2021 MEDICARE ADVANTAGE GUIDE Plus Prescription Drug Coverage
It’s time to get more from Medicare. Plans from a trusted provider. Plan Options
OSF MedAdvantage Open (HMO-POS) OSF MedAdvantage Plus (HMO-POS) OSF MedAdvantage Core (HMO) OSF MedAdvantage Select (HMO)
(877) 633-2531 (TTY 711) Daily from 8 a.m. to 8 p.m. local time Voicemail is used on holidays and weekends, April 1 – September 30
Table of Contents
Strong Partnership, Strong Providers
Pharmacy
Finding a Plan
Perks and Programs
Open and Core Plans
Enrollment
Plus and Select Plans
Formulary
2020 OSF MedAdvantage Service Area Map
Strong Partnership, Strong Providers
Winnebago
Stephenson
Jo Daviess
Carroll
Lake
McHenry
Boone
Ogle Kane
DeKalb Whiteside
DuPage Cook
Lee Kendall Bureau
Rock Island
Will La Salle
Henry
Grundy
Mercer
Putnam Stark
Kankakee
Marshall
Knox
Livingston
Warren
Woodford
Peoria
Iroquois
Henderson
Fulton
McDonough
Tazewell
Ford
McLean
Hancock Mason Schuyler Adams
Champaign
Menard
Cass
Brown
Vermilion
De Witt
Logan
Piatt Macon
Sangamon
Morgan Pike
Many Medicare insurers offer plans with similar benefits. When everything seems the same, what makes one a better fit for you? When choosing the best plan for your next stage of life, consider choosing one that provides great coverage for your entire well-being and works closely with your healthcare team. OSF MedAdvantage does both through a special collaboration between OSF HealthCare and Health AllianceTM. These plans connect the care you
Douglas
Scott
Edgar
Moultrie Christian
trust from OSF with the insurance expertise of Health Alliance. Calhoun
Greene
Coles
Shelby
Macoupin
Montgomery
Clark
Cumberland
Jersey
Effingham
Fayette
Crawford
Jasper
OSF MedAdvantage plans are custom built to help keep you healthy, not just treat you when you’re sick. And now, OSF offers more options than ever before to stay in touch with your care team, whether you visit an office or use tools for care at home. OSF MedAdvantage is one more way we’re finding new options for excellent care with excellent coverage. Bond
Madison
Clay
Lawrence
Richland
Marion
Clinton
Wabash
St. Clair
Wayne
Washington
Perry
Randolph
Edwards
Jefferson
Monroe
Hamilton
White
Franklin
Jackson
Williamson
Union
Check out the list below to see some of our providers. Go to OSFMedAdvantage.org for a full list.
Alexander
Johnson
Pulaski
Saline
Pope
Gallatin
Hardin
Massac
map-medservicearea20OSF-0119
Tier 1
Bloomington/Normal
Monmouth
Galesburg
Morton
OSF HealthCare St. Joseph Medical Center OSF Medical Group OSF HealthCare St. Mary Medical Center OSF Medical Group
Kewanee
OSF HealthCare Saint Luke Medical Center OSF Medical Group
Mendota
OSF HealthCare Saint Paul Medical Center OSF Medical Group
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OSF HealthCare Holy Family Medical Center OSF Medical Group OSF Medical Group
Ottawa
OSF HealthCare Saint Elizabeth Medical Center OSF Medical Group
Peoria
OSF HealthCare Saint Francis Medical Center OSF HealthCare Cardiovascular Institute OSF HealthCare Illinois Neurological Institute OSF Medical Group OSF Orthopedics
Pontiac
OSF HealthCare Saint James - John W. Albrecht Medical Center OSF Medical Group
Rockford
OSF HealthCare Saint Anthony Medical Center OSF HealthCare Cardiovascular Institute OSF HealthCare Illinois Neurological Institute OSF Medical Group
Streator
OSF Medical Group
Washington
OSF Medical Group
We don’t require a referral, but your doctor might. When your doctor directs you to another provider, it’s called a referral. We don’t require this, but your doctor might. Check with your doctor before you see a specialist or other provider to make sure you’ve taken the proper steps. If we don’t have an in-network specialist to treat your specific condition, we’ll help you find one. And you’ll still pay the in-network cost if you get it preauthorized by us.
Find a plan that fits. Your healthcare coverage should match your needs and preferences, so we offer two plan types – health maintenance organization (HMO) and point of service (POS) plans – to fit different lifestyles. If staying in network or having lower monthly premiums gives you peace of mind, you might prefer an HMO plan:
If you travel often or like having freedom to see doctors in and out of network, you might prefer a POS plan:
• Comfort
• Comfort
of having an in-network primary care provider (PCP) to oversee all your care. • Must see doctors in our large provider network but can go out-of-network for emergency and urgent care. • Focus on strong doctor-patient relationships and familiarity with your provider network.
of having an in-network PCP to oversee all your care. • Flexibility to see out-of-network providers but may save money by staying in network. • Balance between security and freedom.
