For information concerning the actual premiums you will pay, please contact PERS or your employee group benefits plan administrator. Your total premium is set by PERS and includes other benefits. Contact PERS for more information. This amount may change on January 1 of each year.
Tells about materials we will send you, your plan premium, your plan membership card, and keeping your membership record up to date.
Tells you how to get in touch with PacificSource Medicare, Medicare, the Quality Improvement Organization, Social Security, Medicaid, and the Railroad Retirement Board.
Explains how to get medical care, use providers in our network, get care when you have an emergency, get out-of-network services, and rules about referrals, lock-in, and cost-sharing.
Explains what medical care is covered, how much you pay, and how much the plan pays. Explains what's covered under optional preventive dental.
Tells how to use the List of Covered Drugs (Formulary) to find out which drugs are covered, what's not covered, as well as rules and restrictions that may apply. Explains where to get your prescriptions filled, drug safety and programs for managing medications.
Tells about the stages of drug coverage (Initial, Coverage Gap, Catastrophic), cost-sharing tiers, what you pay for drugs in each tier, and the late enrollment penalty.
Explains when and how to send a bill to us when you want to ask us to pay you back for our share of the cost for your covered services.
Explains the rights and responsibilities you have as a member of our plan, and what you can do if you think your rights are not being respected.
Information and step-by-step instructions on what to do if you are having problems or concerns. Explains how to file a grievance, ask for coverage decisions, make complaints, and an appeal.
Explains when and how you can end your membership, situations where our plan is required to end your membership, and your rights and responsibilities upon disenrollment.
Includes notices about governing law and about nondiscrimination.
Explains key terms used in this booklet.
Staying active is important to maintaining or improving your health. With the Silver&Fit® Exercise & Healthy Aging Program, you have access to the following at no cost to you:
To learn more and find a fitness center near you, go to www.SilverandFit.com
Silver&Fit is provided by American Specialty Health Fitness, Inc. a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH.
Good hearing is important to your health. That’s why PacificSource Medicare partners with TruHearing to offer a hearing hardware benefit. This plan includes*:
* Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact TruHearing customer service.
For information, visit www.TruHearing.com/PacificSource or call 844-255-7141, TTY 711.
All our Medicare Advantage plans cover routine vision exams once every two calendar years. You can also receive up to $100 reimbursement for eyeglasses or contact lenses every two calendar years, with the freedom to choose the style you like best. This benefit is not included with Original Medicare, which covers only medical eye care, such as exams that look for signs of eye disease.
With PacificSource Medicare, you’re covered for medically necessary emergency and urgent care, and ambulance (ground and air), wherever you travel. You also have access to Assist America®, which can help you obtain services if you become ill or injured while traveling abroad or more than 100 miles from your permanent residence. Services include assistance with:
Toll-free: 855-834-6150, TTY 711
Have a health-related question? Our 24-Hour NurseLine is staffed around the clock, 7 days a week, and there’s no cost to you. When you have a concern that is not life threatening, you can receive trusted health information and advice from the comfort of your home.
Is your problem about your benefits or coverage?
See the information below about Coverage Decisions and Payment Requests or Appeals
See the information below about Complaints
There are three types of problems or concerns:
A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs. If you ask us for reimbursement or to pay a bill you have received from a provider for covered medical services or drugs, we are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal. Please see the section below about appeals.
If you are in any of the five following situations, you can ask us for a coverage decision if:
Start by calling, writing, or faxing us your request for us to provide coverage for the medical care you want or to reimburse you for medical care you paid for. You, your doctor, or your representative can do this. Click here to contact us.
We will give you an answer within 14 calendar days after we receive your request unless you ask for more time or if we need more information that may benefit you. If your health requires it, you can ask for a fast coverage decision which means we will answers within 72 hours. If your doctor tells us that your health requires it, we will automatically give you a fast coverage decision. Otherwise, you must meet two requirements:
If a drug is not covered in the way you would like it to be covered, you can ask us to make an "exception." An exception is a type of coverage decision where you ask:
Start by calling, writing, or faxing us your request for us to provide coverage for the Part D prescription drug you want. You, your doctor, or your representative can do this. Click here to contact us.
We will give you an answer within 72 hours after we receive your request for a drug you have not yet received or within 14 days for a drug you have already received unless you ask for more time or if we need more information that may benefit you. If your health requires it, you can ask for a fast coverage decision (also called an expedited coverage determination) which means we will answers within 24 hours. If your doctor tells us that your health requires it, we will automatically give you a fast coverage decision. Otherwise, you must meet two requirements:
If you are not satisfied with our coverage decision, you may ask for an appeal. Please see the section below about appeals.
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made. When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original decision. When we have completed the review we give you our decision.
In order to process your appeal, we must receive it within 60 calendar days of the denial date.
Start by calling, writing, or faxing us your request for us to provide coverage for the medical service you want. You, your doctor, or your representative can do this. Click here to contact us.
We will give you an answer within 30 calendar days after we receive your request unless you ask for more time, or if we need more time to obtain information that may benefit you. If your health requires it, you can ask for a fast coverage decision to be provided within 72 hours of receipt of your request.
Start by calling, writing, or faxing us your request for us to provide coverage for the Part D prescription drug you want. You, your doctor or prescriber, or your representative can do this. Click here to contact us.
