PriorityMedicare Value SM (HMO-POS) Member handbook An overview of your benefits

Transcription

1 PriorityMedicare Value SM (HMO-POS) Member handbook An overview of your benefits Y0056_1000_1075_3 CMS-approved

2 Table of contents We re here for you...5 Using your dental benefits...19 Quick start guide...6 Benefit basics...7 Getting started with PriorityMedicare Value...9 Plan basics...9 Important documents...10 Member ID card...10 Using your medical benefits...11 Preventive care...11 Comprehensive physical exam...11 Doctor visits and referrals...12 Changing your primary care provider...12 Urgent care...13 Emergency care...13 Hospital care...14 Out-of-pocket maximum/ coverage maximum...14 Using your prescription drug benefits...15 Filling prescriptions...15 Prescription costs...15 Coverage gap...16 Mail-order prescriptions...17 Using out-of-network pharmacies...17 Other advantages of being a member...21 Silver&Fit...21 Your online account...22 Health Journal...22 Taking healthy action...23 Prevent flu, pneumonia and shingles...24 Check your blood pressure...24 Manage your aches and pains...24 Fight cancer...25 Understand diabetes...25 Maintain mental health...25 Health management resources...27 Advance care planning...27 Medication therapy management...28 HIPAA...29 Annual physical checklist...30 HIPAA form...33 Glossary

3 We re here for you Any time you have a question, let us know. Call Customer Service or any of the other contacts listed on this page. Priority Health Medicare Customer Service For general information, visit To verify enrollment, request a member ID card, check claim status or for other questions: By phone: Toll-free a.m. - 8 p.m. Seven days a week TTY: Call a.m. - 8 p.m. Seven days a week By By mail: Go to prioritymedicare.com/contact-us to send a private, secure Priority Health Medicare 1231 East Beltline NE Grand Rapids, MI Priority Health Behavioral Health For mental health and substance abuse questions: By phone: Toll-free Monday - Friday 8 a.m. - 5:30 p.m. Medicare For information about the federal Medicare program: By phone: 800 MEDICARE 24 hours a day, seven days a week ( ) TTY/TDD: hours a day, seven days a week 3

4 Quick start guide Welcome to PriorityMedicare Value You want the most from your Medicare coverage, and we re here to help. Inside this handbook, you ll find an overview of your plan, tips for using it and more. Please review this information. Then keep it in a convenient place and refer to it as needed. 1. Carry your ID card. Show your PriorityMedicare Value member identification (ID) card every time you visit a doctor or dentist or fill a prescription. You ll also need it if you visit an urgent care center or the emergency room. 2. Get your ounce of prevention. All Medicare-approved preventive care services are covered at 100%, such as a diabetes screening and bone mass measurements*. And, be sure to get your yearly comprehensive physical exam there s no copayment required. 3. Register at. All you need is your contract number from your ID card. Your personal online account will give you access to claims information, deductibles, prescriptions filled and other important details and resources. *A separate office visit and/or facility/clinic copayment or coinsurance may apply. A deductible will apply for out-of-network services. Questions about your benefits? Call Customer Service at (TTY users call 711). 4

5 Benefit basics See your provider. Your primary care provider, or physician of choice, is your doctor or other health care provider for regular checkups and will help you get the care you need. Make sure to schedule your annual physical which is a covered benefit of our plan. See a specialist. You don t need a referral to see a specialist. Your primary care provider can help you find one. Or you can locate one online at. Use the Find a Doctor link or contact Priority Health Medicare Customer Service. Use the network. Use providers and pharmacies within the Priority Health Medicare network. There are over 25,000 providers in Michigan to choose from. We ve negotiated discounted rates with them to save you money. See your Provider/Pharmacy directory for more information. Ask for generics. If your prescription is for a name-brand medication, ask your doctor to recommend a generic alternative. The FDA requires that generic drugs have the same active ingredients as name-brand equivalents and they will usually cost you less. The preferred generic tier includes the top 200 of the most commonly used generics and will save you even more money. Travel safe and well. If you need medical assistance when traveling, you re covered. Go to any urgent care center or emergency room a copayment will apply. Be sure to follow up with your primary care provider when you return. Keep your records up to date. Let us know within 30 days if something changes, i.e., your address or the name of your PCP, so we can update our records. 5

