PriorityMedicare MeritSM

Transcription

1 PriorityMedicare MeritSM (PPO) 2013 Member Handbook Y0056_1000_1075_1 CMS-approved

2 Table of contents Welcome to PriorityMedicare Merit...5 Ten quick tips...6 Using your prescription drug benefits...15 Prescription costs Mail-order prescriptions Using out-of-network pharmacies Getting started with PriorityMedicare Merit...9 Plan basics Important documents Member ID card Using your medical benefits...11 Preventative care Comprehensive physical exam Doctor visits and referrals Urgent care Emergency care Hospital care Out-of-pocket maximum Other advantages of being a member...19 Silver&Fit Substance abuse and mental health problems Health management resources Medication Therapy Management Health Journal Your online account Glossary

3 Welcome to PriorityMedicare Merit You want the most from your Medicare coverage, and we re here to help. Inside this handbook, you ll find an overview of your plan, tips for using it and more. Please review this information. Then keep it in a convenient place and refer to it as needed. We look forward to serving you and making your life a little easier. 5

4 Ten quick tips To make your life a little easier 1 Carry your ID card. Show your PriorityMedicare Merit member identification (ID) card every time you visit a doctor or dentist or fill a prescription. You ll also need it if you visit an urgent care center or the emergency room. 2 Pick a Provider. Whether you do it now or later, sometime you re going to want to find a primary care provider (also known as a physician of choice) who ll make sure you get the care you need. 3 See a specialist. You don t need a referral to see a specialist. Your primary care provider can help you find one. Or you can locate one online at. Use the Find a Doctor link or contact Customer Service. 4 Use the network. Use providers and pharmacies within the Priority Health Medicare network. We ve negotiated discounted rates with them to save you money. See your Provider/Pharmacy directory for more information. 7 Travel safe and well. If you need medical assistance when traveling, you re covered. Go to any urgent care center or emergency room a copayment will apply. Be sure to follow up with your primary care provider when you return. 5 Ask for generics. If your prescription is for a namebrand medication, ask your doctor to recommend a generic alternative. The FDA requires that generic drugs have the same active ingredients as namebrand equivalents and they usually cost less. 8 Keep your records up to date. Let us know within 30 days if something changes so we can update our records. 6 Get your ounce of prevention. All Medicare-approved preventive care services are covered at 100%, such as immunizations and bone mass measurements*. And, be sure to get your yearly comprehensive physical exam there s no copayment required. 9 Register at. All you need is your contract number from your ID card. Your personal online account will give you access to claims information, deductibles and other important details and resources. * A separate office visit copay may apply. For out-of-network services, deductibles and copayments apply. 6 Questions about your benefits? Call Customer Service at (TTY users call 711).

5 10 Contact us! We re here to help. Any time you have a question, let us know. Call Customer Service or any of the other contacts listed on this page. Priority Health Medicare Customer Service For general information, visit To verify enrollment, request a member ID card, check claim status or for other questions: By phone: Toll-free a.m. - 8 p.m. 7 days a week TTY: Call a.m. - 8 p.m. 7 days a week By By mail: Go to prioritymedicare.com/contact-us to send a private, secure . Priority Health Medicare 1231 East Beltline NE Grand Rapids, MI Priority Health Behavioral Health For mental health and substance abuse questions: By phone: Toll-free Monday - Friday 8 a.m. - 5:30 p.m. Medicare For information about the federal Medicare program: By phone: 800 MEDICARE ( ) 24 hours a day, 7 days a week TTY/TDD: hours a day, 7 days a week 7

6 Getting started with PriorityMedicare Merit The first step in getting the most out of your PriorityMedicare Merit plan is to understand how it works. PriorityMedicare Merit is a health plan with a Medicare contract. Our plans offer the same benefits provided by Original Medicare plus extra coverage for fitness and wellness programs. Plan basics PriorityMedicare Merit is a Medicare Advantage plan with prescription drug coverage. It provides you with Medicare Parts A (hospitalization), B (medical) and D (prescription drugs) in one convenient plan. PriorityMedicare Merit is a Medicare Advantage preferred provider organization (PPO). As a PPO, it saves you money any time you use our network health care providers. Because it has an out-of-network option, you can use providers outside the network but you may pay more, except in an emergency or for urgently needed care, out-of-area dialysis and post-stabilization care. If you have any questions about your Medicare benefits, rights or responsibilities, contact Customer Service by using the number on the bottom of the next page. We re here to help you understand your Medicare coverage. Save Money Save on health care costs by using doctors, hospitals and pharmacies in our network. See your provider/ pharmacy directory, use the Find a Doctor tool at or call us at the number on the bottom of the next page. 9

