Cmmnwealth Care Alliance (Medicare-Medicaid Plan) Prvider & Pharmacy Directry Rules & General Infrmatin Intrductin This dcument includes rules and general infrmatin abut using the Cmmnwealth Care Alliance (Medicare-Medicaid) Prvider and Pharmacy Directry. It includes infrmatin abut the prvider and pharmacy types in Cmmnwealth Care Alliance s netwrk. The searchable directry listings (search tl) cntain prvider and pharmacy address and cntact infrmatin as well as ther details such as days and hurs f peratins, specialties, and skills. Key terms and their definitins appear in alphabetical rder in the last chapter f the Member Handbk. Table f Cntents Disclaimers... 2 Prvider Directry Infrmatin... 3 Understanding Prvider Types & Care Teams... 3 Chsing a Primary Care Prvider (PCP)... 4 Getting lng-term services and supprts... 5 Using Cmmnwealth Care Alliance s Netwrk... 5 Pharmacy Directry Infrmatin... 6 Understanding the Pharmacy Directry & CCA s Netwrk... 6 Identifying pharmacies in ur netwrk... 7 Lng-term supplies f prescriptins... 7? If yu have questins, please call Cmmnwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Fr mre infrmatin, visit www.cmmnwealthnecare.rg. 1
Disclaimers Cmmnwealth Care Alliance (Medicare-Medicaid Plan) is a health plan that cntracts with bth Medicare and MassHealth t prvide benefits f bth prgrams t enrllees. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. This Directry lists health care prfessinals (such as dctrs, nurse practitiners, and psychlgists), facilities (such as hspitals r clinics), and supprt prviders (such as Adult Day Health and Hme Health prviders) that yu may see as a Cmmnwealth Care Alliance member. We als list the pharmacies that yu may use t get yur prescriptin drugs. We will refer t these grups as netwrk prviders in this Directry. These prviders signed a cntract with us t prvide yu services. Yu can get this infrmatin fr free in Spanish r speak with smene abut this infrmatin in ther languages fr free. Call 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Este dcument está dispnible en españl. Para hablar cn un intérprete, pr favr llame al 1-866-610-2273. Este es un servici gratuit. Yu can get this infrmatin fr free in ther frmats, such as large print, braille, r audi. Call 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. We will keep yur request fr alternative frmats and special languages n file fr future mailings. The search tl is updated frequently, but yu need t knw that: Sme Cmmnwealth Care Alliance netwrk prviders may have been added r remved frm ur netwrk very recently. Sme Cmmnwealth Care Alliance prviders in ur netwrk may n lnger be accepting new members. If yu are having truble finding a prvider wh will accept new members, call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week and we will help yu. T get the mst up-t-date infrmatin abut Cmmnwealth Care Alliance s netwrk prviders in yur area, visit www.cmmnwealthcare.rg r call Member Services at 1-866- 610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. 2
Prvider Directry Infrmatin Understanding Prvider Types & Care Teams This sectin explains key terms yu ll see in ur Prvider and Pharmacy Directry. Prviders are health care prfessinals and supprt prviders such as dctrs, nurses, pharmacists, therapists, and ther peple wh prvide care and services. Services include medical care, lng-term services and supprts, supplies, prescriptin drugs, equipment and ther services. The term prviders als includes facilities such as hspitals, clinics, and ther places that prvide medical services, medical equipment, and lng-term services and supprts. Prviders that are a part f ur plan's netwrk are called netwrk prviders. Netwrk prviders are the prviders that have cntracted with us t prvide services t members in ur plan. When yu see a netwrk prvider, yu usually pay nthing fr cvered services. A Primary Care Prvider (PCP) is a physician, a nurse practitiner r a physician assistant wh gives yu rutine health care. Yur PCP will keep yur medical recrds and get t knw yur health needs ver time. Specialists are dctrs wh prvide health care services fr a specific disease r part f the bdy. There are many kinds f specialists. Here are a few examples: Onclgists care fr patients with cancer. Cardilgists care fr patients with heart cnditins. Orthpedists care fr patients with certain bne, jint, r muscle cnditins. Yu may need a prir authrizatin fr certain number f services befre yu receive them. Prir authrizatin means that Cmmnwealth Care Alliance must give yu apprval befre we will prvide cverage fr a specific service, item, r drug r ut-f-netwrk prvider. Yur PCP/Care Team wrks clsely with Cmmnwealth Care Alliance t arrange fr these services when necessary. If yu dn t get a prir authrizatin, Cmmnwealth Care Alliance may nt cver the service, item, r drug. Prir authrizatin are nt needed fr: Emergency care; Urgently needed care; Kidney dialysis services that yu get at a Medicare-certified dialysis facility when yu are utside the plan s service area;? If yu have questins, please call Cmmnwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Fr mre infrmatin, visit www.cmmnwealthnecare.rg. 3