6 Getting started with PriorityMedicare Value The first step in getting the most out of your PriorityMedicare Value plan is to understand how it works. Our plans offer the same benefits provided by Original Medicare plus extra coverage for hearing, dental, fitness and wellness programs. Plan basics PriorityMedicare Value is a Medicare Advantage plan with prescription drug coverage. It provides you with Medicare Parts A (hospitalization), B (medical) and D (prescription drugs) and more in one convenient plan. PriorityMedicare Value is a Medicare Advantage health maintenance organization (HMO) with a point-of-service (POS) option. As an HMO, it saves you money any time you use our in-network health care providers. Because it has a POS option, it isn t like a traditional HMO so you can see providers that aren t in your network but you may pay more, except in an emergency. If you have any questions about your Medicare benefits, rights or responsibilities, contact Customer Service by using the number on the bottom of these pages. We re here to help you understand your Medicare coverage. 6

7 PriorityMedicare Value handbook Important documents These important documents explain the benefits of your PriorityMedicare Value plan. Keep them in a safe place and refer to them as needed. Evidence of Coverage. This is your contract with Priority Health Medicare. It s a legal document that describes the services covered or excluded by your plan. This member handbook isn t a legal document; it only provides a summary of your benefits. Provider/Pharmacy Directory. This is an abbreviated directory that lists the doctors, hospitals, other health care providers and pharmacies in the Priority Health Medicare network that are located closest to your home. A full provider/pharmacy directory is available online at ; just click on Find a Doctor. Or call Customer Service at the number listed on the bottom of this page. Using your network providers saves you money on your health care and prescription drug costs. Online tools You ll find detailed information about your claims when you register your account online at. Approved Drug List (formulary). This is a list of prescription medications that your PriorityMedicare Value plan covers when prescribed by your doctor. You can also view or print these documents from our website at. Type Medicare documents in the search box to find plan documents. Or request copies from Customer Service by calling the number on the bottom of this page. Member ID card Your PriorityMedicare Value member ID card lists your contract number and copayment or coinsurance amounts. Show it whenever you use your benefits instead of your red, white and blue Medicare card. PriorityMedicare Value will be billed for covered services. You ll have virtually no paperwork. PriorityMedicare Value SM (HMO-POS) ID: Name: First (MI) Last Group: Group number here Issuer: Rx BIN: BIN# Rx PCN: PCN# Rx Group: Group# Prescription: Yes ER: $xx PCP: $xx Specialist: $xx HPID#: CMS XXXXX [XXX] It s illegal for anyone else to use your ID card. If it s lost or stolen, call Customer Service right away. Use the phone number listed on the bottom of this page. Questions about your benefits? Call Customer Service at (TTY users call 711). 7

8 Using your medical benefits Your PriorityMedicare Value plan provides the benefits you need, when you need them. Here s an overview of how to use them and their costs. Preventive care To help you stay healthy, your PriorityMedicare Value plan covers Medicare preventive services at 100% if received from in-network providers (separate office visit copayment may apply). This includes an annual mammogram, a diabetes screening, colorectal screening, prostate cancer screening and other services. See details in your Evidence of Coverage. See Other advantages of being a member for more information. Free yearly comprehensive physical exam Call your primary care provider today if you haven t had a comprehensive physical exam in the past 12 months. A comprehensive physical exam isn t a routine office visit for diabetes, asthma, a heart condition or any other specific body part. During a comprehensive physical exam, your doctor examines you from head to toe, reviews your medications and discusses all of your health conditions past and present. This is a great time to check to see if you re also due for a mammogram (females), or other preventive screenings such as a colonoscopy, so you can get them scheduled during the office visit. Priority Health Medicare covers one comprehensive physical exam every year, so take advantage of your benefits! Learn more Keep the documents you receive in your membership packet in a safe place. Refer to them for detailed information about your PriorityMedicare Value plan. Be sure to bring the helpful checklist located at the back of this handbook with you to your appointment as a reminder of all the things you should cover with your doctor. 8

