getting the care you need. · 2021. 2. 12. · special needs plan (d-snp). we created this handbook...

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Getting thecare you need. Your D-SNP handbook

AetnaBetterHealth.com/virginia-hmosnp

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Welcome. We’re glad you chose an Aetna® Medicare Dual Eligible Special Needs Plan (D-SNP). We created this handbook with you in mind. Inside, you’ll find useful inf ormation and tips to help you get the care and health services you need.

Health care can be hard. But not when you have a whole team on your side. Give them a call to see how they can make getting the care you need easier.

What’s inside?

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3 Getting started 4-5 Your Aetna care team 6-7 Urgent care vs. emergency care 8-9 Your prescriptions 10-13 Extra benefits 14-15 Medicare key terms 16-17 Primary care checklist 19

Here for you.

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At Aetna®, our goal is to help make getting the care you need easy. Getting the right coverage when you need it can lead to better health. Your care team can help you get the benefits and services you need to help you reach your health goals. Our total approach to health includes three features that are at the core of everything we do.

Caring

D-SNPs are designed to take care of your total health and well-being, with the extra benefits and resources you need.

Convenient

Get the care you need in the place you live — giving you the support and confidence you need to get the most out of your plan. Aetna gives you access to the doctors and services you can trust close to home.

Connected

As an Aetna D-SNP member, you have a care team to connect you with helpful resources and programs in your community.

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Getting started. Get off to a grea t start by following these three easy steps:

1 Get to know your benefits Visit AetnaBetterHealth.com/virginia-hmosnp where you can:

• Find a doctor • See what drugs are covered • View the over-the-counter (OTC) catalog

2 Complete your health survey A member of your care team will call you to get to know you and your needs.

Be sure to take this important call to help you get all of the benefits and services available to you.

3 Schedule an appointment with your primary care physician (PCP) • Your plan requires you to have a PCP to help

coordinate your care

• Your PCP is listed on your member ID card

• If you need to change your PCP, just call your dedicated Member Services team

Be sure to take your Aetna® member ID card and your Medicaid ID card (if you have one) whenever you visit a doctor or pharmacy.


AetnaBetterHealth.com/virginia-hmosnp • Register for your personal website

• View your Evidence of Coverage (EOC)

• Find doctors and hospitals in the Aetna® network

• View your member ID card

• View your recent claims and prescriptions

Questions? We can help. 1-855-463-0933 (TTY: 711) 8 AM – 8 PM EST, 7 days a week Your dedicated Member Services team is ready to help.

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Your Aetna® care team.

Get to know your Aetna care team. They’ll help you manage your health and get the most out of your benefits.

Nurse care manager • Works with you and your

doctor to help create your overall care plan

To receive the best help from your care manager, it’s important to complete your health survey.

A member of your care team will call to learn about your needs and create a care plan with the benefits and services right for you. Care management associate

• Helps you with your state Medicaidbenefits

Sometimes, understanding your Medicaid benefits can be difficult. Your care management associate is there to answer any questions you might have. And they make sure you get the benefits you need.

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Social worker • Connects you with local community and state programs to help

you with:

• Meals• Local transportation• Rent, utilities and more

• Helps you with any social services questions that you may have

Get started — take your health survey today. 1-855-463-0933 (TTY: 711) 8:00 AM – 5:00 PM EST

Monday – Friday

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Urgent care vs. emergency care.

If you’re suddenly sick or injured, your first thought may be to head to the emergency room (ER). But depending on your medical issue, the ER may not be the most convenient choice. Urgent care centers can offer a more convenient way to get quick care.

If you’re unsure where to go, you can call our 24/7 Nurse Line.

This isn’t a complete list of reasons to visit an urgent care center or ER. In a medical emergency, call 911 or go to the closest ER.

Urgent care center Emergency room (ER)

PURPOSE Offers treatment for injuries or illnesses that aren’t life threatening

Offers treatment for serious injuries or illnesses

ADVANTAGES Conveniently accepts both walk-ins and appointments, may provide faster treatment, flexible hours

Offers emergency care, treats more serious health issues, open 24/7

SOME CONDITIONS EACH FACILITY TREATS

Allergies

Coughing

Upset stomach

Sinus infection

Broken bones

Sore throat

Flu symptoms

Difficulty breathing

Loss of consciousness

Severe burns

Chest pain or suspected heart attack

Severe bleeding

Acute stomach pain

Poisoning

Need help? 1-855-463-0933 (TTY: 711)

A registered nurse will answer your call 24/7.

In many situations, telehealth may be your best option. Ask your doctor if they offer telehealth visits.

