terms A fast appeal is als called an expedited redeterminatin. If yu are appealing a decisin we made abut a drug yu have nt yet received, yu and yur dctr r ther prescriber will need t decide if yu need a fast appeal. The requirements fr getting a fast appeal are the same as thse fr getting a fast cverage decisin in Sectin 6.4 f this chapter. Step 2: We cnsider yur appeal and we give yu ur answer. When we are reviewing yur appeal, we take anther careful lk at all f the infrmatin abut yur cverage request. We check t see if we were fllwing all the rules when we said n t yur request. We may cntact yu r yur dctr r ther prescriber t get mre infrmatin. Deadlines fr a fast appeal If we are using the fast deadlines, we must give yu ur answer within 72 hurs after we receive yur appeal. We will give yu ur answer sner if yur health requires it. If we d nt give yu an answer within 72 hurs, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. Later in this sectin, we talk abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested, we must prvide the cverage we have agreed t prvide within 72 hurs after we receive yur appeal.

170 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 168 If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Deadlines fr a standard appeal If we are using the standard deadlines, we must give yu ur answer within 7 calendar days after we receive yur appeal. We will give yu ur decisin sner if yu have nt received the drug yet and yur health cnditin requires us t d s. If yu believe yur health requires it, yu shuld ask fr fast appeal. If we d nt give yu a decisin within 7 calendar days, we are required t send yur request n t Level 2 f the appeals prcess, where it will be reviewed by an Independent Review Organizatin. Later in this sectin, we tell abut this review rganizatin and explain what happens at Level 2 f the appeals prcess. If ur answer is yes t part r all f what yu requested If we apprve a request fr cverage, we must prvide the cverage we have agreed t prvide as quickly as yur health requires, but n later than 7 calendar days after we receive yur appeal. If we apprve a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive yur appeal request. If ur answer is n t part r all f what yu requested, we will send yu a written statement that explains why we said n and hw t appeal ur decisin. Step 3: If we say n t yur appeal, yu decide if yu want t cntinue with the appeals prcess and make anther appeal. If we say n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anther appeal. If yu decide t make anther appeal, it means yur appeal is ging n t Level 2 f the appeals prcess (see belw). Sectin 6.6 Step-by-step: Hw t make a Level 2 Appeal If we say n t yur appeal, yu then chse whether t accept this decisin r cntinue by making anth

171 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 169 er appeal. If yu decide t g n t a Level 2 Appeal, the Independent Review Organizatin reviews the decisin we made when we said n t yur first appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: T make a Level 2 Appeal, yu (r yur representative r yur dctr r ther prescriber) must cntact the Independent Review Organizatin and ask fr a review f yur case. If we say n t yur Level 1 Appeal, the written ntice we send yu will include instructins n hw t make a Level 2 Appeal with the Independent Review Organizatin. These instructins will tell wh can make this Level 2 Appeal, what deadlines yu must fllw, and hw t reach the review rganizatin. When yu make an appeal t the Independent Review Organizatin, we will send the infrma tin we have abut yur appeal t this rganizatin. This infrmatin is called yur case file. Yu have the right t ask us fr a cpy f yur case file. Yu have a right t give the Independent Review Organizatin additinal infrmatin t supprt yur appeal. Step 2: The Independent Review Organizatin des a review f yur appeal and gives yu an answer. The Independent Review Organizatin is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with us and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t review ur decisins abut yur Part D bene fits with us. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. The rganizatin will tell yu its decisin in writing and explain the reasns fr it. Deadlines fr fast appeal at Level 2 If yur health requires it, ask the Independent Review Organizatin fr a fast appeal. If the review rganizatin agrees t give yu a fast appeal, the review rganizatin must give yu an answer t yur Level 2 Appeal within 72 hurs after it receives yur appeal request.

172 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 170 If the Independent Review Organizatin says yes t part r all f what yu requested, we must prvide the drug cverage that was apprved by the review rganizatin within 24 hurs after we receive the decisin frm the review rganizatin. Deadlines fr standard appeal at Level 2 If yu have a standard appeal at Level 2, the review rganizatin must give yu an answer t yur Level 2 Appeal within 7 calendar days after it receives yur appeal. If the Independent Review Organizatin says yes t part r all f what yu requested If the Independent Review Organizatin apprves a request fr cverage, we must prvide the drug cverage that was apprved by the review rganizatin within 72 hurs after we receive the decisin frm the review rganizatin. If the Independent Review Organizatin apprves a request t pay yu back fr a drug yu already bught, we are required t send payment t yu within 30 calendar days after we receive the decisin frm the review rganizatin. What if the review rganizatin says n t yur appeal? If this rganizatin says n t yur appeal, it means the rganizatin agrees with ur decisin nt t apprve yur request. (This is called uphlding the decisin. It is als called turning dwn yur appeal. ) If the Independent Review Organizatin uphlds the decisin yu have the right t a Level 3 Appeal. Hwever, t make anther appeal at Level 3, the dllar value f the drug cverage yu are requesting must meet a minimum amunt. If the dllar value f the drug cverage yu are requesting is t lw, yu cannt make anther appeal and the decisin at Level 2 is final. The ntice yu get frm the Independent Review Organizatin will tell yu the dllar value that must be in dispute t cntinue with the appeals prcess. Step 3: If the dllar value f the cverage yu are requesting meets the requirement, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If yur Level 2 Appeal is turned dwn and yu meet the requirements t cntinue with the appeals prcess, yu must decide whether yu want t g n t Level 3 and make a third appeal. If yu decide t make a third appeal, the details n hw t d this are in the written ntice yu gt after yur secnd appeal. The Level 3 Appeal is handled by an administrative law judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess.

173 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 171 SECTION 7 Hw t ask us t cver a lnger inpatient hspital stay if yu think the dctr is discharging yu t sn When yu are admitted t a hspital, yu have the right t get all f yur cvered hspital services that are necessary t diagnse and treat yur illness r injury. Fr mre infrmatin abut ur cverage fr yur hspital care, including any limitatins n this cverage, see Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). During yur cvered hspital stay, yur dctr and the hspital staff will be wrking with yu t prepare fr the day when yu will leave the hspital. They will als help arrange fr care yu may need after yu leave. The day yu leave the hspital is called yur discharge date. When yur discharge date has been decided, yur dctr r the hspital staff will let yu knw. If yu think yu are being asked t leave the hspital t sn, yu can ask fr a lnger hspital stay and yur request will be cnsidered. This sectin tells yu hw t ask. Sectin 7.1 During yur inpatient hspital stay, yu will get a written ntice frm Medicare that tells abut yur rights During yur cvered hspital stay, yu will be given a written ntice called An Imprtant Message frm Medicare abut Yur Rights. Everyne with Medicare gets a cpy f this ntice whenever they are admitted t a hspital. Smene at the hspital (fr example, a casewrker r nurse) must give it t yu within tw days after yu are admitted. If yu d nt get the ntice, ask any hspital emplyee fr it. If yu need help, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can als call MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Read this ntice carefully and ask questins if yu dn t understand it. It tells yu abut yur rights as a hspital patient, including: Yur right t receive Medicare-cvered services during and after yur hspital stay, as rdered by yur dctr. This includes the right t knw what these services are, wh will pay fr them, and where yu can get them. Yur right t be invlved in any decisins abut yur hspital stay, and knw wh will pay fr it. Where t reprt any cncerns yu have abut quality f yur hspital care. Yur right t appeal yur discharge decisin if yu think yu are being discharged frm the hspital t sn.

174 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 172 Legal Terms The written ntice frm Medicare tells yu hw yu can request an immediate review. Requesting an immediate review is a frmal, legal way t ask fr a delay in yur discharge date s that we will cver yur hspital care fr a lnger time. (Sectin 7.2 belw tells yu hw yu can request an immediate review.) 2. Yu must sign the written ntice t shw that yu received it and understand yur rights. Yu r smene wh is acting n yur behalf must sign the ntice. (Sectin 4 f this chapter tells hw yu can give written permissin t smene else t act as yur representative.) Signing the ntice shws nly that yu have received the infrmatin abut yur rights. The ntice des nt give yur discharge date (yur dctr r hspital staff will tell yu yur discharge date). Signing the ntice des nt mean yu are agreeing n a discharge date. 3. Keep yur cpy f the signed ntice s yu will have the infrmatin abut making an appeal (r reprting a cncern abut quality f care) handy if yu need it. Sectin 7.2 If yu sign the ntice mre than tw days befre the day yu leave the hspital, yu will get anther cpy befre yu are scheduled t be discharged. T lk at a cpy f this ntice in advance, yu can call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) r MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Yu can als see it nline at chargeappealntices.html Step-by-step: Hw t make a Level 1 Appeal t change yur hspital discharge date If yu want t ask fr yur inpatient hspital services t be cvered by us fr a lnger time, yu will need t use the appeals prcess t make this request. Befre yu start, understand what yu need t d and what the deadlines are. Fllw the prcess. Each step in the first tw levels f the appeals prcess is explained belw. Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d. Ask fr help if yu need it. If yu have questins r need help at any time, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Or call yur State Health Insurance Assistance Prgram, a gvernment rganizatin that prvides persnalized assistance (see Sectin 2 f this chapter).

175 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 173 During a Level 1 Appeal, the Quality Imprvement Organizatin reviews yur appeal. It checks t see if yur planned discharge date is medically apprpriate fr yu. Step 1: Cntact the Quality Imprvement Organizatin fr yur state and ask fr a fast review f yur hspital discharge. Yu must act quickly. What is the Quality Imprvement Organizatin? This rganizatin is a grup f dctrs and ther health care prfessinals wh are paid by the Federal gvernment. These experts are nt part f ur plan. This rganizatin is paid by Medicare t check n and help imprve the quality f care fr peple with Medicare. This includes reviewing hspital discharge dates fr peple with Medicare. Hw can yu cntact this rganizatin? The written ntice yu received (An Imprtant Message frm Medicare Abut Yur Rights) tells yu hw t reach this rganizatin. (Or find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state in Chapter 2, Sectin 4, f this bklet.) Act quickly: T make yur appeal, yu must cntact the Quality Imprvement Organizatin befre yu leave the hspital and n later than yur planned discharge date. (Yur planned discharge date is the date that has been set fr yu t leave the hspital.) If yu meet this deadline, yu are allwed t stay in the hspital after yur discharge date withut paying fr it while yu wait t get the decisin n yur appeal frm the Quality Imprvement Organizatin. If yu d nt meet this deadline, and yu decide t stay in the hspital after yur planned discharge date, yu may have t pay all f the csts fr hspital care yu receive after yur planned discharge date. If yu miss the deadline fr cntacting the Quality Imprvement Organizatin abut yur appeal, yu can make yur appeal directly t ur plan instead. Fr details abut this ther way t make yur appeal, see Sectin 7.4. Ask fr a fast review : Yu must ask the Quality Imprvement Organizatin fr a fast review f yur discharge. Asking fr a fast review means yu are asking fr the rganizatin t use the fast deadlines fr an appeal instead f using the standard deadlines. Legal Terms A fast review is als called an immediate review r an expedited review.