9 PriorityMedicare Value handbook Doctor visits and referrals Your primary care provider usually handles most of your health care needs. However, you don t need a referral to see a specialist. Just remember that using providers, including specialists, outside our network may cost more. Show your Priority Health Medicare ID card at the time of service and pay any copayments or coinsurance due. We ll be billed for covered expenses. Here s what a doctor visit will cost: In-network: $20 copayment for primary care provider $50 copayment for specialist $ Save money Save on health care costs by using doctors, hospitals and pharmacies in our network. See your provider/pharmacy directory, use the Find a Doctor tool at or call us at the number on the bottom of the page. Out-of-network: 40% coinsurance for doctor office visits (after paying the annual $1,500 deductible) Changing your primary care provider You may change to another primary care provider in our network at any time. Just call Customer Service using the phone number listed on the bottom of this page. We will change your PCP based on your request. Keep in mind: Your primary care provider can be an internist, general practitioner or family medicine provider. Women can choose an obstetrician/gynecologist (OB/GYN) as their primary care provider. Your provider directory includes a list of primary care physicians, as well as specialists, hospitals, pharmacies and other providers. For the most up-todate information, you can use the Find a Doctor tool at or call customer service. Questions about your benefits? Call Customer Service at (TTY users call 711). 9

10 Using your medical benefits Urgent care If you need care right away but it s not life-threatening: Go to an urgent care center. You may also contact your primary care provider for direction. If there s not an urgent care center in your area, go to an emergency room. Contact your primary care provider s office as soon as possible after treatment for follow-up care. You ll find a list of urgent care centers in your provider directory. If you re traveling outside our service area and need to visit an urgent care center anywhere in the world your costs will be the same as if the urgent care center were in our network. $ Save money Unless it s a life-threatening situation, going to an urgent care center is often a good alternative to using an emergency room. Urgent care centers are usually quicker and less expensive. Here s what you can expect to pay for urgent care: $50 copayment for Medicare-covered* urgent care visit Emergency care For emergencies: Call 911 or seek immediate attention. Inform your primary care provider as soon as possible after treatment so follow-up care can be arranged. If you re admitted to the hospital as the result of your emergency room visit, you won t have to pay an emergency room copayment. Your PriorityMedicare Value plan provides worldwide urgent and emergency care coverage. If you re traveling outside our service area even outside the country we ll cover your emergency treatment at the network rate. Here s what you can expect to pay for emergency care: $65 copayment for Medicare-covered* emergency room visit *See your Evidence of Coverage for details on Medicare-covered expenses. 10

11 PriorityMedicare Value handbook Hospital care You can use Medicare-approved hospitals anywhere in the country for medically necessary care. For in-network hospitals, you ll pay a copayment. If the hospital isn t in our network, you ll pay a percentage of the cost yourself after the annual deductible is met. This doesn t apply to emergency, urgent care or dialysis services when the network is not available (generally, when you re out of the area). You ll pay the in-network copayment for these services. Here s what you can expect to pay for hospital care: Get answers If you have a question or dispute about a claim, or if you have questions about the health care services covered by your plan, contact Customer Service at the number on the bottom of this page. In-network: For Medicare covered hospital stays: Days 1-7: $250 copayment per day Out-of-network: 40% coinsurance for each Medicare-covered hospital stay (after paying the annual $1,500 deductible) Out-of-pocket maximum Your PriorityMedicare Value plan limits your out-of-pocket costs (the amount of money you pay yourself) for in-network health care services. This is your in-network out-of-pocket maximum. If you reach this amount in a plan year, we ll pay 100% of your Medicare-covered health care services. In-network: $4,500 You ll find information about this in your Evidence of Coverage. Questions about your benefits? Call Customer Service at (TTY users call 711). 11

12 Using your prescription drug Your PriorityMedicare Value plan includes prescription drug coverage. benefits Priority Health Medicare uses an approved drug list, also called a formulary. The most current list can be found on our website at or by calling Customer Service, using the number on the bottom of these pages. Filling prescriptions To fill a prescription: First make sure the drug is on our approved drug list. Take your prescription to any network pharmacy. Show your PriorityMedicare Value ID card at the pharmacy. Pay any copayment or coinsurance due. (See your quick reference guide on page 2 for cost sharing.) You ll find a list of our network pharmacies in your provider/pharmacy directory. You can also go to and click on Find a Doctor to search for a pharmacy or contact Customer Service. Enjoy choice There are more than 65,000 pharmacies in the Priority Health Medicare network, including national chains. Any location of these chains in the United States is part of our network. Prescription costs Your costs depend on where you fill your prescription, the type and quantity of the drug and the total amount you ve already paid for prescriptions during the year. You must use network pharmacies to fill your prescriptions. Be sure to ask about generics. A generic drug has the same active ingredient formula as the brand name drug. When you and your provider choose a generic drug, you save money and still get the appropriate care. 12

