We're proud to offer three choices of plans that include both Medical (Part A and B) and Prescription Drug (Part D) benefits — Rewards (HMO), Value (HMO), and Classic (HMO-POS) plans. The Summary of Benefits, Evidence of Coverage, and other information below explain the details about each plan:

• Benefits
  • Summary of Benefits
  • Evidence of Coverage
• Prescription drug information
  • Formulary and pharmacies
  • Forms
  • Requirements
  • Extra help for prescription drug costs
• Provider/pharmacy directories
• Your privacy, rights, and procedures for grievances, appeals, and exceptions

Benefits

Summary of Benefits — This booklet explains general information about our Rewards, Value, and Classic options and compares them to original Medicare. It also includes information about premiums, cost sharing, out-of-network coverage, any limitations, and more:

 Rewards, Value, and Classic Summary of Benefits  
(H1099_MP2652 CMS Approved 09012011) 

•  Delta Dental Summary of Benefits (part of the Classic plan benefits) (H1099_MP2764 CMS Approved 11042011)

 Rewards, Value, y Classic Resumen de Beneficios 
(H1099_SP2652 CMS Approved 09012011)

Evidence of Coverage — These documents provide the most detailed information about each plan:

  Rewards Evidence of Coverage (H1099_EL2716 File & Use 09142011)

  Value Evidence of Coverage (H1099_EL2705 File and Use 09152011)

  Classic Evidence of Coverage (H1099_EL2703 File & Use 09142011)

•  Delta Dental Evidence of Coverage (for Classic members only)
  (H1099_MP2722 CMS Approved 09302011)

Prescription drug information

Health First Health Plans has contracts with pharmacies that equal or exceed the Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area. We have more than 100 network pharmacy locations in our local area, and more than 65,000 nation-wide.

Formulary and pharmacies

 Comprehensive formulary — a complete list of covered drugs
(H1099_EL2761 File and Use 10102011)

 Participating pharmacies — listed in the provider/pharmacy directory (H1099_MP2621 CMS Approved 09072011)

Forms

Mail order prescriptions from Health First Family Pharmacy

Mail order prescriptions from MedVantx

Prescription reimbursement form (H1099 EL624_18706A19206)

Requirements

Process for Part D prescription drug prior authorizations, exceptions, appeals and grievances

 Prior authorization requirements 
(H1099_MP2596_19611 CMS Approved 07182011)

Transition policy (H1099_EL2798 File and Use 11072011)

 Medication therapy management, and drug and/or utilization management  (H1099_EL2842 File & Use 12172011)

Step therapy criteria 
(H1099_MP2841 CMS Approved 12122011)

Extra help for prescription drug costs

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to one hundred (100) percent of drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week;
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778; or
• Your local Social Security office.
• Your State Medicaid Office.

Assistance with Best Available Evidence for Low Income Subsidy 

Monthly plan premiums for people who get extra help from Medicare to help pay for their prescription drug costs (H1099_EL2605 File and Use 08162011)

Provider/pharmacy directories

Search for physicians

 Printable physician/pharmacy directory — includes information about authorizations, our network, ancillary services like labs, fitness centers, etc., and also pharmacies (H1099_MP2621 CMS Approved 09072011) 

 Delta Dental provider directory (for Classic members only)
(H1099_MP2811 CMS Approved 11182011)

Your privacy, rights, and procedures
for grievances, appeals, and exceptions

Part D prescription drug prior authorizations, exceptions, appeals and grievances

Medical prior authorizations, appeals and grievances

 Notice of privacy practices

Please refer to the Evidence of Coverage (EOC) for more details about these topics, as well as your rights and responsibilities upon disenrollment:

 Rewards Evidence of Coverage (H1099_EL2716 File & Use 09142011)

  Value Evidence of Coverage (H1099_EL2705 File and Use 09152011)

  Classic Evidence of Coverage (H1099_EL2703 File & Use 09142011)

•  Delta Dental Evidence of Coverage (for Classic members only)
  (H1099_MP2722 CMS Approved 09302011)

For more information about our quality assurance policies and procedures or to obtain an aggregate number of the our grievances, appeals, and exceptions, contact customer service.

H1099_MP2760 CMS Approved 10212011
Last updated: 5/1/2012