176 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 174 Step 2: The Quality Imprvement Organizatin cnducts an independent review f yur case. What happens during this review? Health prfessinals at the Quality Imprvement Organizatin (we will call them the reviewers fr shrt) will ask yu (r yur representative) why yu believe cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish. The reviewers will als lk at yur medical infrmatin, talk with yur dctr, and review infrmatin that the hspital and we have given t them. By nn f the day after the reviewers infrmed ur plan f yur appeal, yu will als get a written ntice that gives yur planned discharge date and explains in detail the reasns why yur dctr, the hspital, and we think it is right (medically apprpriate) fr yu t be discharged n that date. Legal Terms This written explanatin is called the Detailed Ntice f Discharge. Yu can get a sample f this ntice by calling yur Healthcare Cn cierge (phne numbers are printed n the back cver f this bklet) r MEDICARE ( , 24 hurs a day, 7 days a week. TTY users shuld call ) Or yu can see a sample ntice nline at BNI/HspitalDischargeAppealNtices.html Step 3: Within ne full day after it has all the needed infrmatin, the Quality Imprvement Organizatin will give yu its answer t yur appeal. What happens if the answer is yes? If the review rganizatin says yes t yur appeal, we must keep prviding yur cvered inpatient hspital services fr as lng as these services are medically necessary. Yu will have t keep paying yur share f the csts (such as deductibles r cpayments, if these apply). In additin, there may be limitatins n yur cvered hspital services. (See Chapter 4 f this bklet). What happens if the answer is n? If the review rganizatin says n t yur appeal, they are saying that yur planned discharge date is medically apprpriate. If this happens, ur cverage fr yur inpatient hspital services will end at nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal. If the review rganizatin says n t yur appeal and yu decide t stay in the hspital, then

177 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 175 yu may have t pay the full cst f hspital care yu receive after nn n the day after the Quality Imprvement Organizatin gives yu its answer t yur appeal. Step 4: If the answer t yur Level 1 Appeal is n, yu decide if yu want t make anther appeal. Sectin 7.3 If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make anther appeal. Making anther appeal means yu are ging n t Level 2 f the appeals prcess. Step-by-step: Hw t make a Level 2 Appeal t change yur hspital discharge date If the Quality Imprvement Organizatin has turned dwn yur appeal, and yu stay in the hspital after yur planned discharge date, then yu can make a Level 2 Appeal. During a Level 2 Appeal, yu ask the Quality Imprvement Organizatin t take anther lk at the decisin they made n yur first appeal. If the Quality Imprvement Organizatin turns dwn yur Level 2 Appeal, yu may have t pay the full cst fr yur stay after yur planned discharge date. Here are the steps fr Level 2 f the appeal prcess: Step 1: Yu cntact the Quality Imprvement Organizatin again and ask fr anther review. Yu must ask fr this review within 60 calendar days after the day the Quality Imprvement Organizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu stayed in the hspital after the date that yur cverage fr the care ended. Step 2: The Quality Imprvement Organizatin des a secnd review f yur situatin. Reviewers at the Quality Imprvement Organizatin will take anther careful lk at all f the infrmatin related t yur appeal. Step 3: Within 14 calendar days f receipt f yur request fr a secnd review, the Quality Imprvement Organizatin reviewers will decide n yur appeal and tell yu their decisin. If the review rganizatin says yes: We must reimburse yu fr ur share f the csts f hspital care yu have received since nn n the day after the date yur first appeal was turned dwn by the Quality Imprvement Organizatin. We must cntinue prviding cverage fr yur inpatient hspital care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts and cverage limitatins may apply.

178 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 176 If the review rganizatin says n: It means they agree with the decisin they made n yur Level 1 Appeal and will nt change it. The ntice yu get will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Step 4: If the answer is n, yu will need t decide whether yu want t take yur appeal further by ging n t Level 3. Sectin 7.4 There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If the review rganizatin turns dwn yur Level 2 Appeal, yu can chse whether t accept that decisin r whether t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. Yu can appeal t us instead What if yu miss the deadline fr making yur Level 1 Appeal? As explained abve in Sectin 7.2, yu must act quickly t cntact the Quality Imprvement Organizatin t start yur first appeal f yur hspital discharge. ( Quickly means befre yu leave the hspital and n later than yur planned discharge date.) If yu miss the deadline fr cntacting this rganizatin, there is anther way t make yur appeal. If yu use this ther way f making yur appeal, the first tw levels f appeal are different. Step-by-Step: Hw t make a Level 1 Alternate Appeal If yu miss the deadline fr cntacting the Quality Imprvement Organizatin, yu can make an appeal t us, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. Legal Terms A fast review (r fast appeal ) is als called an expedited appeal. Step 1: Cntact us and ask fr a fast review. Fr details n hw t cntact us, g t Chapter 2, Sectin 1 and lk fr the sectin called, Hw t cntact us when yu are making an appeal abut yur medical care. Be sure t ask fr a fast review. This means yu are asking us t give yu an answer using the fast deadlines rather than the standard deadlines.

179 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 177 Step 2: We d a fast review f yur planned discharge date, checking t see if it was medically apprpriate. During this review, we take a lk at all f the infrmatin abut yur hspital stay. We check t see if yur planned discharge date was medically apprpriate. We will check t see if the decisin abut when yu shuld leave the hspital was fair and fllwed all the rules. In this situatin, we will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. Step 3: We give yu ur decisin within 72 hurs after yu ask fr a fast review ( fast appeal ). If we say yes t yur fast appeal, it means we have agreed with yu that yu still need t be in the hspital after the discharge date, and will keep prviding yur cvered inpatient hspital services fr as lng as it is medically necessary. It als means that we have agreed t reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. (Yu must pay yur share f the csts and there may be cverage limitatins that apply.) If we say n t yur fast appeal, we are saying that yur planned discharge date was medically apprpriate. Our cverage fr yur inpatient hspital services ends as f the day we said cverage wuld end. If yu stayed in the hspital after yur planned discharge date, then yu may have t pay the full cst f hspital care yu received after the planned discharge date. Step 4: If we say n t yur fast appeal, yur case will autmatically be sent n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur fast appeal, we are required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yu are autmatically ging n t Level 2 f the appeals prcess.

180 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 178 Step-by-Step: Level 2 Alternate Appeal Prcess If we say n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, an Independent Review Organizatin reviews the decisin we made when we said n t yur fast appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: We will autmatically frward yur case t the Independent Review Organizatin. We are required t send the infrmatin fr yur Level 2 Appeal t the Independent Review Organizatin within 24 hurs f when we tell yu that we are saying n t yur first appeal. (If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. The cmplaint pr cess is different frm the appeal prcess. Sectin 10 f this chapter tells hw t make a cmplaint.) Step 2: The Independent Review Organizatin des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The Independent Review Organizatin is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal f yur hspital discharge. If this rganizatin says yes t yur appeal, then we must reimburse yu (pay yu back) fr ur share f the csts f hspital care yu have received since the date f yur planned discharge. We must als cntinue the plan s cverage f yur inpatient hspital services fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts. If there are cverage limitatins, these culd limit hw much we wuld reimburse r hw lng we wuld cntinue t cver yur services. If this rganizatin says n t yur appeal, it means they agree with us that yur planned hspital discharge date was medically apprpriate. The ntice yu get frm the Independent Review Organizatin will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a Level 3 Appeal, which is handled by a judge.

181 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 179 Step 3: If the Independent Review Organizatin turns dwn yur appeal, yu chse whether yu want t take yur appeal further. There are three additinal levels in the appeals prcess after Level 2 (fr a ttal f five levels f appeal). If reviewers say n t yur Level 2 Appeal, yu decide whether t accept their decisin r g n t Level 3 and make a third appeal. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 8 Hw t ask us t keep cvering certain medical services if yu think yur cverage is ending t sn Sectin 8.1 This sectin is abut three services nly: Hme health care, skilled nursing facility care, and Cmprehensive Outpatient Rehabilitatin Facility (CORF) services This sectin is abut the fllwing types f care nly: Hme health care services yu are getting. Skilled nursing care yu are getting as a patient in a skilled nursing facility. (T learn abut re quirements fr being cnsidered a skilled nursing facility, see Chapter 12, Definitins f imprtant wrds.) Rehabilitatin care yu are getting as an utpatient at a Medicare-apprved Cmprehensive Outpatient Rehabilitatin Facility (CORF). Usually, this means yu are getting treatment fr an illness r accident, r yu are recvering frm a majr peratin. (Fr mre infrmatin abut this type f facility, see Chapter 12, Definitins f imprtant wrds.) When yu are getting any f these types f care, yu have the right t keep getting yur cvered services fr that type f care fr as lng as the care is needed t diagnse and treat yur illness r injury. Fr mre infrmatin n yur cvered services, including yur share f the cst and any limitatins t cverage that may apply, see Chapter 4 f this bklet: Medical Benefits Chart (what is cvered and what yu pay). When we decide it is time t stp cvering any f the three types f care fr yu, we are required t tell yu in advance. When yur cverage fr that care ends, we will stp paying ur share f the cst fr yur care. If yu think we are ending the cverage f yur care t sn, yu can appeal ur decisin. This sectin tells yu hw t ask fr an appeal.

182 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 180 Sectin 8.2 We will tell yu in advance when yur cverage will be ending 1. Yu receive a ntice in writing. At least tw days befre ur plan is ging t stp cvering yur care, yu will receive a ntice. The written ntice tells yu the date when we will stp cvering the care fr yu. The written ntice als tells what yu can d if yu want t ask ur plan t change this decisin abut when t end yur care, and keep cvering it fr a lnger perid f time. 2. Yu must sign the written ntice t shw that yu received it. Sectin 8.3 Legal Terms In telling yu what yu can d, the written ntice is telling hw yu can request a fast-track appeal. Requesting a fast-track appeal is a frmal, legal way t request a change t ur cver age decisin abut when t stp yur care. (Sectin 8.3 belw tells hw yu can request a fast-track appeal.) The written ntice is called the Ntice f Medicare Nn-Cverage. T get a sample cpy, call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet) r MEDICARE ( ), 24 hurs a day, 7 days a week. (TTY users shuld call ) Or see a cpy nline at care-general-infrmatin/bni/maedntices.html Yu r smene wh is acting n yur behalf must sign the ntice. (Sectin 4 tells hw yu can give written permissin t smene else t act as yur representative.) Signing the ntice shws nly that yu have received the infrmatin abut when yur cver age will stp. Signing it des nt mean yu agree with the plan that it s time t stp getting the care. Step-by-step: Hw t make a Level 1 Appeal t have ur plan cver yur care fr a lnger time If yu want t ask us t cver yur care fr a lnger perid f time, yu will need t use the appeals prcess t make this request. Befre yu start, understand what yu need t d and what the deadlines are. Fllw the prcess. Each step in the first tw levels f the appeals prcess is explained belw. Meet the deadlines. The deadlines are imprtant. Be sure that yu understand and fllw the deadlines that apply t things yu must d. There are als deadlines ur plan must fllw. (If yu think we are nt meeting ur deadlines, yu can file a cmplaint. Sectin 10 f this chapter tells yu hw t file a cmplaint.)