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Your prescriptions. Prescription coverage To get the most out of your coverage, use these helpful tips:

Find a pharmacy With access to thousands of pharmacies in our nationwide network, you can get the medicines you need for your physical and emotional well-being.

To find a pharmacy in your network, visit AetnaBetterHealth.com/virginia-hmosnp/find-provider

Look through your over-the-counter (OTC) catalog Depending on your plan, you have a monthly or quarterly allowance to use for certain Medicare-approved over-the-counter products.

View your OTC catalog to see health and wellness products available for home delivery.

Get a 90-day supply Are there medicines you take regularly to maintain your health? With a 90-day supply, you can save time, and perhaps money, by refilling your prescriptions just once every three months.

For more information about a 90-day supply, visit AetnaBetterHealth.com/virginia-hmosnp/members/hmosnp/rxdrugs. Or simply contact your Member Services team.


Find out if your prescription drugsare covered You have prescription drug coverage for a wide range of medicines.

To see if a drug is covered and if there’s a cost, visit AetnaBetterHealth.com/virginia-hmosnp/formulary

Get a medicine review Our Medication Therapy Management (MTM) program helps you and your doctor manage your medicines. If you qualify, we’ll automatically enroll you in our MTM program. Participation is voluntary. And you can opt out of the program at any time.

If you qualify for the program, a pharmacist will review your medicines and talk with you about:

• How to get the most benefit from the drugsyou take

• Any side effects or reactions• Any questions or concerns you have• Options that may help you save money

Questions about your health? Call your care team. 1-855-463-0933 (TTY: 711) 8:00 AM – 5:00 PM EST Monday – Friday

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http://AetnaBetterHealth.com/virginia-hmosnp/members/hmo-snp/rxdrugs

http://AetnaBetterHealth.com/virginia-hmosnp/formulary


Your prescriptions. Your formulary At Aetna®, we have a broad list of covered drugs. It’s always good to check what your prescription drugs will cost. To do this, you’ll need to know what tier your drugs are on.

You can learn about your medicines by viewing your formulary, also called a drug list.

How to read your formulary Every Medicare prescription drug plan has a list of drugs it agrees to cover. Drug lists include both brand-name and generic drugs. They give you the information you need to know about your drug to help determine your cost share.

The drug(s) covered by your plan

The “tier” level or pricing category

The special rules for a drug

Italics means generic drugs

CAPITALS means brand-name drugs

Phrases to know: MO = mail order QL = quantity limit EA = each PA = prior authorization ST = step therapy

Locate your formulary at AetnaBetterHealth.com/ virginia-hmosnp/formulary


Cost management tips

To check the cost of your drug, you need to know what tier it’s on. Your formulary tells you the tier. Generally, the lower the tier, the less you pay. Your Evidence of Coverage shows you the drug cost for each tier. You may have further cost savings depending on your level of Extra Help.

View your formulary and talk to your doctor about the best, lowest cost prescriptions for you.

How can you get information about your drug costs?

Because you’re eligible for Medicaid, you qualify for and are getting “Extra Help” from Medicare to pay for your prescription drug plan costs.*

We sent you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs.” This is also known as the “Low Income Subsidy Rider” or the “LIS Rider.” It tells you about your drug coverage. If you don’t have this insert, just call Member Services at 1-855-463-0933 (TTY: 711) and ask for the LIS rider.

*Cost-sharing is based on your level of Extra Help. For generic or brand-name drugs treated like generics: $0, $1.30 or $3.70 For brand-name drugs: $0, $4 or $9.20

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http://AetnaBetterHealth.com/virginia-hmosnp/formulary


Extra benefits. Transportation Includes rides to and from plan-approved medical locations like doctors and hospitals — plus pharmacies, senior centers, adult day cares and even SilverSneakers® gyms.

Call your care team for more information and to schedule a ride.

Telehealth Telehealth makes seeing the doctor easy, and you can do it from home. With telehealth, you may be able to see network doctors by phone or secure video. Check to see if your doctor offers telehealth.

Say goodbye to smoking You’d be amazed by how fast your health can improve once you’ve quit. And how much better you can feel after you do. With the right tips and support, you can break the habit.

Call your care team to learn more about how we can help you quit.

Questions about your health? Call your care team. 1-855-463-0933 (TTY: 711) 8:00 AM – 5:00 PM EST Monday – Friday

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Stay in touch Did you know you might be able to get Lifeline cell service, plus an Android™ smartphone? And they’re both available at no extra cost to you.

Here’s what you’ll get: • Unlimited texts • Voice minutes • Data • An Android smartphone

Call your care team today to see if you qualify.

SilverSneakers® fitness program With this benefit, you can enjoy access to over 16,000 participating SilverSneakers locations nationwide. You can exercise at home, too, with online videos for yoga, strength training and more at no added cost to you.