7 PriorityMedicare Merit handbook Important documents These important documents explain the benefits for your PriorityMedicare Merit plan. Keep them in a safe place and refer to them as needed. Provider/Pharmacy Directory. This abbreviated directory lists the doctors, hospitals, other health care providers and pharmacies in the Priority Health Medicare network that are located near your home. A full provider/pharmacy directory is available online at ; just click on Find a Doctor. Or call Customer Service at the number listed on the bottom of this page. Using these network providers saves you money on your health care and prescription drug costs. Evidence of Coverage. This is your contract with Priority Health Medicare. It s a legal document that describes the services covered or excluded by your plan. Approved Drug List (formulary). This is a list of prescription medications that your PriorityMedicare Merit plan covers when prescribed by your doctor. Online Tools You ll find detailed information about your claims when you register your account online at. You can also view or print these documents from our website at. Type Medicare documents in the search box to find plan documents. Or request copies from Customer Service by calling the number on the bottom of this page. Member ID card Your PriorityMedicare Merit member ID card lists your contract number and copayment or coinsurance amounts. PriorityMedicare Merit SM (PPO) Name: [Member s Name, First, MI, Last] ID: [Member s ID# with the Plan] Group: [Group #] Show it whenever you use your benefits instead of your red, white and blue Medicare card. PriorityMedicare Merit will be billed for covered services. You ll have virtually no paperwork. Rx BIN: [Bin#] Rx PCN: [PCN#] Issuer: Prescription: Yes ER: $[xx] PCP: $[xx] Specialist: $[xx] CMS H4875 [001] It s illegal for anyone else to use your ID card. If it s lost or stolen, call Customer Service right away. Use the phone number listed on the bottom of this page. 10 Questions about your benefits? Call Customer Service at (TTY users call 711).

8 Using your medical benefits Your PriorityMedicare Merit plan provides the benefits you need, when you need them. Here s an overview of how to use them and their costs. Preventive care To help you stay healthy, your PriorityMedicare Merit plan covers preventive services at 100% if received from network providers (separate office visit copayment may apply). This includes annual mammograms, immunizations, colorectal exams, prostate cancer screenings and other services. See details in your plan s Evidence of Coverage. These services are available from out-of-network providers, too, but you ll be responsible for copayments, deductibles and coinsurance. Free yearly comprehensive physical exam Call your primary care provider today if you haven t had a comprehensive physical exam in the past 12 months. A comprehensive physical exam is not a routine office visit for diabetes, asthma, a heart condition or any other specific body part. During a comprehensive physical exam, your doctor examines you from head to toe, reviews your medications and discusses all of your health conditions past and present. This is a great time to check to see if you re also due for a mammogram (females), lab work or a colonoscopy, so you can get them scheduled during the office visit. Priority Health Medicare covers one comprehensive physical exam every year, so take advantage of your benefits! Save Money Keep the documents you receive in your membership packet in a safe place. Refer to them for detailed information about your PriorityMedicare Merit plan. Be sure to bring the helpful checklist located at the back of this handbook with you to your appointment as a reminder of all the things you should cover with your doctor. 11

9 PriorityMedicare Merit handbook Doctor visits and referrals Your primary care provider handles most of your health care needs. However, you don t need a referral to see a specialist. Just remember that using providers, including specialists, outside our network may cost more. Show your Priority Health Medicare ID card at the time of service and pay any copayments or coinsurance due. We ll be billed for covered expenses. Enjoy Convenience Use our prescription mail-order service for convenience and savings. You could have up to a 90-day supply of your prescription drugs delivered to your home. See page 16 for more information. Here s what a doctor visit will cost: In-network: $30 copayment for primary care provider (after paying the annual in and out-of-network deductible of $325) $45 copayment for specialist (after paying the annual in and out-of-network deductible of $325) Out-of-network: 20% coinsurance for doctor office visits (after paying the annual in and out-of-network deductible of $325) Urgent care If you need care right away but it s not life-threatening: First, call your primary care provider. If you can t reach your primary care provider, go to an urgent care center. If there s not an urgent care center in your area, go to an emergency room. Contact your primary care provider s office as soon as possible after treatment for follow-up care. You ll find a list of urgent care centers in your provider directory. If you re treated at one in our service area that s not in our network, your costs will be higher. However, if you re traveling outside our service area and need to visit an urgent care center anywhere in the world your costs will be the same as if the urgent care center were in our network. Here s what you can expect to pay for urgent care: $55 copayment for Medicare-covered* urgent care visit 12 Questions about your benefits? Call Customer Service at (TTY users call 711).

