Get the most from your health plan benefits

Transcription

1 Get the most from your health plan benefits Dear Valued Member, Thank you for choosing a Florida Blue HMO Medicare Advantage plan for your health care needs. Your membership entitles you to a variety of programs and services and we want to make sure you take full advantage of them. For details about your plan and how to use it, visit floridablue.com/bm_hmo to download your member kit and check out our new member video. In addition, we ve enclosed two guides that you may find helpful: BlueMedicare SM HMO Owners Manual gives you answers to questions about your plan benefits and more. This booklet explains how your health and prescription drug coverage works including information about your health and wellness screenings plus other useful topics. Passport to Health is your personal guide to what you can do to stay healthy, with tips on living well, an overview of common chronic conditions, and helpful trackers and checklists to help you monitor your health, medications, doctor visits and more. Keep these easy-to-read guides handy so you can refer to them whenever you need information about your coverage, or need to get in touch with us should you have questions. Call TTY users should call Hours: 8 a.m. 8 p.m. local time, seven days a week from October 1 February 14, except for Thanksgiving and Christmas. From February 15 to September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. Click BlueMedicareFL.com Visit a Florida Blue Center. Call or go to floridabluecenters.com for locations. Contact your local agent. Y0011_85657H 1115 C: 12/2015 Continued on next page.

2 Your feedback is important to us! Continually improving your Florida Blue HMO Medicare Advantage plan and the benefits that come with it is our top priority. To ensure that we re meeting your needs, in the next few weeks you may receive an independent survey called the Consumer Assessment of Healthcare Providers and Systems in the mail. Should you be one of the few members selected by the Centers for Medicare & Medicaid Services to receive a survey about your health care, please know that your feedback is important to helping us develop better products and services for you. For the results to accurately represent the entire membership, it s important that each questionnaire be completed and returned. If you need help with the survey, please feel free to ask a friend or family member. Your mailed responses are confidential and appreciated. Remember, your Florida Blue HMO plan lets you enjoy: 3 $0 monthly plan premium 1 3 $0 copays for primary care doctor visits 3 FREE preventive care screenings 3 $0 deductible for prescription drug coverage and convenient mail-order delivery program 3 Dental and vision coverage 3 FREE SilverSneakers fitness membership 2 3 No-cost flu shots at most in-network doctors or pharmacies 3 New programs to help with chronic conditions like asthma and diabetes Thank you for helping us continue to improve our products and services for Medicare beneficiaries. Remember, whenever you need us, we re here for you. Sincerely, Luisa Charbonneau Vice President, Government Markets (Medicare) P.S. With the start of a new year, don t forget to get your annual wellness visit at no extra cost to you. 1 You must continue to pay your Medicare Part B premium. Florida Blue HMO is an HMO Plan with a Medicare contract. Enrollment in Florida Blue HMO depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. 2 The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. SilverSneakers is a registered mark of Healthways, Inc. HMO coverage is offered by Health Options, Inc., DBA Florida Blue HMO, an affiliate of Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association.

3 BlueMedicare HMO Owner s Manual Your guide to using your plan

4 Let s get started Understanding your plan benefits how they work, what to do and where to go to get the help you need is not always easy. Don t worry! We ve created this quick-answer guide to give you information to help get you started. For details about your plan and how to use it, visit floridablue.com/bm_hmo to download your member kit and check out our new member video. When you have questions, we ve got you covered. Call Your Member Services team is just a phone call away. Call (TTY users please call ) Hours: 8 a.m. - 8 p.m. local time, seven days a week from October 1 - February 14, except for Thanksgiving and Christmas. From February 15 - September 30, we are open Monday - Friday, 8 a.m. - 8 p.m. local time except for Federal holidays. Register online at BlueMedicareFL.com. Once your coverage is in effect, go to BlueMedicareFL.com, click on Log in, select Member and then Register. Once you register, you can: + Find doctors, hospitals and pharmacies + Look up claims quickly + Access prescription drug coverage information + Use member tools to help you save time and money 2

