Asuris TruAdvantage + Rx Enhanced (PPO) and Asuris TruAdvantage + Rx Classic (PPO)

This is benefit information for coverage beginning January 1, 2010.

Asuris TruAdvantage + Rx Enhanced (PPO) and Asuris TruAdvantage + Rx Classic (PPO) include affordable Part D prescription drug coverage you need for your current medications, as well as security in case your needs change.

• Copays as low as $4 per prescription for Tier 1 generic medications

• Formulary includes most Medicare-approved Part D prescription drugs

• Over 50,000 pharmacies nationwide, plus convenient mail-order service

• Coverage area includes: Benton, Ferry, Franklin, Kittitas, Spokane, Stevens and Whitman counties.

Type of Plan:	Medicare Advantage Preferred Provider Organization (PPO) plus Part D prescription drug coverage (MAPD)
Deductible:	$0 - Asuris TruAdvantage + Rx Enhanced (PPO) $265 prescription drug deductible and $50 medical deductible applied to Medicare-covered services - Asuris TruAdvantage + Rx Classic (PPO)
Copay:	As low as $4 copay per prescription for Tier 1 generic medications

 

Deductible and Copay Overview
	Asuris TruAdvantage + Rx Enhanced (PPO)	Asuris TruAdvantage + Rx Classic (PPO)
Deductible	$0	$265
Tier 1: Copay for generics	$4	$4
Tier 2: Copay for preferred brand-names	$30	$30
Tier 3: Copay for non-preferred brand-names	$56	$56
Tier 4*: Coinsurance for miscellaneous injectables	30%	26%
Tier 5*: Coinsurance for specialty medications	30%	26%
Coverage during the "coverage gap" After you've paid your yearly deductible (if you have one) and the yearly drug costs (paid by you and Asuris) reach $2,830, you enter the Coverage Gap.	You pay $4 copay per prescription for each 30-day supply for Tier 1 generics, or 100% of discounted drug costs for all other covered drugs until the total out-of-pocket costs for the year reach $4,550.	You pay 100% of discounted drug costs until the total out-of-pocket costs for the year reach $4,550.
Catastrophic Coverage	You pay the greater of 5% coinsurance or $2.50/$6.30 copay, depending upon the tier.

*Tiers 4 and 5 products are limited to a 30-day supply and may contain generic products.

Deductibles, copays and coinsurance are based on a 30-day supply of medications (31-day supply for long-term care) and are effective January 1, 2010 through December 31, 2010.

You must go to a network pharmacy to receive coverage.

Benefits, formulary, provider network, pharmacy network, premium and copays/coinsurance may change on January 1, 2011.  Please contact Asuris TruAdvantage (PPO) for details.

Information Brochure
This brochure is an overview of plan benefits, including premiums, cost-sharing and a partial listing of covered services (benefits at-a-glance).
(569k PDF) Information Brochure
 

Summary of Benefits
This brochure contains detailed information about this plan, including applicable conditions and limitations, premiums, cost-sharing (e.g., copays, coinsurance and deductibles), and any conditions associated with receipt or use of benefits.
(1,042k PDF) Summary of Benefits
 

Provider Directory
This brochure contains a listing of providers in your state. This directory is current as of the date at the bottom of each provider listing page. For the most up-to-date listing of providers, please go to Find a Provider, which is an online listing of all providers in our service areas.
(638k PDF) Provider Directory
 

Evidence of Coverage
This is the 2010 Evidence of Coverage Brochure.
(494k PDF) 2010 Evidence of Coverage
(75k PDF) Evidence of Coverage Addendum

This booklet is sent to members after they enroll. It explains the health plan coverage including:

• Service area
• Applicable conditions and limitations
• Premiums
• Cost sharing (e.g., copays, coinsurance and deductibles), including a description of how an individual may obtain additional information on the plan's tiered or copay level applicable to each drug
• Any conditions associated with receipt or use of benefits
• 60-day notice regarding removal or change in the preferred or tiered cost-sharing status of a Part D drug
• Out-of-network coverage
• Quality assurance policies and procedures, including medication therapy management, and drug and/or utilization management
• Potential for contract termination
• How to obtain an aggregate number of grievances, appeals and exceptions
   

Asuris Advantages Value-Added Programs
Asuris Advantages is a set of value-added programs that offer great savings to Asuris Northwest Health members. They are offered by a number of leading health-related companies. These programs include vision and hearing care services, and discounts at fitness centers. These programs are not insurance but are offered in addition to your medical or prescription drug plan to help you get information and support when you need it.
 

