The MyPlanAdvocate website provides information on Medicare-approved HMO plans, PPO plans, PFFS plans, POS plans, prescription drug plans offered by Medicare-approved Part D sponsors, and information on certain Medicare supplemental plans. MyPlanAdvocate represents multiple plans in most markets. To see plan specific information and disclaimers please click the Home link above and enter the required fields.
The benefit information provided is a summary, not a comprehensive description of benefits. To obtain information from the health plan, call (800) 650-6585 — TTY 711 and a MyPlanAdvocate Licensed Sales Agent/Producer can provide you with the customer service telephone number for the health plan from whom you would like to request benefit information. Printed materials may be available in alternative formats or languages. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, of each year. Plans may not be available to you the following contract year because by law, plans can choose to not renew their contract with the Centers for Medicare and Medicaid Services (CMS) or reduce their service area, and CMS may also refuse to renew the contract, thus, resulting in a termination or non-renewal of the health plan. You must continue to pay your Medicare Part B premium. Limitations, copayments, and restrictions may apply. Individuals must have both Part A and Part B to enroll in a MA or MA-PD plan. Members may enroll in the plan only during specific times of the year. You may enroll when you first become eligible for Medicare. In 2011 and subsequent years, you may enroll during the annual election period from October 15 through December 7. You may also enroll in special situations such as if you move, become eligible for Medicaid or Medi-Cal (CA), qualify for Extra Help to pay for your prescriptions, or if you live in an institution.
For some MA and MA-PD plans, you must receive all routine care from plan providers. You must use plan providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor your health plan will be responsible for the costs. For PPO, RPPO, and POS plans, it may cost more to get care from out-of-network providers, except in an emergency or for urgent care. A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare supplement plan. For certain Medicare Advantage Private-Fee-for-Service plans, your provider is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your provider does not agree to accept the plan’s payment terms and conditions of payment, they may choose not to provide health care services to you, except in emergencies. If this happens, you will need to find another provider that will accept the plan’s payment terms and conditions. Providers can find the plan’s terms and conditions on each plan’s website. For other types of Medicare Advantage Private-Fee-For-Service plans, some plans have network providers (that is, providers who have signed contracts with our plan) for all services covered under Original Medicare and some plans have network providers for only certain services covered under Original Medicare. These providers have already agreed to see members of the plan. If your provider is not one of the network providers for a specific plan, then the provider is not required to agree to accept the plan’s terms and conditions, and thus may choose not to treat you, with the exception of emergencies. If your provider does not agree to accept the plan’s payment terms and conditions, they may choose not to provide health care services to you, except in emergencies. If this happens, you will need to find another provider that will accept the plans payment terms and conditions. Providers can find the plan’s terms and conditions on each plan’s website. Benefit information is available in alternate formats or languages from the health plan or insurance company offering the plan. Call (800) 650-6585 — TTY 711 and a MyPlanAdvocate licensed agent can provide you with the customer service telephone number for the health plan from whom you would like to request benefit information in an alternate format or language. For some plans, Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
In general, you must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week; the Social Security Office at 1-800-772-1213 between 7:00 a.m. and 7:00 p.m., Monday through Friday. TTY users should call 1-800-325-0778 or your Medicaid Office. Each plan with a prescription drug benefit will have a formulary, or list of drugs covered by the health plan. Formularies may change during the year. For drugs that are not covered, health plans have a process to request an exception for the non-covered drug. Plans with a prescription drug benefit cover both brand name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. Certain drugs may be covered under Medicare Part B or Part D depending upon the circumstances. Information may need to be submitted describing the use and setting of the drug to make the determination.