183 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 181 Ask fr help if yu need it. If yu have questins r need help at any time, please call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Or call yur State Health Insurance Assistance Prgram, a gvernment rganizatin that prvides persnalized assistance (see Sectin 2 f this chapter). During a Level 1 Appeal, the Quality Imprvement Organizatin reviews yur appeal and decides whether t change the decisin made by ur plan. Step 1: Make yur Level 1 Appeal: cntact the Quality Imprvement Organizatin fr yur state and ask fr a review. Yu must act quickly. What is the Quality Imprvement Organizatin? This rganizatin is a grup f dctrs and ther health care experts wh are paid by the Federal gvernment. These experts are nt part f ur plan. They check n the quality f care received by peple with Medicare and review plan decisins abut when it s time t stp cvering certain kinds f medical care. Hw can yu cntact this rganizatin? The written ntice yu received tells yu hw t reach this rganizatin. (Or find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state in Chapter 2, Sectin 4, f this bklet.) What shuld yu ask fr? Ask this rganizatin fr a fast-track appeal (t d an independent review) f whether it is medically apprpriate fr us t end cverage fr yur medical services. Yur deadline fr cntacting this rganizatin. Yu must cntact the Quality Imprvement Organizatin t start yur appeal n later than nn f the day after yu receive the written ntice telling yu when we will stp cvering yur care. If yu miss the deadline fr cntacting the Quality Imprvement Organizatin abut yur appeal, yu can make yur appeal directly t us instead. Fr details abut this ther way t make yur appeal, see Sectin 8.5. Step 2: The Quality Imprvement Organizatin cnducts an independent review f yur case. What happens during this review? Health prfessinals at the Quality Imprvement Organizatin (we will call them the reviewers fr shrt) will ask yu (r yur representative) why yu believe cverage fr the services shuld cntinue. Yu dn t have t prepare anything in writing, but yu may d s if yu wish.

184 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 182 The review rganizatin will als lk at yur medical infrmatin, talk with yur dctr, and review infrmatin that ur plan has given t them. By the end f the day the reviewers infrmed us f yur appeal, and yu will als get a written ntice frm us that explains in detail ur reasns fr ending ur cverage fr yur services. Legal Terms This ntice explanatin is called the Detailed Explanatin f Nn-Cverage. Step 3: Within ne full day after they have all the infrmatin they need, the reviewers will tell yu their decisin. What happens if the reviewers say yes t yur appeal? If the reviewers say yes t yur appeal, then we must keep prviding yur cvered services fr as lng as it is medically necessary. Yu will have t keep paying yur share f the csts (such as deductibles r cpayments, if these apply). In additin, there may be limitatins n yur cvered services (see Chapter 4 f this bklet). What happens if the reviewers say n t yur appeal? If the reviewers say n t yur appeal, then yur cverage will end n the date we have tld yu. We will stp paying ur share f the csts f this care n the date listed n the ntice. If yu decide t keep getting the hme health care, r skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services after this date when yur cverage ends, then yu will have t pay the full cst f this care yurself. Step 4: If the answer t yur Level 1 Appeal is n, yu decide if yu want t make anther appeal. Sectin 8.4 This first appeal yu make is Level 1 f the appeals prcess. If reviewers say n t yur Level 1 Appeal and yu chse t cntinue getting care after yur cverage fr the care has ended then yu can make anther appeal. Making anther appeal means yu are ging n t Level 2 f the appeals prcess. Step-by-step: Hw t make a Level 2 Appeal t have ur plan cver yur care fr a lnger time If the Quality Imprvement Organizatin has turned dwn yur appeal and yu chse t cntinue getting care after yur cverage fr the care has ended, then yu can make a Level 2 Appeal. During a Level 2 Appeal, yu ask the Quality Imprvement Organizatin t take anther lk at the decisin they made n

185 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 183 yur first appeal. If the Quality Imprvement Organizatin turns dwn yur Level 2 Appeal, yu may have t pay the full cst fr yur hme health care, r skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services after the date when we said yur cverage wuld end. Here are the steps fr Level 2 f the appeal prcess: Step 1: Yu cntact the Quality Imprvement Organizatin again and ask fr anther review. Yu must ask fr this review within 60 days after the day when the Quality Imprvement Organizatin said n t yur Level 1 Appeal. Yu can ask fr this review nly if yu cntinued getting care after the date that yur cverage fr the care ended. Step 2: The Quality Imprvement Organizatin des a secnd review f yur situatin. Reviewers at the Quality Imprvement Organizatin will take anther careful lk at all f the infrmatin related t yur appeal. Step 3: Within 14 days f receipt f yur appeal request, reviewers will decide n yur appeal and tell yu their decisin. What happens if the review rganizatin says yes t yur appeal? We must reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. We must cntinue prviding cverage fr the care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts and there may be cverage limitatins that apply. What happens if the review rganizatin says n? It means they agree with the decisin we made t yur Level 1 Appeal and will nt change it. The ntice yu get will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t the next level f appeal, which is handled by a judge. Step 4: If the answer is n, yu will need t decide whether yu want t take yur appeal further. There are three additinal levels f appeal after Level 2, fr a ttal f five levels f appeal. If reviewers turn dwn yur Level 2 Appeal, yu can chse whether t accept that decisin r t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess.

186 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 184 Sectin 8.5 Yu can appeal t us instead What if yu miss the deadline fr making yur Level 1 Appeal? As explained abve in Sectin 8.3, yu must act quickly t cntact the Quality Imprvement Organizatin t start yur first appeal (within a day r tw, at the mst). If yu miss the deadline fr cntacting this r ganizatin, there is anther way t make yur appeal. If yu use this ther way f making yur appeal, the first tw levels f appeal are different. Step-by-Step: Hw t make a Level 1 Alternate Appeal If yu miss the deadline fr cntacting the Quality Imprvement Organizatin, yu can make an appeal t us, asking fr a fast review. A fast review is an appeal that uses the fast deadlines instead f the standard deadlines. Here are the steps fr a Level 1 Alternate Appeal: Legal Terms A fast review (r fast appeal ) is als called an expedited appeal. Step 1: Cntact us and ask fr a fast review. Fr details n hw t cntact us, g t Chapter 2, Sectin 1 and lk fr the sectin called, Hw t cntact us when yu are making an appeal abut yur medical care. Be sure t ask fr a fast review. This means yu are asking us t give yu an answer using the fast deadlines rather than the standard deadlines. Step 2: We d a fast review f the decisin we made abut when t end cverage fr yur services. During this review, we take anther lk at all f the infrmatin abut yur case. We check t see if we were fllwing all the rules when we set the date fr ending the plan s cverage fr services yu were receiving. We will use the fast deadlines rather than the standard deadlines fr giving yu the answer t this review. Step 3: We give yu ur decisin within 72 hurs after yu ask fr a fast review ( fast appeal ). If we say yes t yur fast appeal, it means we have agreed with yu that yu need services lnger, and will keep prviding yur cvered services fr as lng as it is medically necessary. It als means that we have agreed t reimburse yu fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. (Yu must pay yur share f the csts and there may be cverage limitatins that apply.)

187 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 185 If we say n t yur fast appeal, then yur cverage will end n the date we tld yu and we will nt pay any share f the csts after this date. If yu cntinued t get hme health care, r skilled nursing facility care, r Cmprehensive Outpatient Rehabilitatin Facility (CORF) services after the date when we said yur cverage wuld end, then yu will have t pay the full cst f this care yurself. Step 4: If we say n t yur fast appeal, yur case will autmatically g n t the next level f the appeals prcess. T make sure we were fllwing all the rules when we said n t yur fast appeal, we are required t send yur appeal t the Independent Review Organizatin. When we d this, it means that yu are autmatically ging n t Level 2 f the appeals prcess. Step-by-Step: Level 2 Alternate Appeal Prcess If we say n t yur Level 1 Appeal, yur case will autmatically be sent n t the next level f the appeals prcess. During the Level 2 Appeal, the Independent Review Organizatin reviews the decisin we made when we said n t yur fast appeal. This rganizatin decides whether the decisin we made shuld be changed. Legal Terms The frmal name fr the Independent Review Organizatin is the Independent Review Entity. It is smetimes called the IRE. Step 1: We will autmatically frward yur case t the Independent Review Organizatin. We are required t send the infrmatin fr yur Level 2 Appeal t the Independent Review Organizatin within 24 hurs f when we tell yu that we are saying n t yur first appeal. (If yu think we are nt meeting this deadline r ther deadlines, yu can make a cmplaint. The cmplaint prcess is different frm the appeal prcess. Sectin 10 f this chapter tells hw t make a cmplaint.)

188 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 186 Step 2: The Independent Review Organizatin des a fast review f yur appeal. The reviewers give yu an answer within 72 hurs. The Independent Review Organizatin is an independent rganizatin that is hired by Medicare. This rganizatin is nt cnnected with ur plan and it is nt a gvernment agency. This rganizatin is a cmpany chsen by Medicare t handle the jb f being the Independent Review Organizatin. Medicare versees its wrk. Reviewers at the Independent Review Organizatin will take a careful lk at all f the infrmatin related t yur appeal. If this rganizatin says yes t yur appeal, then we must reimburse yu (pay yu back) fr ur share f the csts f care yu have received since the date when we said yur cverage wuld end. We must als cntinue t cver the care fr as lng as it is medically necessary. Yu must cntinue t pay yur share f the csts. If there are cverage limitatins, these culd limit hw much we wuld reimburse r hw lng we wuld cntinue t cver yur services. If this rganizatin says n t yur appeal, it means they agree with the decisin ur plan made t yur first appeal and will nt change it. The ntice yu get frm the Independent Review Organizatin will tell yu in writing what yu can d if yu wish t cntinue with the review prcess. It will give yu the details abut hw t g n t a Level 3 Appeal. Step 3: If the Independent Review Organizatin turns dwn yur appeal, yu chse whether yu want t take yur appeal further. There are three additinal levels f appeal after Level 2, fr a ttal f five levels f appeal. If reviewers say n t yur Level 2 Appeal, yu can chse whether t accept that decisin r whether t g n t Level 3 and make anther appeal. At Level 3, yur appeal is reviewed by a judge. Sectin 9 in this chapter tells mre abut Levels 3, 4, and 5 f the appeals prcess. SECTION 9 Taking yur appeal t Level 3 and beynd Sectin 9.1 Levels f Appeal 3, 4, and 5 fr Medical Service Appeals This sectin may be apprpriate fr yu if yu have made a Level 1 Appeal and a Level 2 Appeal, and bth f yur appeals have been turned dwn. If the dllar value f the item r medical service yu have appealed meets certain minimum levels, yu may be able t g n t additinal levels f appeal. If the dllar value is less than the minimum level, yu cannt appeal any further. If the dllar value is high enugh, the written respnse yu receive t yur Level 2 Appeal will explain wh t cntact and what t d t ask fr a Level 3 Appeal. Fr mst situatins that invlve appeals, the last three levels f appeal wrk in much the same way. Here is wh handles the review f yur appeal at each f these levels.