Plan Ratings
The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). You may use the web tools on www.medicare.gov and select "Compare Medicare Prescription Drug Plans" or "Compare Health Plans and Medigap Policies in Your Area" to compare the plan ratings for Medicare plans in your area.

Network Pharmacies

We have contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area.

Our pharmacy network includes 90-day supply, retail, mail order and specialty, chain, home infusion, long-term care and Indian Health Service/Tribal/Urban Indian Health Program pharmacies.  Please see the Summary of Benefits or your Evidence of Coverage for more information relating to quantity limitations and requirements for mail-order drug service.
(370k PDF) Pharmacy Directory

 
Listing of our 90-day pharmacies. These pharmacies are able to dispense up to a 90-day supply of most medications.
(104k PDF) 90-Day Pharmacy Listing

 
For additional network pharmacy information, contact Asuris TruAdvantage (PPO) Customer Service at the number to the right.
  

Formulary

Online Search » Search an online list of prescription medications to determine your copay/coinsurance amounts.
 

Abridged Formulary
This is a partial listing of the drugs on our formulary.
(407k PDF) Abridged Formulary
 

Comprehensive Formulary
This is a comprehensive listing of all of the drugs on our formulary.
(552k PDF) Comprehensive Formulary
 

Notice of Formulary Changes
This is a description of recent changes to our formulary drugs.
Notice of Formulary Changes - Coming soon
 

Transition Policy
Information for new enrollees on our Part D prescription drug plans.
(130k PDF) Our Transition Policy
 

Prior Authorization Requirements
Listing of Prior Authorization requirements for consideration of coverage for specific drugs.
 (127k PDF) Prior Authorization Requirements

Q.	What is Medicare? How does it work?
A.	Medicare is a federal health care program, managed by the Centers for Medicare & Medicaid Services (CMS), which provides health insurance to eligible individuals regardless of medical condition and to certain people with disabilities. Original Medicare is a fee-for-service plan with two components, Medicare Part A and Medicare Part B. Medicare Part A provides coverage for hospital bills (inpatient hospital care, hospice care, and home health care). This is financed by payroll taxes, with no premium to beneficiaries who have at least 40 quarters of Medicare-covered employment. The beneficiary pays a $1,100 deductible for hospital stays up to 60 days, with additional copays required for each stay longer than 60 days. Medicare Part B provides coverage for doctor bills (physician care as an inpatient at a hospital, at a doctor's office, or as an outpatient at a hospital or other health care facility) laboratory tests, physical therapy, and ambulance service. The 2010 Medicare Part B beneficiary premium is $110.50 per month. Medicare Part B has a $155 annual deductible, with coinsurance amounts for services after deductible is met.
Q.	What is a Medicare Advantage Plan?
A.	Medicare Advantage is the name for a few different types of plans that contract with the federal government. Medicare Advantage plans include Medicare Managed Care Plan (HMO), Medicare Preferred Provider Organization (PPO), Medicare Private Fee-for-Service plan (PFFS) and Medicare Cost and other specialty plans. Essentially, these plans reduce out-of-pocket expenses and provide greater coverage than traditional Medicare alone, providing all the benefits of Medicare Parts A and B, plus additional benefits. The beneficiary continues to pay the Medicare Part B premium as well as any additional premium charged by the Medicare Advantage plan. Asuris TruAdvantage is a PPO with a Medicare Advantage contract.
Q.	Who is eligible?
A.	Potential members need to be at least 65 years old or qualified as disabled by Medicare. They must have Medicare Parts A and B, live within the plan's service area, and not have end-stage renal disease (ESRD).
Q.	Why should you consider an Asuris TruAdvantage (PPO) plan as compared to an HMO plan or a Medicare Supplement?
A.	There are three types of health care plans that help protect you from unexpected costs. Health Maintenance Organizations (HMOs) are managed care plans that require the member to use only contracted doctors and hospitals and typically referrals are required to see specialists. Preferred Provider Organizations (PPOs) also have a contracted network of providers, but members can still see any provider that accepts Medicare patients and receive coverage. The plan pays more if you receive your care and services in-network. HMOs and PPOs offer increased benefits over Original Medicare such as physicals and vision care.  HMOs and PPOs roll Original Medicare benefits and supplemental benefits into one plan that replaces Medicare. Medicare Supplement plans are secondary policies to Medicare.  They do not have a network of providers and usually cost more per month than HMOs and PPOs.  Most Medicare Supplement plans typically do not offer coverage for physicals or vision care. Medicare Supplement (Medigap) plans help reduce your out-of-pocket medical expenses for unexpected medical costs associated with Medicare deductibles and coinsurance. This coverage can include the Part A and Part B deductibles and coinsurance, the skilled nursing facility coinsurance, as well as other benefits. There are twelve standardized Medigap plans, labeled “A” through “L” each with different sets of benefits and premiums.  Plan A has basic supplemental benefits, Plan J the most comprehensive.  All plans include basic benefits but not all insurance companies offer all Supplement plans.
Q.	What providers can I see?
A.	With an Asuris TruAdvantage (PPO) plan, members are free to see any contracted provider accepting Medicare patients. Our provider networks offer many qualified providers to choose from. When a member chooses to see a provider that is not in our network, the member's share of the costs will be greater. Members are encouraged to see in-network providers to receive the best benefit from the plan and lower out-of-pocket costs. The opportunity for members to choose who provides their care is one of the advantages of our Asuris TruAdvantage (PPO) plans.
Q.	How do you find in-network providers?
A.	You can check online in the Find a Provider section to see if a provider is on our network, or request a printed version of our provider directory.
Q.	What happens if I'm traveling and am outside the service area for an extended period of time?
A.	Asuris TruAdvantage (PPO) plans will cover you for medical emergencies anywhere in the world. There's a copay for services in a hospital emergency room. For non-urgent or routine care that is out-of-network, you'll pay the copay specified by your plan. With all of our Asuris TruAdvantage (PPO) plans, a Part D prescription drug coverage is not available outside the United States and its territories.
Q.	What dental coverage is included?
A.	With all of our Asuris TruAdvantage (PPO) plans, a member can go to any dentist and is covered up to $500 annually for routine preventive dental services such as cleanings, x-rays and exams. See the (1,402k PDF) Summary of Benefits for limitations.
Q.	What vision coverage is included?
A.	With all of our Asuris TruAdvantage (PPO) plans, members are eligible for routine vision exams once every two years. For Asuris TruAdvantage (PPO) and Asuris TruAdvantage + Rx Enhanced (PPO), there is a $10 copay per visit for in-network services, and vision hardware is covered up to $200 every two years. For Asuris TruAdvantage + Rx Classic (PPO), there is a $25 copay per visit for in-network services, and vision hardware is covered up to $100 every two years.
Q.	What about hearing services?
A.	With Asuris TruAdvantage + Rx Enhanced (PPO) and Asuris TruAdvantage (PPO), for Medicare-covered hearing exams (diagnostic hearing exams), there is a $10 copay per visit for in-network services. A $25 copay applies to Asuris TruAdvantage + Rx Classic (PPO).
Q.	Are prescription drugs covered?
A.	Yes, if you choose either Asuris TruAdvantage + Rx Enhanced (PPO) or Asuris TruAdvantage + Rx Classic (PPO). You pay a share of your prescription medication costs (copays or coinsurance), and your plan pays a share.
Q.	What if I don’t want prescription drug coverage?
A.	If you don't want or need prescription drug coverage, you can choose just the Asuris TruAdvantage (PPO) plan. Please note that if you were Medicare eligible, do not have creditable prescription drug coverage and didn't choose a Medicare Part D plan, there is a Medicare-imposed premium penalty for every month you could have enrolled but didn't.
Q.	What other services does Asuris TruAdvantage (PPO) provide?
A.	Access to discount programs such as vision care services, hearing care services, discounts at fitness clubs and discounts on prescription medications.
Q.	Are members locked into Asuris TruAdvantage (PPO) for a specific length of time?
A.	Yes, most people will be required to stay with the same plan for one year. For people currently on Medicare, the Annual Election Period (AEP) is November 15 to December 31. During this time, enroll in an Asuris TruAdvantage (PPO) plan and your coverage will start January 1. If you are already on a Medicare Advantage PPO, HMO or PFFS plan you can still switch to an Asuris TruAdvantage plan, or cancel your plan, during this time. If you are currently on Original Medicare or a Medicare Advantage plan you also have an Open Enrollment Period (OEP) from January 1 to March 31. During this time you can switch Medicare Advantage plans or cancel your plan and go back to Original Medicare Part A and B. Some limitations may apply. Once you enroll in our plan it is effective until January 1 of the following year. Your next opportunity to change or enroll comes on November 15 each year for a January 1 effective date.
Q.	What help is available for people with limited income?
A.	Individuals on limited income, applying for prescription drug plans (such as Asuris TruAdvantage + Rx (PPO)), may qualify for reduced premiums, copayments and/or coinsurance amounts. Please check the Asuris TruAdvantage (PPO) Information Brochure or log onto the CMS web site at www.medicare.gov for more information on eligibility guidelines. Please refer to the Low Income Subsidy flyer for more information on help available for people with limited incomes. (66k PDF) I Have Limited Income What Should I Do?

Members have several options for expressing dissatisfaction with our services or with those of a pharmacy or other provider.

Contact:

Medicare Advantage/Medicare Part D Appeals and Grievances S6D PO Box 12625 Salem, OR 97309-0625 Fax number for appeals and grievances: 1 (888) 309-8784

Grievances

A grievance is any complaint you make about us or one of our plan providers.  This does not involve payment or coverage disputes.

Examples of grievances include:

• Dissatisfaction with the customer service you receive.
• Dissatisfaction with the length of time spent waiting on the phone or in the pharmacy.
• Dissatisfaction with the length of time required to fill a prescription or the accuracy of filling a prescription.

Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling customer service at 1 (800) 541-8981.  TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.

You may also fill out a Grievance Form and return it to us. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative Form and return it to us, along with your complaint form.

We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.

 

Coverage Decisions and Appeals

Contact:

Medicare Part D Prior Authorization MS 2P PO Box 1071 Portland, OR 97207-1071 Number to call for oral coverage decision request: 1 (800) 541-8981 Fax number for coverage decisions:  1 (888) 335-3016 Number to call to request a redetermination (appeal): 1 (866) 749-0355

A coverage decision is made when we make a decision about the prescription drug benefits you can receive under the plan, and the amount you may pay for a drug.

Examples of coverage decisions include:

• Formulary exceptions*
• Copayment tiering exceptions*
  

Coverage decisions will be responded to within 72 hours for standard requests and 24 hours for expedited requests.** Coverage decisions can be submitted by you or your prescribing physician by filling out completely the Coverage Determination form and returning it to us. If you wish to appoint someone to act on your behalf, you must fill out completely an Appointment of Representative form and return it to us, along with your Coverage Determination form.

*If you are asking for a formulary or tiering exception, your prescribing physician  must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to the generic drugs.

**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.

Appeals

An appeal is any complaint you make when you want us to reconsider a decision we have made about your Part D prescription drug benefits.

Examples of appeals include:

• Our decision not to cover a drug, vaccine or other Part D benefit.
• Our decision not to reimburse you for a Part D drug that you paid for.
• Our denial of a coverage determination.
  

Appeals must be filed within 60 days of the payment or coverage denial. You must send an appeal to us in writing or by using our appeal form. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your appeal form.

We must notify you of the outcome of your appeal within 7 calendar days after receiving your appeal.

Additional information may be found by referring to the Evidence of Coverage in the section titled "What to do if you have a problem or complaint."

For more information, you may contact Customer Service at 1 (800) 541-8981. TTY users should call 711. From November 15 through March 1 our telephone hours are 8 a.m. to 8 p.m. seven days a week. After March 1 our telephone hours are 8 a.m. to 8 p.m., Monday through Friday, and you may leave a message on Saturdays, Sundays and holidays. We will return your call on the next business day.

Quality Improvement
Asuris works hard to provide quality programs for our members. We're here to help ensure that medication options for our members are appropriate, safe and effective. We have concurrent drug utilization review and safety initiatives geared to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions or therapy duplications.

Our medication policies and procedures are based on careful review of scientific information and input from practicing physicians.  Our ultimate goal is to enhance health outcomes with improved medication use for our members.

Medication Therapy Management

Medication Therapy Management (MTM) is a covered service offered to members of our Medicare Part D prescription drug plans. MTM is a voluntary program that is offered to our members, with limited eligibility requirements, to assist with controlling chronic disease. The MTM program is not actually a plan benefit, it is an educational program offered to members.

The MTM program is currently available to assist members in controlling the following conditions:

• Asthma
• High Cholesterol
• Diabetes
• Mental Health

For additional information about the program and eligibility, members should contact us at 1 (800) 541-8981.

Your rights and responsibilities upon disenrollment

• You must continue to use network pharmacies until you are disenrolled from our plan.
• You may only disenroll or switch prescription drug plans under certain circumstances.
• You have the right to make a complaint if we ask you to leave our plan.
   

Our rights and responsibilities upon your disenrollment
We will let you know, in writing, the date your coverage ends. We have the right to disenroll you for the following reasons:

• You are no longer eligible for Medicare prescription drug coverage.
• If we are no longer contracting with Medicare or we leave your service area.
• When you move out of our service area.
• You materially misrepresent third-party reimbursement.
• You fail to pay your plan premium.
• You provide fraudulent information when you enroll or let someone else use your enrollment card to get covered services. 

 

General Information

Contact:

Asuris Northwest Health TruAdvantage plans PO Box 12625 Salem, OR 97309-0625