10 Using your medical benefits Emergency care For emergencies: Call 911 or seek immediate attention. Inform your primary care provider as soon as possible after treatment so followup care can be arranged. If you re admitted to the hospital as the result of your emergency room visit, you won t have to pay an emergency room copayment. Your PriorityMedicare Merit plan provides worldwide urgent and emergency care coverage. If you re traveling outside our service area even outside the country we ll cover your emergency treatment at the network rate. Here s what you can expect to pay for emergency care: $65 copayment for Medicare-covered* emergency room visit *See your Evidence of Coverage for details on Medicare-covered expenses. Hospital care You can use Medicare-approved hospitals anywhere in the country for medically necessary care. For in-network hospitals, you ll pay a copayment after the annual deductible is met. If the hospital isn t in our network, you ll pay a higher copayment after the annual deductible is met. This doesn t apply to emergency or urgent care when the network is not available (generally, when you are out of the area), dialysis services, and cases in which PriorityMedicare Merit authorizes use of out-of-network providers. You only pay the in-network copayment for these services (after the annual deductible is met). Here s what you can expect to pay for hospital care: In-network: For Medicare covered hospital stays: Days 1-5: $250 copayment per day (after paying the annual in and out-of-network deductible of $325) Out-of-network: 20% coinsurance for each Medicare-covered hospital stay (after paying the annual in and out-of-network deductible of $325) 13

11 PriorityMedicare Merit handbook Out-of-pocket maximum: Your PriorityMedicare Merit plan limits your out-of-pocket costs (the amount of money you pay yourself) for in-network health care services. This is your in-network out-of-pocket maximum. If you reach this amount in a plan year, we ll pay 100% of your Medicare-covered health care services. Get Answers If you have a question or dispute about a claim, or if you have questions about the health care services covered by your plan, contact Customer Service at the number on the bottom of this page. In-network: $5,000 There is a separate out-of-pocket maximum for out-of-network services. Out-of-network: $8,000 (combined in and out-of-network pocket maximum) You ll find information about this in your Evidence of Coverage. 14 Questions about your benefits? Call Customer Service at (TTY users call 711).

12 Using your prescription drug benefits Your PriorityMedicare Merit plan includes prescription drug coverage. Priority Health Medicare uses an approved drug list, also called a formulary. The most current list can be found on our website at or by calling Customer Service by using the number on the bottom of the previous page. Filling prescriptions To fill a prescription: First make sure the drug is on our approved drug list. Take your prescription to any network pharmacy. Show your PriorityMedicare Merit ID card at the pharmacy. Pay any copayment or coinsurance due, or the total charge if you re responsible for an out-of-pocket cost. You ll find a list of our network pharmacies in your provider/pharmacy directory. You can also go to and click on Find a Doctor to search for a pharmacy or contact Customer Service. Prescription costs Your costs depend on where you fill your prescription, the type and quantity of the drug and the total amount you ve already paid for prescriptions during the year. Enjoy Choice There are more than 65,000 pharmacies in the Priority Health Medicare network, including national chains. Any location of these chains in the U.S. is part of our network. You must use network pharmacies to fill your prescriptions. We ve negotiated discounts, which average 16% on most brand name drugs and up to 25% on generics. Be sure to ask about generics. A generic drug has the same active ingredient formula as the brand name drug. When you and your provider choose a generic drug, you save money and still get good medicine. 15

13 PriorityMedicare Merit handbook Coverage gap The coverage gap, sometimes called the donut hole refers to the period when you must pay for 100% of the discounted cost of your drugs. In 2013, once your total drug spend reaches $2,970 for the year, the coverage gap begins. Your total drug spend includes what you paid (your deductible, copayments, coinsurance) and what your plan paid toward your drug costs. When you re in the coverage gap: You ll need to pay for your own prescriptions, but you ll get a cost-break. You ll pay 47.5% of the cost of brand name drugs and 79% of generics. More discounts will be phased in over the next few years. By 2020, you ll only be responsible for 25%. If your drug total out-of-pocket expense reaches $4,750, catastrophic coverage begins. That means you ll only be responsible for a small copayment or coinsurance. Initial coverage period Coverage gap Catastrophic coverage period $2,970 You'll pay... $4,750 If your total drug spend 1 adds up to $2,970, you ll reach the coverage gap. 1 What you paid plus what your plan paid. In the coverage gap, you ll pay 47.5% for brand name drugs 79% for generics If your out-of-pocket expenses total $4,750 2, you ll be eligible for catastrophic coverage with small copayments or coinsurance. 2 What you paid for generics PLUS the full cost of brand-name drugs (what you paid plus the manufacturers discounts). 16 Questions about your benefits? Call Customer Service at (TTY users call 711).