5 Contents Member Resources... 4 Online Tools... 5 Plan Documents... 6 Health and Wellness Screenings... 7 Annual Wellness Visit... 8 SilverSneakers Fitness Program... 9 Plan Benefits Prescription Drug Coverage Prim Home Delivery Formulary Exceptions Medication Therapy Management Medication Costs and Coverage Vaccination Coverage Questions? Call (TTY users please call ) 3

6 Use your Member Resources As a Florida Blue member, your satisfaction and health is important to us. Here s a list of important resources to keep on hand in case you need us. When you re ready, so are we! Member Services Our Member Services team is ready to assist with: + Benefits, claims and how to make the most of your plan + Finding doctors, hospitals and pharmacies near you + Health information and more! Care Consultant Team Our Care Consultants can help you understand your condition, plus help you explore treatment options, so you re able to make the choices that are best for you. CareCentrix Diabetic supplies, such as glucose meters and test strips, are provided by a durable medical equipment supplier. Have your doctor call our partner, CareCentrix. Care Coordination Program , option 4 For assistance with disease management and extended care, make sure your treatment and recovery are on the right path by simplifying the process through our Care Coordination program. Prim Home Delivery You can save time by using our Prim home delivery option for your prescription drug needs. For more information on how to sign up for the home delivery service, see page 15. 4

7 Take advantage of online member tools When you log in to the BlueMedicare member website, you ll have access to a complete menu of interactive tools: + Personal Health Assessment You ll find the Personal Health Assessment under the Health and Wellness tab. You ll be able to monitor your results, identify certain health risks and get suggestions for improving your health. + Health Assistant You can also locate the Health Assistant under the Health and Wellness tab. It s like an online wellness coach that provides progress reports and motivation. + And much more! Get help finding a doctor or hospital Finding a doctor or other provider is easy and right at your fingertips. Log in to BlueMedicareFL.com and select Find Doctors, Pharmacies and More. Look up prescription drugs and check costs Check if your prescription is covered, compare costs at nearby pharmacies, and find out if there s a generic drug substitute for a brand name drug. Just log in to BlueMedicareFL.com and select Compare Drug Prices under Tools. + Step 1: Enter the drug specifics requested. + Step 2: Select pharmacies based on zip code. + Step 3: Compare prices and lower cost options, when available. Plus, see when Step Therapy, Prior Authorization or other requirements apply. 5

8 Keep your plan documents Below is a list of the materials that you should have received in the mail. This information is important so be sure to keep it in a safe place. Annual Notice of Changes (ANOC) Evidence of Coverage Blue365 brochure BluePrint for Health Schedule Dental and Vision Benefit Schedule Diabetic Supplies Information Formulary Sent to existing members annually. The ANOC describes upcoming plan changes taking effect on the first of the following year. Your member contract. Provides a full description of the plan benefits, processes and requirements. Describes exclusive member discounts and other programs and services available. A wellness and support program providing personalized access to a number of health-related resources. Describes benefits included in most Florida Blue Medicare Advantage plans (if applicable). Complete details on the supplies that can be obtained through our partner, CareCentrix, versus your local pharmacy. The plan s list of covered drugs. Multi-language Insert Information on how to access translation services. Preventive Care Guidelines Prim Pharmacy Directory Provider Directory Information on Medicare-covered preventive services. Order form to obtain mail-order prescription medications. Listing of network pharmacies. Listing of network providers. 6