189 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 187 Level 3 Appeal A judge wh wrks fr the Federal gvernment will review yur appeal and give yu an answer. This judge is called an Administrative Law Judge. If the Administrative Law Judge says yes t yur appeal, the appeals prcess may r may nt be ver - We will decide whether t appeal this decisin t Level 4. Unlike a decisin at Level 2 (Independent Review Organizatin), we have the right t appeal a Level 3 decisin that is favrable t yu. If we decide nt t appeal the decisin, we must authrize r prvide yu with the service within 60 calendar days after receiving the judge s decisin. If we decide t appeal the decisin, we will send yu a cpy f the Level 4 Appeal request with any accmpanying dcuments. We may wait fr the Level 4 Appeal decisin befre authrizing r prviding the service in dispute. If the Administrative Law Judge says n t yur appeal, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu can cntinue t the next level f the review prcess. If the administrative law judge says n t yur appeal, the ntice yu get will tell yu what t d next if yu chse t cntinue with yur appeal. Level 4 Appeal The Appeals Cuncil will review yur appeal and give yu an answer. The Appeals Cuncil wrks fr the Federal gvernment. If the answer is yes, r if the Appeals Cuncil denies ur request t review a favrable Level 3 Appeal decisin, the appeals prcess may r may nt be ver - We will decide whether t appeal this decisin t Level 5. Unlike a decisin at Level 2 (Independent Review Organizatin), we have the right t appeal a Level 4 decisin that is favrable t yu. If we decide nt t appeal the decisin, we must authrize r prvide yu with the service within 60 calendar days after receiving the Appeals Cuncil s decisin. If we decide t appeal the decisin, we will let yu knw in writing. If the answer is n r if the Appeals Cuncil denies the review request, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu might be able t cntinue t the next level f the review prcess. If the Appeals Cuncil says n t yur appeal, the ntice yu get will tell yu whether the rules allw yu t g n t a Level 5 Appeal. If the rules allw yu t g n, the written ntice will als tell yu wh t cntact and what t d next if yu chse t cntinue with yur appeal.

190 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 188 Level 5 Appeal A judge at the Federal District Curt will review yur appeal. This is the last step f the administrative appeals prcess. Sectin 9.2 Levels f Appeal 3, 4, and 5 fr Part D Drug Appeals This sectin may be apprpriate fr yu if yu have made a Level 1 Appeal and a Level 2 Appeal, and bth f yur appeals have been turned dwn. If the value f the drug yu have appealed meets a certain dllar amunt, yu may be able t g n t additinal levels f appeal. If the dllar amunt is less, yu cannt appeal any further. The written respnse yu receive t yur Level 2 Appeal will explain wh t cntact and what t d t ask fr a Level 3 Appeal. Fr mst situatins that invlve appeals, the last three levels f appeal wrk in much the same way. Here is wh handles the review f yur appeal at each f these levels. Level 3 Appeal A judge wh wrks fr the Federal gvernment will review yur appeal and give yu an answer. This judge is called an Administrative Law Judge. If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. We must authrize r prvide the drug cverage that was apprved by the Administrative Law Judge within 72 hurs (24 hurs fr expedited appeals) r make payment n later than 30 calendar days after we receive the decisin. If the answer is n, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu can cntinue t the next level f the review prcess. If the administrative law judge says n t yur appeal, the ntice yu get will tell yu what t d next if yu chse t cntinue with yur appeal. Level 4 Appeal The Appeals Cuncil will review yur appeal and give yu an answer. The Appeals Cuncil wrks fr the Federal gvernment. If the answer is yes, the appeals prcess is ver. What yu asked fr in the appeal has been apprved. We must authrize r prvide the drug cverage that was apprved by the Appeals Cuncil within 72 hurs (24 hurs fr expedited appeals) r make payment n later than 30 calendar days after we receive the decisin. If the answer is n, the appeals prcess may r may nt be ver. If yu decide t accept this decisin that turns dwn yur appeal, the appeals prcess is ver. If yu d nt want t accept the decisin, yu might be able t cntinue t the next level f the review prcess. If the Appeals Cuncil says n t yur appeal r denies yur request t review the appeal, the ntice yu get will tell yu whether the rules allw yu t g n t a Level 5 Appeal. If the rules allw yu t g n, the written ntice will als tell yu wh t cntact and what t d next if yu chse t cntinue with yur appeal.

191 questin mark Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 189 Level 5 Appeal A judge at the Federal District Curt will review yur appeal. This is the last step f the appeals prcess. MAKING COMPLAINTS SECTION 10 Hw t make a cmplaint abut quality f care, waiting times, custmer service, r ther cncerns If yur prblem is abut decisins related t benefits, cverage, r payment, then this sectin is nt fr yu. Instead, yu need t use the prcess fr cverage decisins and appeals. G t Sectin 4 f this chapter. Sectin 10.1 What kinds f prblems are handled by the cmplaint prcess? This sectin explains hw t use the prcess fr making cmplaints. The cmplaint prcess is used fr certain types f prblems nly. This includes prblems related t quality f care, waiting times, and the custmer service yu receive. Here are examples f the kinds f prblems handled by the cmplaint prcess. If yu have any f these kinds f prblems, yu can make a cmplaint Cmplaint Example Quality f yur medical care Are yu unhappy with the quality f the care yu have received (including care in the hspital)? Respecting yur privacy D yu believe that smene did nt respect yur right t privacy r shared infrmatin abut yu that yu feel shuld be cnfidential? Disrespect, pr Has smene been rude r disrespectful t yu? custmer service, Are yu unhappy with hw ur yur Healthcare Cncierge has treated r ther negative yu? behavirs Waiting times D yu feel yu are being encuraged t leave the plan? Are yu having truble getting an appintment, r waiting t lng t get it? Have yu been kept waiting t lng by dctrs, pharmacists, r ther health prfessinals? Or by ur yur Healthcare Cncierge r ther staff at the plan? Examples include waiting t lng n the phne, in the waiting rm, when getting a prescriptin, r in the exam rm.

192 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 190 Cmplaint Example Cleanliness Are yu unhappy with the cleanliness r cnditin f a clinic, hspital, r dctr s ffice? Infrmatin yu get frm us D yu believe we have nt given yu a ntice that we are required t give? D yu think written infrmatin we have given yu is hard t under stand? Timeliness (These types f cmplaints are all related t the timeliness f ur actins related t cverage decisins and appeals) The prcess f asking fr a cverage decisin and making appeals is ex plained in Sectins 4-9 f this chapter. If yu are asking fr a decisin r making an appeal, yu use that prcess, nt the cmplaint prcess. Hwever, if yu have already asked us fr a cverage decisin r made an appeal, and yu think that we are nt respnding quickly enugh, yu can als make a cmplaint abut ur slwness. Here are examples: If yu have asked us t give yu a fast cverage decisin r a fast appeal, and we have said we will nt, yu can make a cmplaint. If yu believe we are nt meeting the deadlines fr giving yu a cver age decisin r an answer t an appeal yu have made, yu can make a cmplaint. When a cverage decisin we made is reviewed and we are tld that we must cver r reimburse yu fr certain medical services r drugs, there are deadlines that apply. If yu think we are nt meeting these deadlines, yu can make a cmplaint. When we d nt give yu a decisin n time, we are required t fr ward yur case t the Independent Review Organizatin. If we d nt d that within the required deadline, yu can make a cmplaint. Sectin 10.2 The frmal name fr making a cmplaint is filing a grievance Legal Terms What this sectin calls a cmplaint is als called a grievance. Anther term fr making a cmplaint is filing a grievance. Anther way t say using the prcess fr cmplaints is using the prcess fr filing a grievance.

193 Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 191 Sectin 10.3 Step-by-step: Making a cmplaint Step 1: Cntact us prmptly either by phne r in writing. Usually, calling yur Healthcare Cncierge is the first step. If there is anything else yu need t d, yur Healthcare Cncierge will let yu knw. Call (TTY: 711) Octber 1 - February 14, 8AM 8PM Eastern, 7 days a week; February 15 - September 30, 8AM 8PM Eastern, Mnday thrugh Friday. If yu d nt wish t call (r yu called and were nt satisfied), yu can put yur cmplaint in writing and send it t us. If yu put yur cmplaint in writing, we will respnd t yur cmplaint in writing. Expedited r fast grievances will be respnded t within 24 hurs if the grievance is related t the plan s refusal t make a fast cverage rganizatinal determinatin r recnsideratinand yu haven t received the medical care yet. We will address ther grievance requests within 30 days after receiving yur cmplaint. If we need mre infrmatin and the delay is in yur best interest r if yu ask fr mre time, we can take up t 14 mre calendar days t respnd t yur cmplaint. Be sure t prvide all pertinent infrmatin. Make sure yur grievance letter includes: yur name, yur member ID number (listed n yur membership ID card), yur address, yur telephne number, what yur grievance is abut, the facts related t yur grievance, and the reslutin yu are seeking. Send yur written cmplaint (als knwn as a grievance) t us within 60 days f the event r incident t: HealthTeam Advantage Attn: Appeals and Grievances 7800 McClud Rad, Suite 100 Greensbr, NC Or: Fax: Whether yu call r write, yu shuld cntact yur Healthcare Cncierge right away. The cmplaint must be made within 60 calendar days after yu had the prblem yu want t cmplain abut. If yu are making a cmplaint because we denied yur request fr a fast cverage decisin r a fast appeal, we will autmatically give yu a fast cmplaint. If yu have a fast cmplaint, it means we will give yu an answer within 24 hurs. Legal Terms What this sectin calls a fast cmplaint is als called an expedited grievance.