14 Using your prescription drug benefits Mail-order prescriptions Save time and money by using our mail-order pharmacy to get up to a 90-day supply of your prescription drugs (specialty drugs are only available in a 31-day supply). The cost for a 90-day supply will be two-and-a-half times the 31-day copayment. You ll need to ask your doctor to write the prescription. Three ways to order your prescriptions: Complete and mail the Express Scripts form enclosed in this packet Order by phone 24 hours a day, seven days a week by calling (TTY users should call 711) Order refills online by going to and typing Express Scripts in the search box Prescriptions will be delivered to your home. Allow 14 days if you order by mail, or allow 7-10 days if you order by phone or online. Using out-of-network pharmacies You must use pharmacies in our network to receive prescription drug benefits from your PriorityMedicare Merit plan, except in certain cases. For example, when you re travelling or in need of a drug that cannot be found at a network pharmacy. If you choose to fill your prescription at a pharmacy that s not in our network, you ll have to pay upfront and seek reimbursement. Priority Health Medicare may reimburse you up to the negotiated in-network pharmacy cost (minus your copayment or coinsurance amount). We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Quantity limitations and restrictions may apply. 17

15 Other advantages of being a member Here are some of the extras you receive as a PriorityMedicare Merit plan member. Silver&Fit An exercise and wellness program As a Priority Health Medicare Advantage plan member, you may choose one of the following two options: There are no copayments, coinsurances or deductibles for the Silver&Fit programs. 1. Fitness center membership Your membership entitles you to take advantage of all the services and amenities included with your Silver&Fit fitness club or exercise center membership. 2. Home fitness program This program offers you the chance to participate in fitness and education activities in the comfort of your own home. When you join, you may choose to receive up to two of the following kits: Strength exercise kit Walking kit Yoga kit Tai Chi kit Pilates kit Aqua aerobics kit Stress management kit Dance kit The kits may include items such as a DVD, a booklet with general information about the topic and a Quick Start guide. Online Tools Whether you want to change your status, change your primary care provider or file a claim, you ll find all the forms you need online at. Or call Customer Service at the number on the bottom of the next page. We ll send you what you need. 19

16 PriorityMedicare Merit handbook Getting started 1. Consult your physician before you begin any exercise program. 2. For more information on enrolling in the program, fitness facilities, or to participate in the Home Fitness Program, visit and type silver in the search box. You may also call toll-free (TTY/TDD ) Monday through Friday, 8 a.m. 9 p.m. Substance abuse and mental health problems If you feel you may have a substance abuse or mental health problem, call: Priority Health Medicare Behavioral Health Department Toll-free Monday - Friday 8 a.m. - 5:30 p.m. TTY users call 711 You don t need to call your primary care provider first. Your call will be kept private. A mental health professional will talk with you about your situation. A treatment plan may be recommended or you may be informed about other services you need. These services will be covered by your PriorityMedicare Merit plan, unless the mental health counselor tells you differently. Health management resources Helping you stay healthy is important to you and to us. That s why we offer special programs to help people with chronic conditions, including: Asthma Diabetes Heart disease If you don t have a health condition but would like help living healthier, we offer programs for: Losing weight (obesity) Quitting smoking Eating healthier All programs are free to members who qualify. Talk with your primary care provider about programs that can help you improve your health. 20 Questions about your benefits? Call Customer Service at (TTY users call 711).

17 Other advantages of being a member Medication Therapy Management (MTM) program If you want to save money on your medications and improve your health, our free Medication Therapy Management (MTM) program can help. The MTM program gives you the chance to meet with a certified personal pharmacist each year for a comprehensive medication review. These pharmacists do much more than dispense drugs. Your MTM Personal Pharmacist is your personal resource and advocate. Getting your yearly medication review is just as important as getting a yearly physical exam. Your health condition can change every year and so can your medication needs. Your yearly medication review gives you the chance to discuss side effects and make changes if necessary. Your personal pharmacist will provide the following at no cost to you: Help understanding how to take your drugs, so you get the best results. Suggestions that will help save you money and relieve symptoms. Solutions that will resolve any concerns you have about your medications, including working with your doctor to make changes that will help you feel better. A master list of all your medications, including over-the-counter drugs that you can share with your doctor during your appointments. You won t need to switch pharmacies to participate in this free program and you can continue to use any Priority Health Medicare network pharmacy to fill your prescriptions. To get started, contact your certified MTM pharmacist to schedule your 30-minute comprehensive medication review. You can find a complete list of participating pharmacists on prioirtyhealth.com or contact Customer Service at the number listed at the bottom of the previous page. 21