13 PriorityMedicare Value handbook Coverage gap The coverage gap, sometimes called the donut hole refers to the period when you must pay for 100% of the discounted cost of your drugs. In 2015, once your total drug spend reaches $2,960 for the year, the coverage gap begins. Your total drug spend includes what you paid (copayments and coinsurance) and what your plan paid toward your drug costs. When you re in the coverage gap*: You ll need to pay for your own prescriptions, but you ll get a cost-break. You ll pay 45% of the cost of brand name drugs and 65% of generics. More discounts will be phased in over the next few years. By 2020, you ll only be responsible for 25%. If your drug total out-of-pocket expense reaches $4,700, catastrophic coverage begins. That means you ll only be responsible for a small copayment or coinsurance. Initial coverage period Donut hole Catastrophic coverage period $2,960 You'll pay... If your total drug spend* adds up to $2,960, you ll reach the donut hole *What you paid plus what your plan paid In the donut hole, you ll pay 45% for brand name drugs 65% for generics $4,700 If your out-of-pocket expenses total $4,700*, you ll be eligible for catastrophic coverage with small copayments *What you paid plus what drug manufacturers paid for brand name drugs while you were in the donut hole Questions about your benefits? Call Customer Service at (TTY users call 711). 13

14 Using your prescription drug benefits Mail-order prescriptions Save time and money by using our mail-order pharmacy to get up to a 90-day supply of your prescription drugs (specialty drugs are only available in a 30-day supply). The cost for a 90-day supply will be two-and-a-half times the 30-day copayment. You ll need to ask your doctor to write your prescription for up to a 90-day supply. Three ways to order your prescriptions: -- Complete and mail the Express Scripts form enclosed in this packet -- Order by phone 24 hours a day, seven days a week by calling (TTY users should call 711) Enjoy convenience Use our prescription mail-order service for convenience and savings. You could have up to a 90-day supply of your prescription drugs delivered to your home. -- Order refills online by going to and typing Express Scripts in the search box Prescriptions will be delivered to your home. Allow 14 days if you order by mail, or allow 7-10 days if you order by phone or online. Any refills on your mail order prescription will need to be authorized by you. (See your quick reference guide on page 2 for cost sharing.) Using out-of-network pharmacies You must use pharmacies in our network to receive prescription drug benefits from your PriorityMedicare Value plan, except in certain cases. For example; when you re travelling or in need of a drug that can t be found at a network pharmacy. If you choose to fill your prescription at a pharmacy that s not in our network, you ll have to pay upfront and seek reimbursement. Priority Health Medicare may reimburse you up to the negotiated in-network pharmacy cost (minus your copayment or coinsurance amount). We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Quantity limitations and other restrictions may apply. 14

15 Using your dental benefits Your PriorityMedicare Value plan includes dental coverage. Be sure to show your PriorityMedicare Value ID card when you seek services. You ll receive a new member packet from Delta Dental with all your dental plan details. If you have questions about your dental plan, call toll-free The automated system provides eligibility information, benefit levels, claim status, names of participating dentists near you and much more. If you have additional questions or wish to speak to someone directly, you can exit the system at anytime to speak with a Customer Service associate during their normal business hours Monday through Friday from 8:30 a.m. to 8 p.m. (Eastern Time). Visit deltadentalmi.com and select Consumer Toolkit, a secure, online tool that provides important information you need to know about your plan and access to a searchable dentist directory. 15