194 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 9. What t d if yu have a prblem r cmplaint (cverage decisins, appeals, cmplaints) 192 Step 2: We lk int yur cmplaint and give yu ur answer. If pssible, we will answer yu right away. If yu call us with a cmplaint, we may be able t give yu an answer n the same phne call. If yur health cnditin requires us t answer quickly, we will d that. Mst cmplaints are answered in 30 calendar days. If we need mre infrmatin and the delay is in yur best interest r if yu ask fr mre time, we can take up t 14 mre calendar days (44 calendar days ttal) t answer yur cmplaint. If we decide t take extra days, we will tell yu in writing. If we d nt agree with sme r all f yur cmplaint r dn t take respnsibility fr the prblem yu are cmplaining abut, we will let yu knw. Our respnse will include ur reasns fr this answer. We must respnd whether we agree with the cmplaint r nt. Sectin 10.4 Yu can als make cmplaints abut quality f care t the Quality Imprvement Organizatin Yu can make yur cmplaint abut the quality f care yu received t us by using the step-by-step prcess utlined abve. When yur cmplaint is abut quality f care, yu als have tw extra ptins: Yu can make yur cmplaint t the Quality Imprvement Organizatin. If yu prefer, yu can make yur cmplaint abut the quality f care yu received directly t this rganizatin (withut making the cmplaint t us). The Quality Imprvement Organizatin is a grup f practicing dctrs and ther health care experts paid by the Federal gvernment t check and imprve the care given t Medicare patients. T find the name, address, and phne number f the Quality Imprvement Organizatin fr yur state, lk in Chapter 2, Sectin 4, f this bklet. If yu make a cmplaint t this rganizatin, we will wrk with them t reslve yur cmplaint. Or yu can make yur cmplaint t bth at the same time. If yu wish, yu can make yur cmplaint abut quality f care t us and als t the Quality Imprvement Organizatin. Sectin 10.5 Yu can als tell Medicare abut yur cmplaint Yu can submit a cmplaint abut HealthTeam Advantage Plan I directly t Medicare. T submit a cm plaint t Medicare, g t Medicare takes yur cmplaints seriusly and will use this infrmatin t help imprve the quality f the Medicare prgram. If yu have any ther feedback r cncerns, r if yu feel the plan is nt addressing yur issue, please call MEDICARE ( ). TTY/TDD users can call

195 CHAPTER 10 Ending yur membership in the plan

196 Chapter 10. Ending yur membership in the plan 194 Chapter 10. Ending yur membership in the plan SECTION 1 Sectin 1.1 Intrductin This chapter fcuses n ending yur membership in ur plan SECTION 2 Sectin 2.1 When can yu end yur membership in ur plan? Yu can end yur membership during the Annual Enrllment Perid Sectin 2.2 Yu can end yur membership during the annual Medicare Advantage Disenrllment Perid, but yur chices are mre limited Sectin 2.3 Sectin 2.4 In certain situatins, yu can end yur membership during a Special Enrllment Perid Where can yu get mre infrmatin abut when yu can end yur membership? SECTION 3 Sectin 3.1 SECTION 4 Sectin 4.1 Hw d yu end yur membership in ur plan? Usually, yu end yur membership by enrlling in anther plan Until yur membership ends, yu must keep getting yur medical services and drugs thrugh ur plan Until yur membership ends, yu are still a member f ur plan SECTION 5 Sectin 5.1 Sectin 5.2 HealthTeam Advantage Plan I must end yur membership in the plan in certain situatins When must we end yur membership in the plan? We cannt ask yu t leave ur plan fr any reasn related t yur health Sectin 5.3 Yu have the right t make a cmplaint if we end yur membership in ur plan

197 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 10. Ending yur membership in the plan 195 SECTION 1 Intrductin Sectin 1.1 This chapter fcuses n ending yur membership in ur plan Ending yur membership in HealthTeam Advantage Plan I may be vluntary (yur wn chice) r invluntary (nt yur wn chice): Yu might leave ur plan because yu have decided that yu want t leave. There are nly certain times during the year, r certain situatins, when yu may vluntari ly end yur membership in the plan. Sectin 2 tells yu when yu can end yur member ship in the plan. The prcess fr vluntarily ending yur membership varies depending n what type f new cverage yu are chsing. Sectin 3 tells yu hw t end yur membership in each situa tin. There are als limited situatins where yu d nt chse t leave, but we are required t end yur membership. Sectin 5 tells yu abut situatins when we must end yur membership. If yu are leaving ur plan, yu must cntinue t get yur medical care and prescriptin drugs thrugh ur plan until yur membership ends. SECTION 2 When can yu end yur membership in ur plan? Yu may end yur membership in ur plan nly during certain times f the year, knwn as enrllment perids. All members have the pprtunity t leave the plan during the Annual Enrllment Perid and during the annual Medicare Advantage Disenrllment Perid. In certain situatins, yu may als be eligible t leave the plan at ther times f the year. Sectin 2.1 Yu can end yur membership during the Annual Enrllment Perid Yu can end yur membership during the Annual Enrllment Perid (als knwn as the Annual Crdinated Electin Perid ). This is the time when yu shuld review yur health and drug cverage and make a decisin abut yur cverage fr the upcming year. When is the Annual Enrllment Perid? This happens frm Octber 15 t December 7. What type f plan can yu switch t during the Annual Enrllment Perid? During this time, yu can review yur health cverage and yur prescriptin drug cverage. Yu can chse t keep yur current cverage r make changes t yur cverage fr the upcming year. If yu decide t change t a new plan, yu can chse any f the fllwing types f plans: Anther Medicare health plan. (Yu can chse a plan that cvers prescriptin drugs r ne that des nt cver prescriptin drugs.) Original Medicare with a separate Medicare prescriptin drug plan. r Original Medicare withut a separate Medicare prescriptin drug plan.

198 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 10. Ending yur membership in the plan 196 Sectin 2.2 If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs: If yu switch t Original Medicare and d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu have pted ut f autmatic enrllment. Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) See Chapter 1, Sectin 5 fr mre infrmatin abut the late enrllment penalty. When will yur membership end? Yur membership will end when yur new plan s cverage begins n January 1. Yu can end yur membership during the annual Medicare Advantage Disenrllment Perid, but yur chices are mre limited Yu have the pprtunity t make ne change t yur health cverage during the annual Medicare Advantage Disenrllment Perid. When is the annual Medicare Advantage Disenrllment Perid? This happens every year frm January 1 t February 14. What type f plan can yu switch t during the annual Medicare Advantage Disenrllment Perid? During this time, yu can cancel yur Medicare Advantage Plan enrllment and switch t Original Medicare. If yu chse t switch t Original Medicare during this perid, yu have until February 14 t jin a separate Medicare prescriptin drug plan t add drug cverage. When will yur membership end? Yur membership will end n the first day f the mnth after we get yur request t switch t Original Medicare. If yu als chse t enrll in a Medicare prescriptin drug plan, yur membership in the drug plan will begin the first day f the mnth after the drug plan gets yur enrllment request. Sectin 2.3 In certain situatins, yu can end yur membership during a Special Enrllment Perid In certain situatins, members f HealthTeam Advantage Plan I may be eligible t end their membership at ther times f the year. This is knwn as a Special Enrllment Perid. Wh is eligible fr a Special Enrllment Perid? If any f the fllwing situatins apply t yu, yu are eligible t end yur membership during a Special Enrllment Perid. These are just exam ples, fr the full list yu can cntact the plan, call Medicare, r visit the Medicare website ( Usually, when yu have mved. If yu have Medicaid. If yu are eligible fr Extra Help with paying fr yur Medicare prescriptins.

199 Chapter 10. Ending yur membership in the plan 197 If we vilate ur cntract with yu. If yu are getting care in an institutin, such as a nursing hme r lng-term care hspital. When are Special Enrllment Perids? The enrllment perids vary depending n yur situatin. What can yu d? T find ut if yu are eligible fr a Special Enrllment Perid, please call Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users call If yu are eligible t end yur membership because f a special situatin, yu can chse t change bth yur Medicare health cverage and prescriptin drug cverage. This means yu can chse any f the fllwing types f plans: Anther Medicare health plan. (Yu can chse a plan that cvers prescriptin drugs r ne that des nt cver prescriptin drugs.) Original Medicare with a separate Medicare prescriptin drug plan. r Original Medicare withut a separate Medicare prescriptin drug plan. If yu receive Extra Help frm Medicare t pay fr yur prescriptin drugs: If yu switch t Original Medicare and d nt enrll in a separate Medicare prescriptin drug plan, Medicare may enrll yu in a drug plan, unless yu have pted ut f autmatic enrllment. Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) See Chapter 1, Sectin 5 fr mre infrmatin abut the late enrllment penalty. When will yur membership end? Yur membership will usually end n the first day f the mnth after yur request t change yur plan is received. Sectin 2.4 Where can yu get mre infrmatin abut when yu can end yur membership? If yu have any questins r wuld like mre infrmatin n when yu can end yur membership: Yu can call yur Healthcare Cncierge (phne numbers are printed n the back cver f this bklet). Yu can find the infrmatin in the Medicare & Yu 2018 Handbk. Everyne with Medicare receives a cpy f Medicare & Yu each fall. Thse new t Medi care receive it within a mnth after first signing up. Yu can als dwnlad a cpy frm the Medicare website ( Or, yu can rder a printed cpy by calling Medicare at the number belw.

200 Chapter 10. Ending yur membership in the plan 198 Yu can cntact Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call SECTION 3 Hw d yu end yur membership in ur plan? Sectin 3.1 Usually, yu end yur membership by enrlling in anther plan Usually, t end yur membership in ur plan, yu simply enrll in anther Medicare plan during ne f the enrllment perids (see Sectin 2 in this chapter fr infrmatin abut the enrllment perids). Hwever, if yu want t switch frm ur plan t Original Medicare withut a Medicare prescriptin drug plan, yu must ask t be disenrlled frm ur plan. There are tw ways yu can ask t be disenrlled: Yu can make a request in writing t us. Cntact yur Healthcare Cncierge if yu need mre infrmatin n hw t d this (phne numbers are printed n the back cver f this bklet). --r--yu can cntact Medicare at MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Nte: If yu disenrll frm Medicare prescriptin drug cverage and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. ( Creditable cverage means the cverage is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage.) See Chapter 1, Sectin 5 fr mre infrmatin abut the late enrllment penalty.