Services frm a wmen s health specialist; r Preventive services. Additinally, if yu are eligible t get services frm Indian health prviders, yu may see these prviders withut a referral. We must pay the Indian health prvider fr thse services even if they are ut f ur plan s netwrk. Mre infrmatin n prir authrizatin is available in Chapter 3 f the Member Handbk. Yu will have a Care Team that yu chse. Yur Care Team includes a grup f peple yu chse t be invlved in yur care. A Care Team will get t knw yur needs and wrk with yu t help yu create and carry ut a Persnal Care Plan. Yur Care Team will talk with yu abut the services that are right fr yu. Everyne n the Care Team wrks tgether t make sure yur care is crdinated. This means that they make sure that yu get all f the tests, labs, and ther care that yu need, and the results are shared with the apprpriate prviders. It als means that yur PCP shuld knw all medicines yu take s that he r she can reduce any negative effects. Yur PCP will always get yur permissin befre sharing yur medical infrmatin with ther prviders. Members f yur Care Team may include: A Care Manager helps yu manage yur medical prviders and services. Yur Care Manager wrks with yu, the health plan, and yur Care Team t make sure yu get the care yu need. Yur Primary Care Prvider A Lng-Term Services and Supprts (LTS) Crdinatr t help yu find and access supprt services available t yu in the cmmunity. Bth the Care Manager and LTS Crdinatr can wrk as a part f yur Care Team t make sure yu get the care yu need. Others if necessary. Yur Care Team r ur Member Services will als help yu find ther prviders f medical, behaviral health, r lng-term services and supprts if yu need t see a specialist r ther health care prvider. That way, yu will see the right prvider t help yu with yur cncerns. Chsing a Primary Care Prvider (PCP) First, yu will need t chse a Primary Care Prvider. Yu can chse any PCP in ur netwrk wh is accepting new members. T chse a PCP, g t the list f prviders n page 1 and chse a prvider: that yu use nw, r wh has been recmmended by smene yu trust, r 4
whse ffices are easy fr yu t get t. When yu first enrll in Cmmnwealth Care Alliance, yu can keep seeing yur current PCP and yur ther prviders fr 90 days, r until yu and yur Care Team cmplete a cmprehensive assessment f yur needs and gals and develp yur Individualized Care Plan. After that, if yu d nt chse a PCP in ur netwrk, Cmmnwealth Care Alliance will chse ne fr yu. If yu want help in chsing a PCP, please call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Or, visit www.cmmnwealthnecare.rg. If yu have questins abut whether any service r care that yu want r need is cvered, talk t yur Care Team r call Member Services and ask befre yu get the service r care. Getting lng-term services and supprts As a Cmmnwealth Care Alliance member, yu will be able t get lng-term services and supprts (LTSS), such as persnal care, hmemaking, cmpanin, day prgrams, adult fster care, and transprtatin amngst thers. Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. If yu need LTSS, an LTS Crdinatr can help yu and yur Care Team determine what ptins are available t supprt yu in the way yu want. Yu always have the right t have an LTS Crdinatr n yur Care Team. Yur LTS Crdinatr (als knwn as a Lng-Term Services and Supprts Crdinatr) and/r Care Manager will talk t yu and discuss what different types f services are available and which might be right fr yu. Yur Care Manager r LTS Crdinatr will als help yu find an apprpriate prvider and arrange fr these services t be prvided t yu. In rder t get lng-term services and supprts, yu will need a prir authrizatin frm Cmmnwealth Care Alliance. Please see Benefit Chart in Chapter 4 f yur Member Handbk, fr mre infrmatin n cvered services and prir authrizatin requirements. Using Cmmnwealth Care Alliance s Netwrk Yu must get all f yur cvered services frm prviders within ur netwrk. These prviders have an agreement t wrk with us and prvide yu services. If yu g t prviders wh are nt in Cmmnwealth Care Alliance s netwrk (withut prir authrizatin r apprval frm us), yu will have t pay the bill. The nly exceptins t this rule are when yu need urgent r emergency care r dialysis and cannt get t a prvider in the plan, such as when yu are away frm hme. Yu can als g? If yu have questins, please call Cmmnwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Fr mre infrmatin, visit www.cmmnwealthnecare.rg. 5
utside the plan fr ther nn-emergency services if Cmmnwealth Care Alliance gives yu permissin first. Als, when yu first enrll in Cmmnwealth Care Alliance, yu can keep seeing yur current prviders fr 90 days, r until yu and yur Care Team cmplete a cmprehensive assessment f yur needs and gals and develp yur Individualized Care Plan. Fr a full list f services that require prir authrizatin, please see the Benefits Chart in Chapter 4, Sectin D. Yu may change prviders within the netwrk at any time, except t a PCP frm anther grup r practice, then it wuld be effective the 1st f the fllwing mnth. If yu have been ging t ne netwrk prvider, yu d nt have t keep ging t that same prvider. Yu may change yur PCP fr any reasn. Als, it s pssible that yur PCP might leave ur plan s netwrk. In that case, yu wuld have t find a new PCP. Cmmnwealth Care Alliance wrks with all the prviders in ur netwrk t accmmdate the needs f peple with disabilities. As applicable, the list f netwrk prviders in this Directry includes infrmatin abut the accmmdatins they prvide. If yu need t see a prvider and are nt sure if they ffer the accmmdatins yu need, Cmmnwealth Care Alliance can help yu. Talk t yur Care Team fr assistance. Pharmacy Directry Infrmatin Understanding the Pharmacy Directry & CCA s Netwrk These netwrk pharmacies are pharmacies that have agreed t prvide prescriptin drugs t yu as a member f the plan. Cmmnwealth Care Alliance is happy t help yu find a netwrk pharmacy that meets yur needs. Fr instance, we can help yu find pharmacies that: Are accessible by public transit Have pharmacists that speak yur language Offer specific accmmdatins Please cntact Cmmnwealth Care Alliance Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week fr assistance. Cmmnwealth Care Alliance members must use netwrk pharmacies t get prescriptin drugs. Yu must use netwrk pharmacies except in emergency r urgent care situatins. If yu g t an ut-f-netwrk pharmacy fr prescriptins when it is nt an emergency, yu will have t pay ut f pcket fr the service. Read the Cmmnwealth Care Alliance Member Handbk fr mre infrmatin. Sme netwrk pharmacies may nt be listed in this Directry. This directry is updated ften, but sme netwrk pharmacies may have been added r remved frm ur plan very recently. 6
Fr up-t-date infrmatin abut Cmmnwealth Care Alliance netwrk pharmacies in yur area, please visit ur web site at www.cmmnwealthcare.rg r call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. T get a cmplete descriptin f yur prescriptin cverage, including hw t fill yur prescriptins, please read the Member Handbk and Cmmnwealth Care Alliance s List f Cvered Drugs. Fr the mst up-t-date List f Cvered Drugs, please visit ur web site at www.cmmnwealthcare.rg r call Member Services at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Identifying pharmacies in ur netwrk Alng with retail pharmacies, yur plan s netwrk f pharmacies includes: Mail-Order Pharmacies Hme infusin pharmacies Yu can g t any f the Hme Infusin pharmacies in ur netwrk, as they service all cunties in yur plans service area. Fr mre infrmatin abut the Hme Infusin services available please cntact the pharmacy directly. Lng-term care (LTC) pharmacies Residents f a lng-term care facility, such as a nursing hme, may access their prescriptin drugs cvered under Cmmnwealth Care Alliance thrugh the facility s pharmacy r anther netwrk pharmacy. Yu can g t any f the Lng- Term Care pharmacies in ur netwrk, as they service all cunties in yur plans service area. Yu are nt required t cntinue ging t the same pharmacy t fill yur prescriptins. Yu can g t any f the pharmacies in ur netwrk. Lng-term supplies f prescriptins Mail-Order Prgrams. We ffer a mail-rder prgram that allws yu t get up t a 90-day supply f yur prescriptin drugs sent directly t yur hme. Maintenance drugs are prescriptin drugs that yu use n an nging basis, fr a chrnic r lng term medical cnditin. There is n cpay fr mail rder drugs. If a prescriber initiates a prescriptin n yur behalf, the mail rder pharmacy is required t btain cnsent frm yu prir t shipping r delivery any medicatins. Yu can get prescriptin drugs shipped t yur hme thrugh ur netwrk mail rder delivery prgram. Typically, yu shuld expect t get yur prescriptin drugs within 14 days frm the time that the mail rder pharmacy gets the rder. If yu d nt get yur prescriptin drug(s) within this time, if yu wuld like t cancel an autmatic rder, r if yu need t ask fr a refund fr prescriptins yu gt that yu? If yu have questins, please call Cmmnwealth Care Alliance at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. Fr mre infrmatin, visit www.cmmnwealthnecare.rg. 7
did nt want r need, please cntact us at 1-866-610-2273 (TTY: call MassRelay at 711), 8 a.m. 8 p.m., 7 days a week. The call is free. 90-Day Retail Pharmacy Prgrams. Sme retail pharmacies may als ffer up t a 90-day supply f cvered maintenance prescriptin drugs. Maintenance drugs are prescriptin drugs that yu use n an nging basis, fr a chrnic r lng term medical cnditin. There is n cpay fr mail rder drugs. 8