|Summary of Benefits for Medica Prime Solution® Value Plan|
January 1 – December 31, 2009
Thank you for your interest in Medica Prime Solution® Value. Our plan is offered by Medica Health Plans, a Medicare Cost Managed Care organization. This Summary of Benefits tells you some features of our plan. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call Medica Advantage Solution Choice and ask for the “Evidence of Coverage.”
You Have Choices In Your Health Care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like Medica Prime Solution Value. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare program.
You may be able to join or leave a plan only at certain times. Please call Medica Advantage Solution Value at the telephone numbers listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week.
How Can I Compare My Options?
You can compare Medica Prime Solution and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.
Where Is Medica Prime Solution Available?|
Who is eligible to join Medica Prime Solution?|
You can join Medica Prime Solution if you are entitled to Medicare Part A and enrolled in Medicare Part B or enrolled in Medicare Part B only and live in the service area. However, individuals with End- Stage Renal Disease are generally not eligible to enroll in Medica Prime Solution unless they are members of our organization and have been since their dialysis began.
Can I choose my doctors?
Medica Prime Solution Value has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or visit us HERE. Our customer service number is listed at the end of this introduction.
What happens if I go to a doctor who’s not in your network?
You can always choose to go to a doctor outside our network. We may not pay for the services you receive outside of our network, but Medicare will pay for its share of charges it approves. You will be responsible for Original Medicare deductible and coinsurance.
Does my plan cover Medicare Part B or Part D drugs?
Medica Prime Solution does cover Medicare Part B prescription drugs and if you purchase the Medica Part D Rider, Medicare Part D prescription drugs.
Where can I get my prescriptions if I join this plan and purchase the Medica Part D Rider?
Medica Prime Solution Value has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a Pharmacy Directory or visit us HERE. Our customer service number is listed at the end of this introduction.
Medica Prime Solution Value has a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower co-pay or coinsurance. You may go to an other network pharmacy, but you may have to pay more for your prescription drugs.
What is a prescription drug formulary?
Medica Prime Solution Value uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site HERE.
If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy.
How can I get extra help with prescription drug plan costs?
If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join Medica Prime Solution Value, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227),
TTY users should call 1-877-486-2048.
You can call this number 24 hours a day, 7 days a week.
What are my protections in this plan?|
All Medicare Cost Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Cost Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
If you purchase a Medica Part D Rider, the following applies: You have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.
What is a Medication Therapy Management (MTM) Program?
A Medication Therapy Management (MTM) Program is a free service we offer. You may be identified to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact Medica Prime Solution for more details.
What types of drugs may be covered under Medicare Part B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Medica Prime Solution for more details.