201 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 10. Ending yur membership in the plan 199 The table belw explains hw yu shuld end yur membership in ur plan. If yu wuld like t switch frm ur plan t: This is what yu shuld d: Anther Medicare health plan. Enrll in the new Medicare health plan. Original Medicare with a separate Medicare prescriptin drug plan. Original Medicare withut a separate Medicare prescriptin drug plan. Nte: If yu disenrll frm a Medi care prescriptin drug plan and g withut creditable prescriptin drug cverage, yu may need t pay a late enrllment penalty if yu jin a Medicare drug plan later. See Chapter 1, Sectin 5 fr mre in frmatin abut the late enrllment penalty. Yu will autmatically be disenrlled frm HealthTeam Advantage Plan I when yur new plan s cverage begins. Enrll in the new Medicare prescriptin drug plan. Yu will autmatically be disenrlled frm HealthTeam Advantage Plan I when yur new plan s cverage begins. Send us a written request t disenrll. Cntact yur Healthcare Cncierge if yu need mre infrmatin n hw t d this (phne numbers are printed n the back cver f this bklet). Yu can als cntact Medicare, at MEDICARE ( ), 24 hurs a day, 7 days a week, and ask t be disenrlled. TTY users shuld call Yu will be disenrlled frm HealthTeam Advantage Plan I when yur cverage in Original Medicare begins. SECTION 4 Until yur membership ends, yu must keep getting yur medical services and drugs thrugh ur plan Sectin 4.1 Until yur membership ends, yu are still a member f ur plan If yu leave HealthTeam Advantage Plan I, it may take time befre yur membership ends and yur new Medicare cverage ges int effect. (See Sectin 2 fr infrmatin n when yur new cverage begins.) During this time, yu must cntinue t get yur medical care and prescriptin drugs thrugh ur plan. Yu shuld cntinue t use ur netwrk pharmacies t get yur prescriptins filled until yur membership in ur plan ends. Usually, yur prescriptin drugs are nly cvered if they are filled at a netwrk pharmacy including thrugh ur mail-rder pharmacy services. If yu are hspitalized n the day that yur membership ends, yur hspital stay will usually be cvered by ur plan until yu are discharged (even if yu are discharged after yur new health cverage begins).

202 Chapter 10. Ending yur membership in the plan 200 SECTION 5 HealthTeam Advantage Plan I must end yur membership in the plan in certain situatins Sectin 5.1 When must we end yur membership in the plan? HealthTeam Advantage Plan I must end yur membership in the plan if any f the fllwing happen: If yu n lnger have Medicare Part A and Part B. If yu mve ut f ur service area. If yu are away frm ur service area fr mre than six mnths. If yu mve r take a lng trip, yu need t call yur Healthcare Cncierge t find ut if the place yu are mving r traveling t is in ur plan s area. (Phne numbers fr yur Healthcare Cncierge are printed n the back cver f this bklet.) If yu becme incarcerated (g t prisn). If yu are nt a United States citizen r lawfully present in the United States. If yu lie abut r withhld infrmatin abut ther insurance yu have that prvides prescriptin drug cverage. If yu intentinally give us incrrect infrmatin when yu are enrlling in ur plan and that infrmatin affects yur eligibility fr ur plan. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first.) If yu cntinuusly behave in a way that is disruptive and makes it difficult fr us t prvide medical care fr yu and ther members f ur plan. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first.) If yu let smene else use yur membership card t get medical care. (We cannt make yu leave ur plan fr this reasn unless we get permissin frm Medicare first.) If we end yur membership because f this reasn, Medicare may have yur case investi gated by the Inspectr General. If yu d nt pay the plan premiums fr 3 calendar mnths. We must ntify yu in writing that yu have 3 calendar mnths t pay the plan premium befre we end yur membership. If yu are required t pay the extra Part D amunt because f yur incme and yu d nt pay it, Medicare will disenrll yu frm ur plan and yu will lse prescriptin drug cverage.

203 Chapter 10. Ending yur membership in the plan 201 Where can yu get mre infrmatin? If yu have questins r wuld like mre infrmatin n when we can end yur membership: Yu can call yur Healthcare Cncierge fr mre infrmatin (phne numbers are printed n the back cver f this bklet). Sectin 5.2 We cannt ask yu t leave ur plan fr any reasn related t yur health HealthTeam Advantage Plan I is nt allwed t ask yu t leave ur plan fr any reasn related t yur health. What shuld yu d if this happens? If yu feel that yu are being asked t leave ur plan because f a health-related reasn, yu shuld call Medicare at MEDICARE ( ). TTY users shuld call Yu may call 24 hurs a day, 7 days a week. Sectin 5.3 Yu have the right t make a cmplaint if we end yur membership in ur plan If we end yur membership in ur plan, we must tell yu ur reasns in writing fr ending yur membership. We must als explain hw yu can file a grievance r make a cmplaint abut ur decisin t end yur membership. Yu can als lk in Chapter 9, Sectin 10 fr infrmatin abut hw t make a cmplaint.

204 CHAPTER 11 Legal ntices

205 Chapter 11. Legal ntices 203 Chapter 11. Legal ntices SECTION 1 SECTION 2 SECTION 3 Ntice abut gverning law Ntice abut nndiscriminatin Ntice abut Medicare Secndary Payer subrgatin rights...204

206 Chapter 11. Legal ntices 204 SECTION 1 Ntice abut gverning law Many laws apply t this Evidence f Cverage and sme additinal prvisins may apply because they are required by law. This may affect yur rights and respnsibilities even if the laws are nt included r explained in this dcument. The principal law that applies t this dcument is Title XVIII f the Scial Security Act and the regulatins created under the Scial Security Act by the Centers fr Medicare & Medicaid Services, r CMS. In additin, ther Federal laws may apply and, under certain circumstances, the laws f the state yu live in. SECTION 2 Ntice abut nndiscriminatin We dn t discriminate based n race, ethnicity, natinal rigin, clr, religin, sex, gender, age, mental r physical disability, health status, claims experience, medical histry, genetic infrmatin, evidence f insurability, r gegraphic lcatin. All rganizatins that prvide Medicare Advantage plans, like ur plan, must bey Federal laws against discriminatin, including Title VI f the Civil Rights Act f 1964, the Rehabilitatin Act f 1973, the Age Discriminatin Act f 1975, the Americans with Disabilities Act, Sectin 1557 f the Affrdable Care Act, and all ther laws that apply t rganizatins that get Federal funding, and any ther laws and rules that apply fr any ther reasn. SECTION 3 Ntice abut Medicare Secndary Payer subrgatin rights We have the right and respnsibility t cllect fr cvered Medicare services fr which Medicare is nt the primary payer. Accrding t CMS regulatins at 42 CFR sectins and , HealthTeam Advantage, as a Medicare Advantage Organizatin, will exercise the same rights f recvery that the Secretary exercises under CMS regulatins in subparts B thrugh D f part 411 f 42 CFR and the rules established in this sectin supersede any State laws.

207 CHAPTER 12 Definitins f imprtant wrds

208 Chapter 12. Definitins f imprtant wrds 206 Chapter 12. Definitins f imprtant wrds Ambulatry Surgical Center An Ambulatry Surgical Center is an entity that perates exclusively fr the purpse f furnishing utpatient surgical services t patients nt requiring hspitalizatin and whse expected stay in the center des nt exceed 24 hurs. Annual Enrllment Perid A set time each fall when members can change their health r drug plan r switch t Original Medicare. The Annual Enrllment Perid is frm Octber 15 until December 7. Appeal An appeal is smething yu d if yu disagree with ur decisin t deny a request fr cverage f health care services r prescriptin drugs r payment fr services r drugs yu already received. Yu may als make an appeal if yu disagree with ur decisin t stp services that yu are receiving. Fr example, yu may ask fr an appeal if we dn t pay fr a drug, item, r service yu think yu shuld be able t receive. Chapter 9 explains appeals, including the prcess invlved in making an appeal. Balance Billing When a prvider (such as a dctr r hspital) bills a patient mre than the plan s allwed cst-sharing amunt. As a member f HealthTeam Advantage Plan I (PPO), yu nly have t pay ur plan s cst-sharing amunts when yu get services cvered by ur plan. We d nt allw prviders t balance bill r therwise charge yu mre than the amunt f cst-sharing yur plan says yu must pay. Benefit Perid The way that bth ur plan and Original Medicare measures yur use f skilled nursing facility (SNF) services. A benefit perid begins the day yu g int a skilled nursing facility. The benefit perid ends when yu haven t received any skilled care in a SNF fr 60 days in a rw. If yu g int a skilled nursing facility after ne benefit perid has ended, a new benefit perid begins. There is n limit t the number f benefit perids. Brand Name Drug A prescriptin drug that is manufactured and sld by the pharmaceutical cmpany that riginally researched and develped the drug. Brand name drugs have the same active-ingredient frmula as the generic versin f the drug. Hwever, generic drugs are manufactured and sld by ther drug manufacturers and are generally nt available until after the patent n the brand name drug has expired. Catastrphic Cverage Stage The stage in the Part D Drug Benefit where yu pay a lw cpayment r cinsurance fr yur drugs after yu r ther qualified parties n yur behalf have spent $5,000 in cvered drugs during the cvered year. Centers fr Medicare & Medicaid Services (CMS) The Federal agency that administers Medicare. Chapter 2 explains hw t cntact CMS. Cinsurance An amunt yu may be required t pay as yur share f the cst fr services r prescriptin drugs. Cinsurance is usually a percentage (fr example, 20%). Cmbined Maximum Out-f-Pcket Amunt This is the mst yu will pay in a year fr all Part A and Part B services frm bth netwrk (preferred) prviders and ut-f-netwrk (nn- preferred) prviders. See Chapter 4, Sectin 1.2, fr infrmatin abut yur cmbined maximum ut-f-pcket amunt. Cmplaint The frmal name fr making a cmplaint is filing a grievance. The cmplaint prcess is used fr certain types f prblems nly. This includes prblems related t quality f care, waiting times, and the custmer service yu receive. See als Grievance, in this list f definitins.