For more information, visit SilverSneakers.com/GetStarted

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http://SilverSneakers.com/GetStarted


Medicare key terms. Coinsurance — This is the amount you may have to pay for your share of services. It’s usually a percentage (for example, 20 percent).

Copayment (copay) — This is the amount you may have to pay for your share of services. It’s usually a set dollar amount (for example, $10 for a prescription drug or $20 for a doctor visit).

Cost sharing — These are amounts your plan may require you to pay for your care. Examples of cost sharing include deductibles, copays and coinsurance.

Deductible — This is the amount some plans require you to pay for covered services before the plan starts to pay.

Drug tiers — This is a group of drugs in a formulary. Each tier requires a different level of payment. Higher tiers usually have higher cost sharing. For example, a drug on Tier 2 generally will cost more than a drug on Tier 1.

Explanation of Benefits (EOB) — This is a notice explaining charges, payments or any balances owed after a provider or pharmacy you’ve visited submits a claim. It may be sent by mail or electronically.

Evidence of Coverage (EOC) — This document gives you detailed information on your plan’s coverage, costs and your rights and responsibilities as a plan member.

Formulary — Also called a drug list, this is a list of prescription drugs your health plan covers. It can include both generic and brand-name drugs. Drugs in the formulary may cost less than drugs that are not on the list. How much a plan covers may vary from drug to drug.


In network — This means we have a contract with a doctor, pharmacy or other health care provider. We negotiate reduced rates with them to help you save money.

Maintenance medicines — These are prescription drugs people take on a regular basis. They help treat chronic conditions, such as asthma, diabetes, high blood pressure and other health conditions. You may be able to save money on your maintenance prescriptions by filling a 90-day supply at a retail or mail-order pharmacy.

Mail-order pharmacy — A convenient service where you can have your medicines delivered directly to your door. The preferred mail order service for your plan is CVS Caremark® Mail Service Pharmacy.

Premium — This is the amount you may be required to pay each month for coverage.

Urgent care centers — These centers can treat urgent medical issues that aren’t life threatening. A few examples are sprains, fractures and minor burns. If you have a medical issue that threatens your life, always visit the nearest ER or call 911 first.

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Primary care checklist.

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Your primary care physician (PCP) can help you build a plan to reach your health goals.

Here’s a checklist of important topics you may want to discuss with your PCP. Take this sheet, your Aetna® member ID card, and your Medicaid ID card (if you have one) to your next appointment. Then check the boxes and take notes as you talk about each item.

Medical history

Recent health changes

Major life events

Medicines Prescriptions:

Over the counter:

Medicine side effects

Vaccines Flu shot (date):Shingles (date):

Screenings (Blood pressure, cholesterol, colorectal)

Women’s health (Mammogram, pap smear, bone density)

Long-term health conditions (Diabetes monitoring, kidney function)

Mental health

Fall prevention

Write down any questions you’d like to discuss with your doctor.

We’re here to help. Be sure to call us if: • You have any questions • You’ve made an address change • You’d like someone else, like a

caregiver, to act on your behalf

1-855-463-0933 (TTY: 711) 8 AM – 8 PM EST, 7 days a week

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Thank you. Thanks again for being a valued member of the Aetna® family.

For mail order, you can get prescription drugs shipped to your home through the network mail-order delivery program. Typically, mail-order drugs arrive within 7 to 14 days. You can call the phone number on your member ID card if you do not receive your mail-order drugs within this time frame. Members who get “Extra Help” are not required to fill prescriptions at preferred network pharmacies in order to get low-income subsidy (LIS) copays. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary. Aetna Medicare’s pharmacy network includes limited lower-cost preferred pharmacies in: Rural Nebraska, Suburban Illinois, Suburban South Carolina, Rural Maine, Rural Michigan, Urban Michigan, Rural Alaska. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call the number on your member ID card or consult the online pharmacy directory at AetnaMedicare.com/pharmacyhelp. Participating physicians, hospitals and other health care providers are independent contractors and are neither agents nor employees of Aetna. The availability of any particular provider cannot be guaranteed, and provider network composition is subject to change. See Evidence of Coverage for a complete description of plan benefits, exclusions, limitations and conditions of coverage. Plan features and availability may vary by service area. SilverSneakers is a registered trademark of Tivity Health, Inc. © 2020 Tivity Health, Inc. All rights reserved. ©2020 Aetna Inc. Y0001_NR_4041_23376_2021_C 72.05.357.1-VA

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getting the care you need. · 2021. 2. 12. · special needs plan (d-snp). we created this handbook...

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