16 Other advantages of being a member Here are some of the extras you receive as a PriorityMedicare Value plan member. Silver&Fit An exercise and wellness program As a Priority Health Medicare Advantage plan member, you may choose one of the following two options: There are no copayments, coinsurances or deductibles for the Silver&Fit programs. 1. Fitness center membership Your membership entitles you to take advantage of all the services and amenities included with your Silver&Fit fitness club or exercise center membership. 2. Home fitness program This program offers you the chance to participate in fitness and education activities in the comfort of your own home. When you join, you may choose to receive up to two kits. The kits may include items such as a DVD, a booklet with general information about the topic and a Quick Start guide. Example kits include: Beginner Tai Chi kit Cardio strength kit Stress management kit Walking kit Yoga kit Getting started 1. Consult your physician before you begin any exercise program. 2. For more information about enrolling in the program, fitness facilities, or to participate in the Home Fitness Program, visit and type silver in the search box. You may also call toll-free (TTY/TDD ) Monday through Friday, 8 a.m. 9 p.m. 16

17 PriorityMedicare Value handbook Your online account If you have Internet access, register your account online. Go to and click on Register in the upper right hand corner. You ll need to enter your contract number, which is on your Priority Health Medicare ID card (after your name). With an online account, you can: Check the status of your claims, deductible and out-of-pocket balances. Check your prescription history. Find a doctor. Use a variety of tools and resources from Priority Health and more. Health Journal As a PriorityMedicare Value plan member, you ll also receive our newsletter. It s full of advice for taking good care of your health and tips for getting the most from your PriorityMedicare Value benefits. Online tools Whether you want to change your status, change your primary care provider or file a claim, you ll find all the forms you need online at. Or call Customer Service at the number on the bottom of this page. We ll send you what you need. Questions about your benefits? Call Customer Service at (TTY users call 711). 17

18 Taking healthy action Our goal is to improve the health and lives of our members. Throughout the year, we provide information on health screenings, vaccines and check-ups so you can be your healthiest. Our team of case managers who are health care professionals will work with you to make sure you re getting the care you need when you need it. If you have questions or want to work with a case manager, contact Customer Service by calling the number listed on the back of your ID card. Prevent flu, pneumonia and shingles The flu can lead to pneumonia, but there s a way to reduce your risk of both. Getting a flu vaccine and a pneumonia vaccine every year can help keep you healthy. Getting a one-time shingles vaccine can help you maintain a higher quality of life. Check your blood pressure High blood pressure is often called the silent killer, because there are no symptoms before real problems begin. It can lead to heart disease, stroke, and kidney disease. Routine physical exams usually start with a blood pressure check. Your doctor will tell you if your numbers fall outside the normal range for your age. 18

19 PriorityMedicare Value handbook Manage your aches and pains Chronic sources of aches and pains include osteoporosis and arthritis. Both of these conditions can cause falls, which are a major source of injury. Determine your risk of osteoporosis Osteoporosis is a thinning of the bones. Symptoms of osteoporosis include persistent backache, gradual loss of height and fractures of the spine, wrist or hip. If you think you re at risk for osteoporosis, or you ve broken a bone or fallen in the last six months, ask your doctor about getting a bone mineral density test. Strengthen your bones: Do weight-bearing exercises such as walking, climbing stairs, jogging, yoga and weight-lifting. Get plenty of calcium every day from the foods you eat. Good sources of calcium include dairy products, canned sardines and salmon, and dark green leafy vegetables. Don t smoke. Smoking increases your risk for osteoporosis. Treat arthritis Arthritis causes joint problems, pain, swelling, and stiffness, but it doesn t have to keep you from being active. Your doctor can diagnose arthritis and recommend a treatment program that may include lifestyle changes or taking medications to slow down rheumatoid arthritis. Prevent falls Falling is the leading cause of fatal and non-fatal injuries. Slipping on ice, stumbling on a stair or a rug, and losing your balance often results in broken bones and cuts, or even traumatic brain injury. The best prevention often starts at home making sure your environment is safe. Questions about your benefits? Call Customer Service at (TTY users call 711). 19

