2015 medicare advantage prescription drug plan h2758_salespresentation_2015 approved
TRANSCRIPT
2015 Medicare Advantage
Prescription Drug Plan
H2758_SalesPresentation_2015 Approved
Presentation Topics
About BeHealthy America
Medicare Eligibility Requirements
A Look at the Four Parts of Medicare (A, B, C and D)
Who is Eligible for BeHealthy America’s Plan?
Enrollment Overview
Presentation Topics
How to Enroll on BeHealthy America
How to contact BeHealthy America
What happens after an Enrollment Application is completed?
Member Rights and Safeguards
Important Disclaimer Information
Providers and BeHealthy America’s 2015 HMO Plan.
Q and A
Who is BeHealthy America?
A Medicare Advantage Prescription Drug (MAPD) Plan
Founded by local healthcare and medical professionals
Serves members in Sarasota and Manatee counties Personalized local service Located in Sarasota, Florida
Who is Eligible for Medicare?
There are 3 ways to obtain Medicare:
Turning age 65 Social Security Disability for 24 consecutive months
(eligibility begins on the 25th month) Diagnosed with End Stage Renal Disease (ESRD)
A Look at the Four Parts of Medicare
Medicare Part A Inpatient Hospital Home Health Care Skilled Nursing Hospice Care Nursing Rehabilitation Care No monthly premium for most individuals Deductibles and Cost-Sharing Apply
A Look at the Four Parts of Medicare
Medicare Part B Physician, Diagnostic, Preventive and Outpatient
Services Medical Equipment Some Drugs Deductibles and Cost-Sharing Apply Monthly premium applies, based on income level
A Look at the Four Parts of Medicare
Medicare Part C – Medicare Advantage Plans (MA) Offered through private insurance companies Includes benefits and services covered under Parts A
& B Additional Benefits that you don’t get with Original
Medicare HMO, PPO, PFFS or Cost Plans Often includes Prescription Drug coverage (MAPD)
A Look at the Four Parts of Medicare
Medicare Part D – Medicare Prescription Drug Coverage Can be offered as a stand-alone plan that goes with
original Medicare Stand Alone Prescription Drug Plans (PDP),may have
an additional monthly premium A Medicare Advantage (MA) plan can offer medical and
prescription benefits together as an Medicare Advantage Prescription Drug (MAPD) plan
Part D includes the mandatory use of a drug formulary
Who is Eligible to Join BeHealthy America’s MAPD Plan?
Medicare beneficiaries residing in our service areas Manatee County
Sarasota County
Must be enrolled in Medicare Parts A and B Medicare beneficiaries with End Stage Renal
Disease (ESRD) are not eligible to join
Important Eligibility Enrollment Dates
When to enroll and/or make a plan change for:
Initial Enrollment Period (IEP)• A seven month period when you are first eligible for
a Medicare Part A and/or B
Important Eligibility Enrollment Dates
When to enroll and/or make a plan change for:
Annual Enrollment Period (AEP)• October 15th through December 7th of each year
• For January 1st effective dates
Important Eligibility Enrollment Dates
When to enroll and/or make a plan change for:
Medicare Advantage Disenrollment Period (MADP)
• January 1st through February 14th each year
Important Eligibility Enrollment Dates
When to enroll and/or make a plan change for:
Lock-In• February 15th through December 31st each year
Important Eligibility Enrollment Dates
When to enroll and/or make a plan change for:
Special Enrollment Period (SEP)• Low Income Subsidy (LIS) eligibility
• During specific life events
How Do I Enroll?
BeHealthy America makes it easy to enroll:1. Enroll after our presentation
2. Schedule an appointment
3. Enroll by telephone at [855-522-2985]
4. Enroll online through the CMS Online Enrollment Center at www.medicare.gov
How Do I Contact BeHealthy America?