209 Chapter 12. Definitins f imprtant wrds 207 Cmprehensive Outpatient Rehabilitatin Facility (CORF) A facility that mainly prvides rehabilitatin services after an illness r injury, and prvides a variety f services including physical therapy, scial r psychlgical services, respiratry therapy, ccupatinal therapy and speech-language pathlgy services, and hme envirnment evaluatin services. Cpayment An amunt yu may be required t pay as yur share f the cst fr a medical service r supply, like a dctr s visit, hspital utpatient visit, r a prescriptin drug. A cpayment is a set amunt, rather than a percentage. Fr example, yu might pay $10 r $20 fr a dctr s visit r prescriptin drug. Cst-sharing Cst-sharing refers t amunts that a member has t pay when services r drugs are received. (This is in additin t the plan s mnthly premium.) Cst-sharing includes any cmbinatin f the fllwing three types f payments: (1) any deductible amunt a plan may impse befre services r drugs are cvered; (2) any fixed cpayment amunt that a plan requires when a specific service r drug is received; r (3) any cinsurance amunt, a percentage f the ttal amunt paid fr a service r drug, that a plan requires when a specific service drug is received. A daily cst-sharing rate may apply when yur dctr prescribes less than a full mnth s supply f certain drugs fr yu and yu are required t pay a cpayment. Cst-Sharing Tier Every drug n the list f cvered drugs is in ne f five cst-sharing tiers. In general, the higher the cst-sharing tier, the higher yur cst fr the drug Cverage Determinatin A decisin abut whether a drug prescribed fr yu is cvered by the plan and the amunt, if any, yu are required t pay fr the prescriptin. In general, if yu bring yur prescriptin t a pharmacy and the pharmacy tells yu the prescriptin isn t cvered under yur plan, that isn t a cverage determinatin. Yu need t call r write t yur plan t ask fr a frmal decisin abut the cverage. Cverage determinatins are called cverage decisins in this bklet. Chapter 9 explains hw t ask us fr a cverage decisin. Cvered Drugs The term we use t mean all f the prescriptin drugs cvered by ur plan. Cvered Services The general term we use in this EOC t mean all f the health care services and supplies that are cvered by ur plan. Creditable Prescriptin Drug Cverage Prescriptin drug cverage (fr example, frm an emplyer r unin) that is expected t pay, n average, at least as much as Medicare s standard prescriptin drug cverage. Peple wh have this kind f cverage when they becme eligible fr Medicare can generally keep that cverage withut paying a penalty, if they decide t enrll in Medicare prescriptin drug cverage later. Custdial Care Custdial care is persnal care prvided in a nursing hme, hspice, r ther facility setting when yu d nt need skilled medical care r skilled nursing care. Custdial care is persnal care that can be prvided by peple wh dn t have prfessinal skills r training, such as help with activities f daily living like bathing, dressing, eating, getting in r ut f a bed r chair, mving arund, and using the bathrm. It may als include the kind f health-related care that mst peple d themselves, like using eye drps. Medicare desn t pay fr custdial care.

210 Chapter 12. Definitins f imprtant wrds 208 Daily cst-sharing rate A daily cst-sharing rate may apply when yur dctr prescribes less than a full mnth s supply f certain drugs fr yu and yu are required t pay a cpayment. A daily cst-sharing rate is the cpayment divided by the number f days in a mnth s supply. Here is an example: If yur cpayment fr a ne-mnth supply f a drug is $30, and a ne-mnth s supply in yur plan is 30 days, then yur daily cst-sharing rate is $1 per day. This means yu pay $1 fr each day s supply when yu fill yur prescriptin. Deductible The amunt yu must pay fr health care r prescriptins befre ur plan begins t pay. Disenrll r Disenrllment The prcess f ending yur membership in ur plan. Disenrllment may be vluntary (yur wn chice) r invluntary (nt yur wn chice). Dispensing Fee A fee charged each time a cvered drug is dispensed t pay fr the cst f filling a prescriptin. The dispensing fee cvers csts such as the pharmacist s time t prepare and package the prescriptin. Durable Medical Equipment (DME) Certain medical equipment that is rdered by yur dctr fr medical reasns. Examples include walkers, wheelchairs, crutches, pwered mattress systems, diabetic supplies, IV infusin pumps, speech generating devices, xygen equipment, nebulizers r hspital beds rdered by a prvider fr use in the hme. Emergency A medical emergency is when yu, r any ther prudent laypersn with an average knwledge f health and medicine, believe that yu have medical symptms that require immediate medical attentin t prevent lss f life, lss f a limb, r lss f functin f a limb. The medical symptms may be an illness, injury, severe pain, r a medical cnditin that is quickly getting wrse. Emergency Care Cvered services that are: 1) rendered by a prvider qualified t furnish emergency services; and 2) needed t treat, evaluate, r stabilize an emergency medical cnditin. Evidence f Cverage (EOC) and Disclsure Infrmatin This dcument, alng with yur enrllment frm and any ther attachments, riders, r ther ptinal cverage selected, which explains yur cverage, what we must d, yur rights, and what yu have t d as a member f ur plan. Exceptin A type f cverage determinatin that, if apprved, allws yu t get a drug that is nt n yur plan spnsr s frmulary (a frmulary exceptin), r get a nn-preferred drug at preferred lwer cst-sharing level (a tiering exceptin). Yu may als request an exceptin if yur plan spnsr requires yu t try anther drug befre receiving the drug yu are requesting, r the plan limits the quantity r dsage f the drug yu are requesting (a frmulary exceptin). Extra Help A Medicare prgram t help peple with limited incme and resurces pay Medicare prescriptin drug prgram csts, such as premiums, deductibles, and cinsurance. Generic Drug A prescriptin drug that is apprved by the Fd and Drug Administratin (FDA) as having the same active ingredient(s) as the brand name drug. Generally, a generic drug wrks the same as a brand name drug and usually csts less. Grievance - A type f cmplaint yu make abut us r ne f ur netwrk prviders r pharmacies, including a cmplaint cncerning the quality f yur care. This type f cmplaint des nt invlve cverage r payment disputes.

211 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 12. Definitins f imprtant wrds 209 Healthcare Cncierge A department within ur plan respnsible fr answering yur questins abut yur membership, benefits, grievances, and appeals. See Chapter 2 fr infrmatin abut hw t cntact yur Healthcare Cncierge. Hme Health Aide A hme health aide prvides services that dn t need the skills f a licensed nurse r therapist, such as help with persnal care (e.g., bathing, using the tilet, dressing, r carrying ut the prescribed exercises). Hme health aides d nt have a nursing license r prvide therapy. Hspice - An member wh has 6 mnths r less t live has the right t elect hspice. We, yur plan, must prvide yu with a list f hspices in yur gegraphic area. If yu elect hspice and cntinue t pay premiums yu are still a member f ur plan. Yu can still btain all medically necessary services as well as the supplemental benefits we ffer. The hspice will prvide special treatment fr yur state. Hspital Inpatient Stay A hspital stay when yu have been frmally admitted t the hspital fr skilled medical services. Even if yu stay in the hspital vernight, yu might still be cnsidered an utpatient. Incme Related Mnthly Adjustment Amunt (IRMAA) If yur incme is abve a certain limit, yu will pay an incme-related mnthly adjustment amunt in additin t yur plan premium. Fr example, individuals with incme greater than $85,000 and married cuples with incme greater than $170,000 must pay a higher Medicare Part B (medical insurance) and Medicare prescriptin drug cverage premium amunt. This additinal amunt is called the incme-related mnthly adjustment amunt. Less than 5% f peple with Medicare are affected, s mst peple will nt pay a higher premium. Initial Cverage Limit The maximum limit f cverage under the Initial Cverage Stage. Initial Cverage Stage This is the stage befre yur ttal drug csts including amunts yu have paid and what yur plan has paid n yur behalf fr the year have reached $3,750. Initial Enrllment Perid When yu are first eligible fr Medicare, the perid f time when yu can sign up fr Medicare Part A and Part B. Fr example, if yu re eligible fr Medicare when yu turn 65, yur Initial Enrllment Perid is the 7-mnth perid that begins 3 mnths befre the mnth yu turn 65, includes the mnth yu turn 65, and ends 3 mnths after the mnth yu turn 65. In-Netwrk Maximum Out-f-Pcket Amunt The mst yu will pay fr cvered Part A and Part B services received frm netwrk (preferred) prviders. After yu have reached this limit, yu will nt have t pay anything when yu get cvered services frm netwrk prviders fr the rest f the cntract year. Hwever, until yu reach yur cmbined ut-f-pcket amunt, yu must cntinue t pay yur share f the csts when yu seek care frm an ut-f-netwrk (nn-preferred) prvider. See Chapter 4, Sectin 1.2 fr infrmatin abut yur in-netwrk maximum ut-f-pcket amunt. Institutinal Special Needs Plan (SNP) A Special Needs Plan that enrlls eligible individuals wh cn tinuusly reside r are expected t cntinuusly reside fr 90 days r lnger in a lng-term care (LTC) facility. These LTC facilities may include a skilled nursing facility (SNF); nursing facility (NF); (SNF/NF); an intermediate care facility fr the mentally retarded (ICF/MR); and/r an inpatient psychiatric facility. An institutinal Special Needs Plan t serve Medicare residents f LTC facilities must have a cntractual arrangement with (r wn and perate) the specific LTC facility(ies). Institutinal Equivalent Special Needs Plan (SNP) An institutinal Special Needs Plan that enrlls eligible individuals living in the cmmunity but requiring an institutinal level f care based n the State assessment. The assessment must be perfrmed using the same respective State level f care assessment

212 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 12. Definitins f imprtant wrds 210 tl and administered by an entity ther than the rganizatin ffering the plan. This type f Special Needs Plan may restrict enrllment t individuals that reside in a cntracted assisted living facility (ALF) if neces sary t ensure unifrm delivery f specialized care. List f Cvered Drugs (Frmulary r Drug List ) A list f prescriptin drugs cvered by the plan. The drugs n this list are selected by the plan with the help f dctrs and pharmacists. The list includes bth brand name and generic drugs. Lw Incme Subsidy (LIS) See Extra Help. Medicaid (r Medical Assistance) A jint Federal and state prgram that helps with medical csts fr sme peple with lw incmes and limited resurces. Medicaid prgrams vary frm state t state, but mst health care csts are cvered if yu qualify fr bth Medicare and Medicaid. See Chapter 2, Sectin 6 fr infrmatin abut hw t cntact Medicaid in yur state. Medically Accepted Indicatin A use f a drug that is either apprved by the Fd and Drug Administratin r supprted by certain reference bks. See Chapter 5, Sectin 3 fr mre infrmatin abut a medically accepted indicatin. Medically Necessary Services, supplies, r drugs that are needed fr the preventin, diagnsis, r treatment f yur medical cnditin and meet accepted standards f medical practice. Medicare The Federal health insurance prgram fr peple 65 years f age r lder, sme peple under age 65 with certain disabilities, and peple with End-Stage Renal Disease (generally thse with permanent kidney failure wh need dialysis r a kidney transplant). Peple with Medicare can get their Medicare health cverage thrugh Original Medicare r a Medicare Advantage Plan. Medicare Advantage Disenrllment Perid A set time each year when members in a Medicare Advantage plan can cancel their plan enrllment and switch t Original Medicare. The Medicare Advantage Disenrllment Perid is frm January 1 until February 14, Medicare Advantage (MA) Plan Smetimes called Medicare Part C. A plan ffered by a private cmpany that cntracts with Medicare t prvide yu with all yur Medicare Part A and Part B benefits. A Medicare Advantage Plan can be an HMO, PPO, a Private Fee-fr-Service (PFFS) plan, r a Medicare Medical Savings Accunt (MSA) plan. When yu are enrlled in a Medicare Advantage Plan, Medicare services are cvered thrugh the plan, and are nt paid fr under Original Medicare. In mst cases, Medicare Advantage Plans als ffer Medicare Part D (prescriptin drug cverage). These plans are called Medicare Advantage Plans with Prescriptin Drug Cverage. Everyne wh has Medicare Part A and Part B is eligible t jin any Medicare health plan that is ffered in their area, except peple with End-Stage Renal Disease (unless certain exceptins apply). Medicare Cverage Gap Discunt Prgram A prgram that prvides discunts n mst cvered Part D brand name drugs t Part D enrllees wh have reached the Cverage Gap Stage and wh are nt already receiving Extra Help. Discunts are based n agreements between the Federal gvernment and certain drug manufacturers. Fr this reasn, mst, but nt all, brand name drugs are discunted. Medicare-Cvered Services Services cvered by Medicare Part A and Part B. All Medicare health plans, including ur plan, must cver all f the services that are cvered by Medicare Part A and B. Medicare Health Plan A Medicare health plan is ffered by a private cmpany that cntracts with Medi care t prvide Part A and Part B benefits t peple with Medicare wh enrll in the plan. This term in