18 PriorityMedicare Merit handbook Your online account If you have Internet access, register your account online. Go to prioirtyhealth.com and click on Create account in the log-in box. You ll need to enter your contract number, which is on your Priority Health Medicare ID card (after your name). With an online account, you can: Check the status of your claims, deductible and out-of-pocket balances Check your prescription history Find a doctor Use a variety of tools and resources from Priority Health and more. No computer? Don t worry. Just call the Customer Service number on bottom of this page. We ll be glad to help you. Health Journal As a PriorityMedicare Merit plan member, you ll also receive our newsletter. It s full of advice for taking good care of your health and tips for getting the most from your PriorityMedicare Merit benefits. 22 Questions about your benefits? Call Customer Service at (TTY users call 711).

19 Annual physical checklist Be sure to bring this helpful checklist with you to your appointment as a reminder of all the things you should cover with your doctor. Recommended exams and tests Complete physical exam with your doctor Annual flu shot Pneumonia vaccine Bone density test to check for osteoporosis (especially if you ve broken a bone or fallen in the last 6 months) Spirometry test, if recently diagnosed with chronic obstructive pulmonary disease (COPD), chronic bronchitis or emphysema Annual glaucoma test from an in-network eye care professional (go to and use the Find a Doctor tool to find an eye care professional in your area. You ll need to search under Specialists and select Ophthalmology or Optometrist ) Colon cancer screening Mammogram A comprehensive medication review (for more information go to priorityhealth. com and search keyword medication or call our Pharmacy Customer Service at toll-free Diabetes care: Diabetes dilated eye exam Cholesterol screening ACE inhibitor or ARB therapy Kidney function test HbA1C blood glucose test Also talk with your doctor about the following: How you can stay active or how you can become active Ways to prevent falls How you can improve bladder control Your feelings of sadness, worry or confusion Your LDL cholesterol level and how you can control it How to control your high blood pressure and lower it to less than 140/90 Disease-modifying anti-rheumatic drugs (DMARDs) to slow down rheumatoid arthritis disease progression Risks of medication you may be taking and safer alternatives Your treatment options, if you re considering surgery Completing an advance directive form Additional things you want to talk to your doctor about:

20 Glossary We want you to understand your benefits, so we ve put together explanations of a few terms we often use. Refer to your Evidence of Coverage for a complete glossary. If you have questions about any of the information in our materials, call Customer Service using the number on the bottom of the next page. Coinsurance This is the portion of your health care costs that you re responsible for paying, apart from any copayments or deductibles. Copayment A specified charge for a service, such as the amount you ll pay for an office visit or to fill a prescription. You usually must pay this immediately when getting health services. You ll find your copayment amounts listed on your ID card and in your Evidence of Coverage. Deductible The amount you must pay for health care or prescriptions before your plan begins to pay. See your Evidence of Covers for details about the deductible for your plan. Out-of-pocket costs The amount you must pay for health care or prescriptions including copayments, coinsurance and deductibles. Preventive care Care that helps to prevent illness before it occurs. Preventive care may also detect and treat certain conditions. Examples include routine immunizations, mammograms and prostate cancer screenings. Prior approval or prior authorization Priority Health Medicare must approve certain prescriptions, tests and procedures in advance in order for them to be covered otherwise, you could be required to pay the entire cost yourself. This includes scheduled inpatient hospital care, home health care and skilled nursing facility admissions. Refer to your Evidence of Coverage for details. Priority Health Medicare network Priority Health Medicare has special rates with a network of doctors, hospitals, pharmacies and other health care providers. You save on your health care costs when you use these network providers. Provider This may be your doctor, your doctor s office or a hospital or other facility that you use for health care. 25

21 Contact us Priority Health Medicare 1231 East Beltline NE Grand Rapids, MI By phone: Toll-free: , 8 a.m. - 8 p.m., 7 days a week TTY: Call 711, 8 a.m. - 8 p.m., 7 days a week Other Priority Health locations: Farmington Hills Holland Jackson Kalamazoo Traverse City The benefit information provided is a brief summary, not a complete description of benefits. For more information contact Priority Health Medicare or refer to your Evidence of Coverage. You must continue to pay your Part B premium. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1 of each year. 27

22 A PPO plan with a Medicare contract. This member handbook isn t a legal document. The official Medicare program provisions are contained in the relevant laws, regulations and rulings Priority Health MR HHH 10/12