Call Us Customer Service
Toll-free telephone [855-522-2870] or TDD/TYY [855-522-2973]
We are open:
• October 1 to February 14: Monday through Sunday, 8:00 am – 8:00 pm
• February 15 to September 30: Monday through Friday, 8:00 am – 8:00 pm
Visit Our Office We are conveniently located in Lakewood Ranch at:
6948 Professional Parkway EastSarasota, FL 34240
What Happens After an Enrollment Application is Completed?
1. Completed enrollment applications are sent to BeHealthy for review
2. The Centers for Medicaid and Medicare Services (CMS) must approve all enrollment applications
3. Outbound Enrollment Verification call or letter
4. Confirmation Letter
New Member Enrollment Package The BeHealthy America Identification Card The Evidence of Coverage (EOC) Provider and Pharmacy Directory Drug Formulary Additional Information
What Happens After an Enrollment Application is Completed?
Member Rights and Safeguards
You always have the right to appeal any denial of coverage or payment for any benefits or services you believe should be covered
You can file a grievance if you are not satisfied with our benefits or services
Please refer to BeHealthy America’s Evidence of Coverage or you can contact our Customer Service team for more
detailed information
Disclaimers
BeHealthy America, Inc. is an HMO plan with a Medicare contract. Enrollment in BeHealthy America, Inc. depends on contract renewal.
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan.
Limitations, co-payment, and restrictions may apply.
Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1 of each year.
You must continue to pay your Medicare Part B premium.
Disclaimers
This information is available for free in other languages. Please contact the customer service number at 855-522-2780 or TDD/TTY relay 855-522-2973 Monday – Friday from 8:00 AM to 8:00 PM. From October 1 – February 14, we’re available seven days a week from 8:00 AM to 8:00 PM.
Other Pharmacies, Physicians and Providers are available in our network. Medicare beneficiaries may also enroll in BeHealthy America through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
Contracted Hospitals
Blake Medical Center Doctors Hospital of Sarasota Englewood Community Hospital Lakewood Ranch Medical Center Manatee Memorial Hospital
Contracted Providers
MAXhealth
21st Century Oncology
Sarasota Arthritis Center
Sarasota Vascular Specialists
Gulf Coast Medical Group
Kennedy-White Orthopedic Group
The Eye Associates
West FL Physician Network
Manatee Cardiology
Manatee Cardiologists
HCA – Healthcare America
HCA – Pinnacle Medical Group
Coastal Orthopedics and Sports Medicine of SW FL
North River Family Center
Cortez Foot & Ankle Specialists
BeHealthy America has contracts with the following medical provider groups in Sarasota and Manatee counties:
And many more quality medical providers
Why Choose BeHealthy America’s Medicare Advantage Part D (MAPD) Plan?
[$0] Monthly Plan Premium [$0] Copay for Primary Care Office Visits [$0] Copay for Tier One Generic Medications Prescription Drug Coverage in Gap Dental, Vision and Hearing Services Health Club Membership Transportation Service
Why Choose BeHealthy America’s Medicare Advantage Part D (MAPD) Plan?