We will give you an answer within 7 calendar days after we receive your request. If your health requires it, you can ask for a fast coverage decision to be provided within 72 hours of receipt of your request.
If we say no to all or part of your appeal, you can go on to a Level 2 Appeal process. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through several more levels of appeal.
A complaint is when you have a problem or concern with the quality of care, waiting times, customer service or other concerns about service provided to you. This type of complaint does not involve a coverage decision or a payment dispute. If your problem is about the plan’s coverage or payment, you should look at the section above about making an appeal. A complaint is when you tell us about a problem or concern with:
Start by calling or writing Customer Service with your complaint. Click here to contact us. In order to review your complaint, we must receive it within 60 calendar days after you had the problem or concern you want us to address.
Most complaints are answered within 30 calendar days. If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint. If you are making a complaint because we denied your request for a "fast coverage decision" or a "fast appeal," we will automatically give you a "fast" response. If you have a "fast" complaint, it means we will give you an answer within 24 hours.
Once we have reviewed your complaint, we will respond and address your concerns in writing.
For concerns about the quality of your medical care, you can make the complaint to us, and/or, you can make your complaint to a Quality Improvement Organization. The Quality Improvement Organization is a group of practicing doctors and other health care experts paid by the Federal government to check and improve the care given to Medicare patients. To find the name, address, and phone number of the Quality Improvement Organization for your state, look in Chapter 2 of your Evidence of Coverage. If you make a complaint to this organization, we will work with them to resolve your complaint.
For complaints about our plan, you can also submit directly to Medicare. To submit a complaint to Medicare, go to www.Medicare.gov/MedicareComplaintForm/home.aspx .
You can submit an appeal or complaint through our secure website for members, InTouch. Click "InTouch Login" at the top of our plan website to register or login into your account. There are two ways you can access our online appeal and complaint forms:
An online form will appear for you to fill out. The form has two sections, one is for appeals (Tab 1) and the other is for complaints (grievances) (Tab 2). Fill out the section that applies to your situation. After you have completed the form(s) click “Submit” to submit your request to the plan for review. Follow up notices will be sent to you by mail (or phone call for expedited reviews).
If you have someone filing a complaint on your behalf, or someone appealing our decision for you other than your doctor or prescriber (for Part D prescription appeals), unless you have a Power of Attorney for Healthcare on file, your complaint/appeal must include an Appointment of Representative form authorizing this person to represent you, or a copy of the Power of Attorney for Healthcare. Click here to complete the "Appointment of Representative" form. While we can accept a complaint or appeal request without the form, we cannot review the issue until we receive it. If we do not receive the form within 44 days after receiving your complaint or appeal request (our deadline for making a decision), your appeal request will be sent to the Independent Review Organization for dismissal. Complaints will be dismissed directly by the plan without further review.
You can call Customer Service for information on how to get an overall number of complaints, appeals, and exceptions filed with us.
We are always available to help you. But in some situations you may also want help or guidance from someone who is not connected with us. You can always contact your State Health Insurance Assistance Program (SHIP). You can also contact Medicare. Here are two ways to get information directly from Medicare:
You also have the right to hire a lawyer to act for you. You may contact your own lawyer, or get the name of a lawyer from your local bar association or other referral service. There are also groups that will give you free legal services if you qualify. However, you are not required to hire a lawyer to ask for any kind of coverage decision or appeal a decision.
Your plan includes Part D prescription drug coverage. The List of Covered Drugs (also called a formulary) includes a list of drugs selected by the plan with the help of a team of doctors and pharmacists. The drugs on this list are covered under Medicare Part D. The drug list also include both brand name and generic drugs. A generic drug is a prescription drug that has the same active ingredients as the brand name drug. Generally, it works just as well as the brand name drug and usually costs less. There are generic drug substitutes available for many brand name drugs.
Your plan does not cover all prescription drugs. In some cases, the law does not allow any Medicare plan to cover certain types of drugs and in other cases your plan decided not to include a particular drug on the Drug list. Every drug on the drug List is in one of cost-sharing tiers below:
To find out which cost-sharing tier your drug is in, look up your drug through our online drug search. You can also find whether your prescription drug has any restrictions. Our plan uses different types of restrictions to help our members use drugs in the most effective ways.
For more information about Part D prescription drugs, you can contact us. We have a team of pharmacy experts that can help you avoid adverse events, ensure your drugs don’t interact with each other, find alternative medications that may work for your conditions, and we can help provide you with one-on-one consultations with a clinical pharmacist. Call Customer Service for more information.
Your plan premium includes coverage for both medical services and prescription drug coverage. If you have limited resources and income, you may be able to get Extra Help paying for your drug costs. The amount of financial help awarded is based on income and resources. You may get help with your monthly premiums or drug copayments. In addition, there is no gap in coverage (no donut hole). According to the Social Security Administration, Extra Help is estimated to be worth about $4,000 per year. Some people are automatically eligible. You will qualify for Extra Help if you have Medicare and any of these conditions.
You may be eligible for Extra Help if you meet the following conditions:
If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. The amount of Extra Help you get will determine your total monthly plan premium as a member of our plan. The links below provide you with the premium you would pay as a member of our plan while you are getting Extra Help, and Best Available Evidence which will assist you in determining what level of assistance you may qualify for if Medicare’s system does not reflect the most up-to-date and accurate subsidy information.
If you aren’t getting extra help, you can see if you qualify by contacting us or by: