Medicare Advantage Oregon | Medicare Prescriptions

Information Brochure
This brochure is an overview of Medicare, this plan, benefits at-a-glance, advantages, and more.

(696k PDF) Information Brochure

Summary of Benefits
This brochure provides a detailed description of the product, benefits at-a-glance, advantages and more.

(501k PDF) Summary of Benefits

Evidence of Coverage

This is the 2009 Evidence of Coverage Brochure.

(481k PDF) 2009 Evidence of Coverage

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., co-payments, coinsurance and deductibles), including a description of how an individual may obtain additional information on the plan's tiered or co-payment 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
   

Regence Advantages Value-Added Programs
Regence Advantages is a set of value-added programs that offer great savings to Regence BlueCross BlueShield of Oregon 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 take charge of your health.

Network Pharmacies

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

(331k PDF) Pharmacy Directory

Listing of our 90-day pharmacies. These pharmacies are able to dispense up to a 90-day supply of most medications.

(98k PDF) 90-Day Pharmacy Listing

Formulary

Search prescription medications to determine your copay/coinsurance amounts.

(426k PDF) Abridged Formulary

(595k PDF) Comprehensive Formulary

Information for new enrollees on our Part D prescription drug plans.

(103k PDF) Our Transition Policy

Listing of Prior Authorization requirements for consideration of coverage for specific drugs.

  (124k PDF) Prior Authorization Requirements

Planning to Enroll Later? It Could Cost You Extra

To avoid paying extra for your Regence MedAdvantage + Rx Core, Regence MedAdvantage + Rx Classic or Regence MedAdvantage + Rx Enhanced prescription drug plan, you'll need to enroll as soon as you're eligible. How much more depends on how long you wait to enroll.
 

To calculate your penalty, Medicare uses the following information:

• The monthly Part D base premium established by the Centers for Medicare and Medicaid Services (not the rate you pay to your health plan). For 2009, that base premium is $30.36. 
• The number of months you waited to enroll after you became eligible.
• A 1% late enrollment penalty percentage.
   

Medicare multiplies the number of months you waited to enroll after you became eligible by the 1% of premium late enrollment penalty percentage. The resulting percentage amount is added to your monthly rate.
 

For example, if you waited 12 months to enroll, you'll pay an extra $3.64 each month for your coverage [$30.36 x 12% = $3.64] Keep in mind that the base prescription premium can increase each year, so your penalty amount can increase with it. You must pay this penalty as long as you have Medicare prescription drug coverage.
 

That's why it pays to enroll right away!

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

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, 8 a.m. to 8 p.m., seven days a week. TTY users should call 711. You may also fill out a Complaint 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 complaint.

Coverage Determinations

A coverage determination 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 determinations include:

• Formulary exceptions*
• Copayment tiering exceptions*
   

Coverage determinations will be responded to within 72 hours for standard requests and 24 hours for expedited requests.** Coverage determinations can be submitted by you or your prescribing physician by filling out the Coverage Determination form in its entirety and returning 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 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 may 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 "Appeals and Grievances: what to do if you have complaints."

For more information, you may contact Customer Service seven days a week, 8 a.m. to 8 p.m., at 1-800-541-8981.  TTY users should call 711.

Quality Improvement
Regence 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 program 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 and Diabetes
• Asthma and High Cholesterol
• Diabetes and High Cholesterol
• Asthma, Diabetes and High Cholesterol

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 abuse your enrollment card.

Notification in the event of Medicare contract termination
We have a contract with the Centers for Medicare & Medicaid Services (CMS), which is the government agency that runs Medicare. This contract may be renewed each year. However, we or CMS can decide to end the contract at any time. You will generally be notified 90 days in advance if this situation occurs. However, your advance notice may be 30 days or less if CMS ends our contract in the middle of the year.

General Information

In- and Out-of-network Coverage
Coverage is provided for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary. Members may see out-of-network providers, but may pay more, with the exception of emergency or urgently-needed care.

Annual Renewal of Contract
Regence BlueCross BlueShield of Oregon MedAdvantage is a PPO with a Medicare Advantage contract.  CMS renews this contract annually and availability of this coverage beyond the end of the 2009 contract year is not guaranteed.

Part D Enrollment
Regence MedAdvantage + Rx Part D prescription drug coverage is only available to members of Regence MedAdvantage + Rx. If a beneficiary is already enrolled in a Medicare Advantage plan with Part D prescription drug coverage, the beneficiary must receive their Medicare Prescription Drug Benefit through that plan.

Medicare Premium Payment
Regence MedAdvantage members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third-party.