9 Take control of your health and wellness Getting your preventive screenings and immunizations are an important part of staying healthy. To make sure you re getting the support you need, this checklist can help you stay on track. General Screenings/ Immunizations Abdominal Aortic Aneurysm screening Age Varies How often One-time screening; see doctor for details. Blood pressure Any At least once a year Cholesterol levels Any Every 5 years (more frequently if at risk) Height and Weight (Body Mass Index) Any Annually Glaucoma screening Any Annually, if high risk Osteoporosis bone density screening Any Breast cancer screening 40+ Annually Cervical cancer screening Once every 2 years Varies Once every 2 years; annually, if high risk Flu vaccine Any Once a year during flu season Pneumonia vaccine Any Typically a twice in a lifetime shot Colon cancer screening Fecal Occult blood test 50+ Annually Colon Cancer screening Colonoscopy 50+ Every 10 years; every 2 years if OR high risk Sigmoidoscopy 50+ Every 4 years Please reference your Passport to Health booklet for a complete list of screenings and immunizations. To schedule a preventive care appointment, just call your primary care doctor in your plan. Questions? Call (TTY users please call ) 7

10 Don t miss your yearly wellness visit Your Welcome to Medicare preventive visit is available to you within your first 12 months of Medicare Part B enrollment. Your annual no-cost wellness visit is available to you after you ve been enrolled in Medicare Part B for 12 months. This routine exam helps you and your doctor determine if you have any health risks and may include the following: + A review of your family/medical history + A review of your prescription medications and current health care providers + Routine measurements including height, weight, BMI and blood pressure + A personalized schedule of preventive screenings and tests + A review of your risk of injury from falling and joint health + Assessment of overall emotional and physical health + Screening schedule Contact your primary care doctor to make an appointment. If you need help finding a new provider, please call our Member Services team. 8 Questions? Call (TTY users please call )

11 Stay Fit with SilverSneakers Stay in shape and exercise your way to health with Healthways SilverSneakers Fitness Program. Since there are more than 12,000 locations, you can find a workout location near you with expert staff, exercise equipment and fitness classes designed especially for people with Medicare all at no additional cost to you. The SilverSneakers program is included in your BlueMedicare plan, and you ve probably already received your membership card and details in the mail. If you need help choosing a participating location or to get a replacement card, call (TTY users call 711), Monday - Friday, 8 a.m. - 8 p.m. local time, or visit SilverSneakers.com. 9

12 Understand your plan benefits Dental Benefits Take care of your smile by using your BlueMedicare plan dental benefits. Annual exams, cleanings and x-rays may be covered at no cost to you through Florida Combined Life, a Florida Blue affiliate. To find an in-network dental professional in your area, visit BlueMedicareFL.com or call toll-free (TTY users call ), Monday - Friday, 7 a.m. - 8 p.m. ET. Vision Benefits Have your eyes checked annually by using your vision benefits, provided through Davis Vision. Davis Vision may call you to schedule an eye appointment. You get coverage on frames and lenses, too. To find an in-network eye care professional in your area, call toll-free

13 Urgent and Convenient Care Centers For colds, flu, allergies, sprains, minor injuries and more, urgent care centers are open when your doctor s office is not. With walk-in service and quality care, urgent care centers are a great alternative to the ER (emergency room) or doctor s office. Similarly, convenient care centers, often located inside many national pharmacy chains, can treat common illnesses, write prescriptions and administer vaccinations. If you need help finding an urgent care or convenient care center, call Member Services at (TTY users call ) or log in to BlueMedicareFL.com. 11

14 Know your prescription drug coverage Because your health is important to us, we d like to help you achieve better health. To do this, we ll monitor your medications and make sure you re: + Taking your medicine the way your doctor prescribed + Not taking medicines that have high risk of harm You may also want to make a list of all your prescription and over-the-counter medicines including vitamins and herbal supplements. You can use the enclosed Passport to Health booklet to record your medications and then share your list with your doctor. Ask him/her to discuss the risks and benefits of each medicine or identify any possible harmful drug interactions. Have questions? We ve got you covered. Your Member Services team is just a phone call away. Just call (select the option for prescription and pharmacy related questions). TTY users call Register online at BlueMedicareFL.com. Go to BlueMedicareFL.com and register for your member account. Then, click on Secure Member Website, log in, click My Plan, then select Pharmacy. Once you register, you can: + View and print a list of covered medications (formulary) + Find a pharmacy + Compare medication prices and print forms + Get answers to commonly asked questions 12