Over the Counter (OTC) Allowance 24/7 Nurse Hotline Smoking Cessation Assistance Preventive Services and Screenings Over 500 Doctors from which to Choose Friendly Local Service
BeHealthy America’s 2015 Benefit Overview
Benefit Member Responsibility
Monthly Plan Premium [$0]
Annual Deductible [$0]
Maximum Out of Pocket (MOOP) [$4,500]
PCP Visit [$0]
Specialist Visit [$35]
Annual Wellness Exam [$0 copay]
Preventive Screenings and Immunizations
[$0 copay]
Silver and Fit Gym Membership [100% covered by the plan]
BeHealthy America’s 2015 Benefit Overview
Benefit Member Responsibility
Hospital Inpatient [ $125/day (Days 1-7); $0/day (days 8-90) ]
Ambulance [$150 copay]
Urgent Care [$35 Copay]
Emergency Room [ $65 copay ]
Durable Medical Equipment [20% coinsurance]
Diabetic Supplies [$0/monitoring supplies; $10 Copay/Orth Shoes or Inserts]
Diagnostic X-Rays and Routine Lab [$0 Copay]
BeHealthy America’s 2015 Benefit Overview
Additional Benefits
Podiatry Services Dental
Chiropractic Services Vision
Hearing 24 hour Nurse Hotline
Over the Counter (OTC) Allowance Transportation
Smoking Cessation Local Customer Service
BeHealthy America’s 2015 Prescription Drug Benefit Overview
Benefit Member Responsibility
Tier 1 Drugs - Preferred Generics [$0 Copay]
Tier 2 Drugs - Non-Preferred Generics [$7 Copay]
Tier 3 - Preferred Brand [$25 Copay]
Tier 4 - Non-Preferred Brand [$55 Copay]
Tier 5 - Specialty Drugs [33% Coinsurance]
Part B Drugs and Home Infusion Drugs [20% (Part B Drugs) / $0 Copay (Home Infusion Drugs)]
BeHealthy America Drug Formulary. This formulary will be distributed and can also be found at www.BeHealthyus.com.
Tier 1 generic prescriptions are covered 100%
Different out-of-pocket costs may apply for members who:
Have limited income
Live in long term care facilities
Access to Indian/Tribal/Urban (Indian Health Services) providers
Some medications may have quantity limits or they may need authorization from a medical provider
BeHealthy offers national in-network prescription coverage
BeHealthy America’s 2015 Prescription Drug Benefit Overview
BeHealthy America’s 2015 Prescription Drug Benefit Overview
Stage 1Yearly Deductible Stage
Stage 2Initial Coverage Stage
Not Applicable Members stay in this stage their year-to-date “total drug costs” reach [$2,960].
BeHealthy America’s 2015 Prescription Drug Benefit OverviewStage 3
Coverage Gap StageStage 4
Catastrophic Coverage Stage
Members pay either:
• a [$0] copay OR
• [65%] for covered generic drugsOR
• [45%] of covered brand drugs.
Members stay in this stage until their year-to-date costs reach [$4,700].
Members pay the greater of:
• [5%] of the cost of the drug, OR
• a [$2.65] copay for generic (including brand drugs treated as generic)
• a [$6.60] copay for all other drugs.
Understanding Drug Formulary Terms
Formulary Exception: Members can ask the plan to make an exception to the coverage rules
Transition Process: A newly eligible member, switching plans or having a change in level of health care, can receive a one-time 30-day supply of their current medication(s). Members in a long-term care will receive a 31-day supply
Cost Tiers: Each drug is categorized by Tier. These Tiers determine how much members will pay for that drug
Restrictions: Some drugs have Prior Authorization, Quantity Limits and/or Step Therapy requirements
Network: Extensive network of participating pharmacies and well as mail order options for long term medications
Understanding Drug Formulary Terms
Part D Late Enrollment Penalty
What is it? Are there exceptions?
Yes, if you have creditable drug coverage or you qualify for Extra Help, you will not pay a penalty
Help With Medicare Costs
Beneficiaries may qualify for extra help to pay prescription drug premiums and costs
Beneficiaries can call Medicare to see if they qualify for extra help:
1-800-MEDICARE (1-800-633-4227)
or
TDD/TTY relay users should call 1-877-486-2048,
24 hours a day/7 days a week
Help With Medicare Costs
Beneficiaries can also check with the following resources to see if they may quality for “extra help”
Contact the Social Security Office at 1-800-722-1213
between 7 AM and 7 PM, Monday through Friday
TDD/TTY Relay users should call 1-800-325-0778
Or call the Florida Medicaid Office at 1-866-762-2237
Review of BeHealthy America’s Summary of Benefits
Q & A Session
Thank you for considering BeHealthy America for your Medicare Advantage
PrescriptionDrug (MAPD) plan option!