20 Taking healthy action Reduce your risk of falling: Exercise regularly to maintain flexibility, strength and balance. Install safety devices, such as grab bars, in the shower and tub. Eliminate hazards, such as loose throw rugs and tangled electrical wires. Talk to your doctor if your medication makes you dizzy or lightheaded. Have your vision checked regularly at least once a year. Fight cancer Healthy living and getting regular screenings are the best ways to prevent cancer. Ask your doctor about: Colorectal cancer screening to find polyps (or growths) in the colon, rectum and digestive tract. Finding and removing polyps can prevent cancer from ever getting a chance to develop. Mammogram of the breasts to help find cancerous tumors before they re big enough for you or your doctor to feel. Getting regular mammograms and doing monthly breast self-exams can help find cancer early when it s most treatable. Understand diabetes Should you develop diabetes, visit your doctor at least twice a year for help managing your condition. Diabetes affects the way your body uses sugar (glucose), which is your body s main source of fuel. As a result, you may develop dangerously high blood sugar levels. You may need to get the following tests to help you manage your condition and be your healthiest: a urine test, blood test, Alc blood test, blood pressure test, diabetes dilated eye exam and cholesterol test. Maintain mental health Your mental health is just as important as your physical health. Millions of Americans suffer from different forms of depression or dementia. Your mental health can also be affected by insomnia, or by feelings of grief and isolation brought on by the changes of aging: the loss of a spouse, retirement or relocating to a different city. These conditions are very real and there are many good ways to treat them. 20

21 PriorityMedicare Value handbook End insomnia Insomnia is the inability to get to sleep or stay asleep at night. It can be occasional brought on by recent stress in your life or it can be a chronic condition, sometimes prompted by depression. If you re experiencing insomnia ask your doctor for help. You can also make changes on your own. Adopt good sleep habits There are many things you can do to help you sleep better at night including keeping a regular sleep schedule, avoiding naps, engaging in relaxing activities, maintaining a regular exercise routine, and avoiding caffeine, nicotine and alcohol late in the day. Overcome depression Clinical depression feelings of loneliness, sadness, and exhaustion most of the time is very common in older people. Symptoms of depression can be brought on by the loss of a loved one, changes in your life circumstances, retirement or relocation. Treatment usually counseling, medication, or both depends on the type of depression, so an evaluation from a mental health specialist is often necessary. Your doctor may also recommend exercise, or other lifestyle changes, to boost your mood. Beat the blues If you re feeling depressed, one of the best things you can do is be social go to a movie, meet a friend for coffee or take a walk. Exercise, good company and eating right can help improve your mood and keep your body healthy. Deal with dementia The loss of mental functions, including thinking, memory, and reason, is often referred to as dementia. One of the most common causes is Alzheimer s disease, but there are more than 50 other causes of dementia. Symptoms include changes in personality, mood and behavior. Some dementias are treatable, including those resulting from substance abuse, hypo- or hyperthyroid conditions or metabolic disorders. Questions about your benefits? Call Customer Service at (TTY users call 711). 21

22 Taking healthy action Lifestyle changes if you re diagnosed with dementia: Educate yourself about your specific type of dementia. Include your family and close friends in your treatment process. The more they know, the more helpful they can be. Ask your doctor about the latest treatment methods and drug therapies available. Try to accept your new limitations and don t give up on life. Health management resources Helping you stay healthy is important to you and to us. That s why we offer special programs to help people with chronic conditions, including: COPD problems with breathing Diabetes Heart disease If you don t have a health condition but would like help living healthier, we offer programs for: Losing weight (obesity) Quitting smoking Eating healthier All programs are free to members who qualify. Talk with your primary care provider about programs that can help you improve your health. Advance care planning Sometimes people become unable to make health care decisions for themselves due to accidents or serious illness. You may want to prepare in advance in case this happens to you. You can contact a Priority Health case manager to ask about advanced care planning and discuss your health care goals, preferences and wishes. Identify an advocate for a discussion and complete an advanced directive. Give a copy of the form to your doctor, your hospital and to the person you name on the form as the one to make decisions for you if you can t. 22

23 PriorityMedicare Value handbook Medication Therapy Management (MTM) program If you want to save money on your medications and improve your health, our free Medication Therapy Management (MTM) program can help. The MTM program gives you the chance to meet with a certified personal pharmacist each year for a comprehensive medication review. These pharmacists do much more than dispense drugs. Your MTM personal pharmacist is your own resource and advocate. Getting your yearly medication review is just as important as getting a yearly physical exam. Your health condition can change every year and so can your medication needs. Your yearly medication review gives you the chance to discuss side effects and make changes if necessary. Your personal pharmacist will provide the following at no cost to you: Help understanding how to take your drugs, so you get the best results. Suggestions that will help save you money and relieve symptoms. Solutions that will resolve any concerns you have about your medications, including working with your doctor to make changes that will help you feel better. A master list of all your medications, including over-the-counter drugs that you can share with your doctor during your appointments. You won t need to switch pharmacies to participate in this free program, and you can continue to use any Priority Health Medicare network pharmacy to fill your prescriptions. If you d like to request a comprehensive medication review, contact the number on the back of your ID card. Visit and type medication management in the search box to learn more about our MTM program. Questions about your benefits? Call Customer Service at (TTY users call 711). 23

24 Taking healthy action HIPAA Have you ever tried to get health-related information about your spouse and been denied? It s a frustrating experience, but it s one that you never have to repeat if we have the correct form on file. Your health information is protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). It safeguards your medical records and gives you more control over how your personal health information is used and disclosed. However, we must receive a signed HIPAA Authorization Form to release information in some cases. We can t discuss your information - even with your spouse - if we haven t received the form (You ll find a copy of the HIPAA form in the back of this booklet). This HIPAA requirement applies to all members ages 18 and older, unless it is a behavioral health issue. There is also a HIPAA form available for members to revoke or cancel authorization at any time. 24

25 Annual physical checklist Be sure to bring this helpful checklist with you to your appointment as a reminder of all the things you should cover with your doctor. Recommended exams and tests Annual flu shot Pneumonia vaccine Shingles vaccine (once in a lifetime) Bone density test to check for osteoporosis Annual glaucoma test Colon cancer screening (age 50-86) Mammogram (women age 50-74) A screening to check for diabetes Also talk with your doctor about the following: How you can stay physically active and the importance of exercise Ways to prevent falls and problems with balance or walking How you can improve bladder control What you can do if you have feelings of sadness, worry or loneliness What you can do if you have feelings of confusion or forgetfulness Risks of high cholesterol Risks of high blood pressure Body or joint pain you may be experiencing Proper use of your medicines (comprehensive medication reviews are available at no cost to you) Risks of drug and alcohol use Completing an advance directive form Additional things you want to talk to your doctor about:

26 Have you had your annual comprehensive physical exam? If not, call your primary care provider today and schedule an appointment. Fill this form out to help you keep track of your health conditions and medicines. Keep a copy for yourself and bring one with you to your appointment to discuss with your doctor. Diagnosis/condition (list past and present, for example, asthma, diabetes, etc.) Year (when diagnosed) New symptoms/changes Physician name (Primary care provider and specialists, for example, cardiologist, rheumatologist, etc.) Allergies Screenings completed this year Immunizations completed this year Health tip: Remember to talk to your primary care provider about any screenings or immunizations that you may need. Phone number

27 Medicines Name of medicine Dosage (how much do you take and how often) Notes Reason for taking the medicine Side effects (discuss with your doctor) Medication Tips Take medications exactly as prescribed and at the same time of day. Use a pill reminder system. Place medication where it will be easy to remember, but out of reach of children. Continue taking medication as directed even if you feel better. If you forget to take your medication, take it as soon as you remember. If it is almost time for your next dose, skip the missed dose and go back to your regular schedule. Don t double your dose. Plan ahead. If your medication is running low, refill your medication. Don t wait until the last pill is gone.

28 Authorization for release of personal and health information A. Member whose information is to be released Member name Address Date of birth / / City State ZIP code Contract number (on ID card) Phone I request and authorize Priority Health* to release my personal and health information. This may include claims and billing information. It may also include medical records that Priority Health has received from medical practitioners, including records regarding general medical care, alcohol and drug abuse treatment, psychological or psychiatric treatment, social services counseling, human immunodeficiency virus (HIV) or acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC), communicable diseases or infections, venereal diseases, tuberculosis, hepatitis and demographic information. (* Priority Health includes Priority Health/Priority Health Managed Benefits, Inc./Priority Health Insurance Company/Priority Health Government Programs, Inc.) B. Type of information Priority Health may release (check ONE box) All of my information (including personal, health, demographic, claims, billing and medical records) OR Only my claims and billing information OR Other, such as information regarding a specific date of service or issue (explain) C. Who may receive your information? Individual/entity name Phone Address City State ZIP code D. What is the purpose of this Authorization? (check ONE box) At my request Other (explain) E. When will this Authorization expire? (check ONE box) Note: If I fail to list an expiration date or event below, this authorization will expire one year from the date signed. No expiration Upon my coverage termination On the following date / / (MM/DD/YYYY) Upon my death Upon my written revocation On the following event I understand that I may refuse to sign this Authorization. I may revoke this Authorization at any time by notifying Priority Health in writing at the address listed below. The revocation will not be effective for information that Priority Health discloses between the time that this Authorization is signed and when the revocation is received. If Priority Health requested this Authorization, I understand that I have the right to receive a copy of this Authorization after I sign it. I understand that Priority Health will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this Authorization. I understand that the persons to whom information is disclosed under this Authorization may possibly redisclose the information to others without my knowledge or consent, and therefore, the privacy of my personal and health information may no longer be protected by law. F. Signature required If signed by a person other than the member, please check the relationship and provide proof of authority to do so: Parent of a minor child Power of attorney Signature Printed name Legal guardian Personal representative of deceased member Date / / G. Finalize and send Form must be fully completed Submit form via one of the following - Scan and to HIPAA@ - Fax to: Mail to: Priority Health, MS 2005, 1231 East Beltline, N.E., Grand Rapids, MI, This form satisfies all required elements of a valid authorization under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

29 Glossary We want you to understand your benefits, so we ve put together explanations of a few terms we often use. Refer to your Evidence of Coverage for a complete glossary. If you have questions about any of the information in our materials, call Customer Service using the number on the bottom of this page. Coinsurance An amount you may be required to pay as your share of the cost for services or prescription drugs after you pay any deductibles. Coinsurance is usually a percentage (for example, 20%). Copayment An amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor s visit, hospital outpatient visit, or a prescription drug. A copayment is usually a set amount, rather than a percentage. For example, you might pay $10 or $20 for a doctor s visit or prescription drug. You ll find your copayment amounts listed on your ID card, in the Quick Reference Guide on page 2 or in your Evidence of Coverage. Deductible The amount you must pay for health care or prescriptions before your plan begins to pay. See your Evidence of Coverage or the Quick Reference Guide on page 2 for details about the deductible for your plan. Network pharmacy A network pharmacy is a pharmacy where members of our plan can get their prescription drug benefits. We call them network pharmacies because they contract with our plan. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies. Out-of-pocket costs The amount you pay for your health care or prescriptions including copayments, coinsurance and deductibles. Out-of-pocket maximum The most you ll pay during a contract period (usually a year) before your health plan pays 100 percent of your covered medical expenses. This doesn t include your premiums, balance-billed charges, or services you get that your plan doesn t cover. Questions about your benefits? Call Customer Service at (TTY users call 711). 29

30 Preventive care Health care to prevent illness or detect illness at an early stage, when treatment is likely to work best. For example, preventative services include diabetes screenings, mammograms and prostate cancer screenings. Prior authorization Approval in advance to get services or certain drugs that may or may not be on our formulary. In a PPO, you don t need prior authorization to obtain out-of-network services. Covered services that need prior authorization are marked in the Evidence of Coverage Benefits Chart in Chapter 4. Some drugs are covered only if your doctor or other network provider gets prior authorization from us. Covered drugs that need prior authorization are marked in the formulary. Refer to your Evidence of Coverage for details. Priority Health Medicare network Priority Health Medicare has an agreement with a network of doctors, hospitals, pharmacies and other health care providers. You save on your health care costs when you use these network providers. Provider Provider is the general term we use for doctors, other health care professionals, hospitals, and other health care facilities that are licensed or certified by Medicare and by the State to provide health care services. This may be your doctor, your doctor s office or a hospital or other facility that you use for health care. A doctor is a Priority Health Medicare network provider when they have an agreement with our plan to accept our payment as payment in full, and in some cases to coordinate as well as provide covered services to members of our plan. 30

31 Priority Health has HMO-POS and PPO plans with a Medicare contract. Enrollment in Priority Health Medicare depends on contract renewal. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1 of each year. This member handbook isn t a legal document. The Evidence of Coverage is a legal document. The official Medicare program provisions are contained in the relevant laws, regulations and rulings. You must continue to pay your Part B premium. Limitations, copayments, and restrictions may apply Priority Health MR B 10/14