15 Review your formulary The list of prescription drugs covered by your Florida Blue plan is called a formulary. You can find the BlueMedicare formulary online anytime at BlueMedicareFL.com. Print it for your reference and/or share it with your doctor. You can also find a copy in your plan documents that were listed on page 6. Understanding your formulary Your formulary consists of five tiers or cost-sharing levels. The copay/ coinsurance increases with each tier level. The tiers are usually based on the availability of other drugs that can be used to treat the same specific medical condition and drug cost. Tier placement is designed to promote the use of the most effective and least costly drugs. This helps to improve affordability. TIER CATEGORY DESCRIPTION 1 Preferred generic drugs Lowest copay generic drugs 2 Generic drugs Higher copay generic drugs 3 4 Preferred brand name drugs Non-preferred brand name drugs Lower copay brand name drugs Higher copay brand name drugs or some generic drugs considered as high-risk medications 5 Specialty drugs High-cost generic and brand drugs 13

16 Medicare drug coverage stages Your Medicare Part D prescription drug coverage consists of three stages: + Initial Coverage Stage Initial coverage begins when you fill your first prescription of the year. During this stage, we pay our share of the cost of your drugs and you pay your share (copay or coinsurance*). You stay in this stage until your total drug costs, paid by you and us (or any third party on your behalf), reach $3,310, in *The coinsurance for each specialty drug is always based on a percentage of the negotiated drug cost. + Coverage Gap Stage For 2016, you ll continue to pay the same copay as in the Initial Coverage Stage for some generic drugs. Gap coverage varies by area. For brand name drugs, you ll pay 45% of the negotiated drug cost. Once you ve paid true out-of-pocket costs of $4,850 in 2016 (this includes payments made by you or certain individuals or organizations on your behalf and the 50% manufacturer s coverage gap discount), you are no longer in the coverage gap. + Catastrophic Coverage Stage Catastrophic coverage starts after your total paid out-of-pocket costs reach $4,850 for your Part D drugs and lasts until the end of the year. During the catastrophic stage, you pay the greater of $2.95 or 5% for generic drugs and $7.40 or 5% for brand name drugs. 14 Questions? Call (TTY users please call )

17 Sign up for Prim home delivery You can save time when you order your prescription drugs through our Prim home delivery program. Prim will deliver up to a 90-day supply of your long-term prescription drugs right to your door. Sign-up is easy Call Call , 24 hours a day, seven days a week (TTY users dial ). Online/Click Or, go to BlueMedicareFL.com, log in, click My Plan, then Pharmacy; select Home Delivery Service, then print and follow the instructions on the form. For new prescriptions, your doctor can use eprescribe, or fax the original prescription to Prim . You can also mail it to Prim directly. Tip You can save more money by using generic drugs. Be sure to ask your doctor if there is a generic substitute for your brand-name prescription drug. Before making the change, review your formulary to ensure the generic is covered. 15

18 When your doctor prescribes a non-formulary or high-copay drug Exceptions may be available if: 1. Your drug is subject to any Utilization Management restrictions 2. Your drug is not on the formulary 3. Your drug is on a tier for which you believe the copay is too high Your BlueMedicare HMO formulary was designed to include a wide range of drugs to cover various conditions. Talk to your doctor to see if there is a covered formulary alternative that may be better for you. If a drug is not covered as you believe it should be, ask your doctor about alternative formulary drugs or to request an exception by completing a coverage determination form. Types of Exceptions + Formulary Exception If your doctor prescribes a drug that is not on our formulary, you may ask your doctor to submit a formulary exception request so that your drug that is not on the formulary may be covered. If your exception request is approved, the nonformulary drug will be covered at the tier 4 copay. + Tier Exception You may obtain a tier exception to lower the copay of a drug. Tier exceptions may be requested to change the copay from tier 2 non-preferred generic to tier 1 preferred generic; or from tier 4 non-preferred brand to tier 3 preferred brand. Drugs on tier 5 are not eligible for a tiering exception. + Utilization Management In some cases, Step Therapy requires you to try a less costly drug before a higher priced alternative drug can be approved. You may request an exception to waive the Step Therapy requirement. The Quantity Limits of some drugs are based on maximum doses. If your therapy requires more than the monthly limit allows, talk with your doctor about requesting a quantity limit exception. In some cases, Prior Authorization may be required before prescribing certain medications. This safeguard ensures the medicines are clinically appropriate. 16