213 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 12. Definitins f imprtant wrds 211 cludes all Medicare Advantage Plans, Medicare Cst Plans, Demnstratin/Pilt Prgrams, and Prgrams f All-inclusive Care fr the Elderly (PACE). Medicare Prescriptin Drug Cverage (Medicare Part D) Insurance t help pay fr utpatient prescriptin drugs, vaccines, bilgicals, and sme supplies nt cvered by Medicare Part A r Part B. Medigap (Medicare Supplement Insurance) Plicy Medicare supplement insurance sld by private insurance cmpanies t fill gaps in Original Medicare. Medigap plicies nly wrk with Original Medicare. (A Medicare Advantage Plan is nt a Medigap plicy.) Member (Member f ur Plan, r Plan Member ) A persn with Medicare wh is eligible t get cvered services, wh has enrlled in ur plan and whse enrllment has been cnfirmed by the Centers fr Medicare & Medicaid Services (CMS). Netwrk Pharmacy A netwrk pharmacy is a pharmacy where members f ur plan can get their pre scriptin drug benefits. We call them netwrk pharmacies because they cntract with ur plan. In mst cases, yur prescriptins are cvered nly if they are filled at ne f ur netwrk pharmacies. Netwrk Prvider Prvider is the general term we use fr dctrs, ther health care prfessinals, hspitals, and ther health care facilities that are licensed r certified by Medicare and by the State t prvide health care services. We call them netwrk prviders when they have an agreement with ur plan t accept ur payment as payment in full, and in sme cases t crdinate as well as prvide cvered services t members f ur plan. Our plan pays netwrk prviders based n the agreements it has with the prviders r if the prviders agree t prvide yu with plan-cvered services. Netwrk prviders may als be referred t as plan prviders. Optinal Supplemental Benefits Nn-Medicare-cvered benefits that can be purchased fr an additinal premium and are nt included in yur package f benefits. If yu chse t have ptinal supplemental benefits, yu may have t pay an additinal premium. Yu must vluntarily elect Optinal Supplemental Benefits in rder t get them. Organizatin Determinatin The Medicare Advantage Plan has made an rganizatin determinatin when it makes a decisin abut whether items r services are cvered r hw much yu have t pay fr cvered items r services. Organizatin determinatins are called cverage decisins in this bklet. Chapter 9 explains hw t ask us fr a cverage decisin. Original Medicare ( Traditinal Medicare r Fee-fr-service Medicare) Original Medicare is ffered by the gvernment, and nt a private health plan such as Medicare Advantage Plans and prescriptin drug plans. Under Original Medicare, Medicare services are cvered by paying dctrs, hspitals, and ther health care prviders payment amunts established by Cngress. Yu can see any dctr, hspital, r ther health care prvider that accepts Medicare. Yu must pay the deductible. Medicare pays its share f the Medicare-apprved amunt, and yu pay yur share. Original Medicare has tw parts: Part A (Hspital Insurance) and Part B (Medical Insurance) and is available everywhere in the United States. Out-f-Netwrk Pharmacy A pharmacy that desn t have a cntract with ur plan t crdinate r prvide cvered drugs t members f ur plan. As explained in this Evidence f Cverage, mst drugs yu get frm ut-f-netwrk pharmacies are nt cvered by ur plan unless certain cnditins apply. Out-f-Netwrk Prvider r Out-f-Netwrk Facility A prvider r facility with which we have nt

214 Chapter 12. Definitins f imprtant wrds 212 arranged t crdinate r prvide cvered services t members f ur plan. Out-f-netwrk prviders are prviders that are nt emplyed, wned, r perated by ur plan r are nt under cntract t deliver cvered services t yu. Using ut-f-netwrk prviders r facilities is explained in this bklet in Chapter 3. Out-f-Pcket Csts See the definitin fr cst-sharing abve. A member s cst-sharing requirement t pay fr a prtin f services r drugs received is als referred t as the member s ut-f-pcket cst requirement. PACE plan A PACE (Prgram f All-Inclusive Care fr the Elderly) plan cmbines medical, scial, and lng-term care services fr frail peple t help peple stay independent and living in their cmmunity (instead f mving t a nursing hme) as lng as pssible, while getting the high-quality care they need. Peple enrlled in PACE plans receive bth their Medicare and Medicaid benefits thrugh the plan. Part C see Medicare Advantage (MA) Plan. Part D The vluntary Medicare Prescriptin Drug Benefit Prgram. (Fr ease f reference, we will refer t the prescriptin drug benefit prgram as Part D.) Part D Drugs Drugs that can be cvered under Part D. We may r may nt ffer all Part D drugs. (See yur frmulary fr a specific list f cvered drugs.) Certain categries f drugs were specifically excluded by Cngress frm being cvered as Part D drugs. Part D Late Enrllment Penalty An amunt added t yur mnthly premium fr Medicare drug cverage if yu g withut creditable cverage (cverage that is expected t pay, n average, at least as much as standard Medicare prescriptin drug cverage) fr a cntinuus perid f 63 days r mre. Yu pay this higher amunt as lng as yu have a Medicare drug plan. There are sme exceptins. Fr example, if yu receive Extra Help frm Medicare t pay yur prescriptin drug plan csts, yu will nt pay a late enrllment penalty. Preferred Prvider Organizatin (PPO) Plan A Preferred Prvider Organizatin plan is a Medicare Advantage Plan that has a netwrk f cntracted prviders that have agreed t treat plan members fr a specified payment amunt. A PPO plan must cver all plan benefits whether they are received frm netwrk r ut-f-netwrk prviders. Member cst-sharing will generally be higher when plan benefits are received frm ut-f-netwrk prviders. PPO plans have an annual limit n yur ut-f-pcket csts fr services received frm netwrk (preferred) prviders and a higher limit n yur ttal cmbined ut-fpcket csts fr services frm bth netwrk (preferred) and ut-f-netwrk (nn-preferred) prviders. Premium The peridic payment t Medicare, an insurance cmpany, r a health care plan fr health r prescriptin drug cverage. Primary Care Physician (PCP) Yur primary care prvider is the dctr r ther prvider yu see first fr mst health prblems. He r she makes sure yu get the care yu need t keep yu healthy. He r she als may talk with ther dctrs and health care prviders abut yur care and refer yu t them. In many Medicare health plans, yu must see yur primary care prvider befre yu see any ther health care prvider. See Chapter 3, Sectin 2.1 fr infrmatin abut Primary Physicians. Prir Authrizatin Apprval in advance t get services r certain drugs that may r may nt be n ur frmulary. In a PPO, yu d nt need prir authrizatin t btain ut-f-netwrk services. Hwever, yu may want t check with the plan befre btaining services frm ut-f- netwrk prviders t cnfirm that the service is cvered by yur plan and what yur cst-sharing respnsibility is. Cvered services that need prir authrizatin are marked in the Benefits Chart in Chapter 4. Sme drugs are cvered nly if yur

215 2018 Evidence f Cverage fr HealthTeam Advantage Plan I (PPO) Chapter 12. Definitins f imprtant wrds 213 dctr r ther netwrk prvider gets prir authrizatin frm us. Cvered drugs that need prir authrizatin are marked in the frmulary. Prsthetics and Orthtics These are medical devices rdered by yur dctr r ther health care prvid er. Cvered items include, but are nt limited t, arm, back and neck braces; artificial limbs; artificial eyes; and devices needed t replace an internal bdy part r functin, including stmy supplies and enteral and parenteral nutritin therapy. Quality Imprvement Organizatin (QIO) A grup f practicing dctrs and ther health care experts paid by the Federal gvernment t check and imprve the care given t Medicare patients. See Chapter 2, Sectin 4 fr infrmatin abut hw t cntact the QIO fr yur state. Quantity Limits A management tl that is designed t limit the use f selected drugs fr quality, safety, r utilizatin reasns. Limits may be n the amunt f the drug that we cver per prescriptin r fr a defined perid f time. Rehabilitatin Services These services include physical therapy, speech and language therapy, and ccupatinal therapy. Service Area A gegraphic area where a health plan accepts members if it limits membership based n where peple live. Fr plans that limit which dctrs and hspitals yu may use, it s als generally the area where yu can get rutine (nn-emergency) services. The plan may disenrll yu if yu permanently mve ut f the plan s service area. Skilled Nursing Facility (SNF) Care Skilled nursing care and rehabilitatin services prvided n a cntinuus, daily basis, in a skilled nursing facility. Examples f skilled nursing facility care include physical therapy r intravenus injectins that can nly be given by a registered nurse r dctr. Special Enrllment Perid A set time when members can change their health r drug plan r return t Original Medicare. Situatins in which yu may be eligible fr a Special Enrllment Perid include: if yu mve utside the service area, if yu are getting Extra Help with yur prescriptin drug csts, if yu mve int a nursing hme, r if we vilate ur cntract with yu. Special Needs Plan A special type f Medicare Advantage Plan that prvides mre fcused health care fr specific grups f peple, such as thse wh have bth Medicare and Medicaid, wh reside in a nursing hme, r wh have certain chrnic medical cnditins. Step Therapy A utilizatin tl that requires yu t first try anther drug t treat yur medical cnditin befre we will cver the drug yur physician may have initially prescribed. Supplemental Security Incme (SSI) A mnthly benefit paid by Scial Security t peple with limited incme and resurces wh are disabled, blind, r age 65 and lder. SSI benefits are nt the same as Scial Security benefits. Urgently Needed Services Urgently needed services are prvided t treat a nn-emergency, unfreseen medical illness, injury, r cnditin that requires immediate medical care. Urgently needed services may be furnished by netwrk prviders r by ut-f-netwrk prviders when netwrk prviders are temprarily unavailable r inaccessible.

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