19 Transition supply (temporary supply) You may be eligible for a temporary supply of prescription drugs. This may give you and your doctor time to change your prescription to a medicine that is on the formulary, or to request an exception for a medication that is restricted in some way. A temporary supply may be available through your pharmacy if: + You are in the first 90 days of your plan membership or the first 90 days of the calendar year + You have been taking a medicine that is no longer on the formulary + The drug you ve been taking is subject to new restrictions + Copays and coinsurance may apply A temporary supply is limited to a 30-day supply. If you live in a long-term care facility, the temporary supply may be up to 98 days. Questions? Call (TTY users please call ) 17

20 Medication Therapy Management BlueMedicare HMO Medication Therapy Management (MTM) program is included in your plan coverage at no additional cost. MTM is a patient-centered comprehensive program designed to improve medication use, minimize the risk of harmful effects and ensure that medications are taken correctly. We ll review your prescription drugs and, if you meet certain criteria, you ll automatically be enrolled in the MTM program. Please notify us if you decide not to participate. As an MTM participant, you ll receive a medication review to help ensure safe and effective medication use. A pharmacist or other health care professional may call you to review your list of medications, explain how your medications work and their possible side effects, and address questions or concerns about your medications. By understanding your health and medication needs, we may be able to help you maintain your overall health and wellness, help you improve your condition with the medications you take, or identify and/or prevent problems that can occur when taking several medicines. Covering the cost of medications Many major drug manufacturers offer assistance programs for individuals who meet certain requirements. Visit medicare.gov/ pharmaceutical-assistance-program/index.aspx to learn more about Pharmaceutical Assistance Programs. Extra Help is a Federal program that helps pay for the cost of Medicare prescription drug coverage. You may qualify for Extra Help, also called the low-income subsidy, if your yearly income and resources are below certain limits. 18

21 To get more information or to see if you qualify, call: Medicare ( ). TTY users call , 24 hours a day, 7 days a week; or + the Social Security office at , 7 a.m. - 7 p.m., Monday - Friday. TTY users call ; or + your State Medicaid Office at TTY users call Vaccination coverage Medicare Part D covers all medically necessary vaccines that are not covered under Part C. Examples are the shingles or tetanus vaccines. Cost-sharing rules about vaccinations can be complex. Check with Member Services for more information. Flu and pneumonia vaccines are covered under your Part C (medical benefit) and are available from your doctor or certain participating retail pharmacies. Hepatitis B vaccine may be covered under the medical or pharmacy benefit based on your medical condition. Call Member Services at before you get a vaccination. TTY users call We ll review your coverage, what you ll pay, and how to save money by using providers and pharmacies in your plan s network. If you can t use a provider or pharmacy in the network, we ll explain what you need to do in order for us to pay our part of the cost. 19

22 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/ or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. SilverSneakers is a registered mark of Healthways, Inc. Florida Blue HMO is an HMO plan with a Medicare contract. Enrollment in Florida Blue HMO depends on contract renewal. HMO coverage is offered by Health Options, Inc., DBA Florida Blue HMO, an affiliate of Blue Cross and Blue Shield of Florida, Inc., DBA Florida Blue. These companies are Independent Licensees of the Blue Cross and Blue Shield Association. Y0011_85628H 1115 C: 12/2015