All of our Medicare Advantage plans offer strong networks of trusted doctors while giving you friendly customer service close to home, care coordination with a personal touch and plenty of perks to help keep you healthy.
Guide
OSF MedAdvantage Open and Core Plans
These plans have lower monthly premiums, no medical deductible and predictable copayments on services like specialist visits, hospital stays and labs. Both the Open and Core Plans have pharmacy coverage and copayments as low as $0 for primary care visits.
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OSF MedAdvantage Plus and Select Plans
These plans have a medical deductible, and after you meet the deductible, most services at Tier 1 providers are covered at 100%. The medical deductible doesn’t apply on services like wellness or emergency care. Both the Plus and Select Plans include pharmacy coverage. Guide
Pharmacy Basics Our plans have built-in prescription coverage, so all your healthcare and pharmacy benefits are in one place. Late Enrollment Penalty If you don’t enroll in a prescription drug (Part D) plan when you’re first eligible, you may have to pay a penalty for enrolling later. That penalty will increase for every month you didn’t have prescription coverage.
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Drug Formulary A formulary is the list of drugs we cover. Generally, we only cover drugs listed in the formulary. You can find it at OSFMedAdvantage.org or in the back pocket of this guide. You can’t be enrolled in a Medicare Advantage HMO or HMO-POS plan and a stand-alone prescription drug plan (PDP) at the same time.
2021 Rx Benefits Our prescription drug plans help you save with special programs, discounts and more. 90 Day Supply Option
Drug Compare Tool
Limit your trips to the pharmacy with two convenient options. With our Mail Order benefit, you are able to get a 90-day supply of your drugs delivered directly to you for two copays. If you prefer to get your drugs at a retail pharmacy, you are able to visit any in-network pharmacy and get a 90-day supply for three copays.
See how much you’ll pay each month and how much you could save by switching to a pharmacy with lower prescription costs or by taking a lower-cost drug. You can check costs at different pharmacies and see the differences in costs between retail (pickup) or mail order (delivery of a 90-day supply). You can also estimate your total annual drug costs.
Medication Therapy Management If you take multiple medications, this program can help you use them safely and effectively.
No Rx Deductible Unlike many other Medicare Advantage plans, our Part D plans have no pharmacy deductible.
Extra Help You might be able to get help to pay for your prescription drug premiums and costs through the Extra Help program. To see if you qualify, call one of the following: • (800) MEDICARE (800-633-4227), 24 hours a day, seven days a week (TTY 1-877-486-2048). • The Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800 325-0778). • The Illinois Department of Human Services at (800) 843-6154, 8a.m. to 5p.m., Monday through Friday (TTY 866-324-5553).
Guide
2021 Rx Benefits Stages of Pharmacy Coverage
Most people stay in this stage.
INITIAL COVERAGE
$4,130 Few people reach this stage.
COVERAGE GAP $6,550
Even fewer people reach this stage.
CATASTROPHIC COVERAGE
Initial Coverage
Catastrophic Coverage
Until the amount you pay plus the amount we pay reaches $4,130: • Tier 1 $2. • Tier 2: $15. • Tier 3: $47. • Tier 4: 50%. • Tier 5: 33%.
Catastrophic coverage begins when your out-of-pocket drug costs reach $6,550. Here, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following: • 5% of the cost. or • $3.70 for covered generic drugs (including brand-name drugs treated as generic) and $9.20 for covered brandname drugs.
Coverage Gap The coverage gap, sometimes called the “donut hole,” begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,130. Here, you pay the following until you reach $6,550: • 25% for covered generic drugs. • 25% for covered brand-name drugs.
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Perks and Programs Fitness, dental, travel ‌ sound like your type of plan? Enjoy special programs, extra perks and programs to help you stay healthy on the go and close to home.
Guide
Care coordinators, health coaches help you meet your health goals. We’re not only here to help when you get sick or hurt. We’re here to help you stay healthy in the first place.
like registered nurses, social workers, health coaches, dietitians, pharmacists and others whose main goal is to make sure our members have the resources they need to stay healthy or work through their medical issues.
Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we’ve got you covered. We give you programs to help you achieve your goals or get you back on track.
The care coordination team is available for all of these situations and will reach out to members to offer their services. Members can also request these services rather than waiting to be contacted. You don’t have to do it alone. We’re there for you every step of the way.
A Team Focused on You
Community Outreach
We connect you to a team that works with your doctors and takes your personalized plan a step further, giving you extra help and resources along the way.
Community is important to us, so we like to get out and meet our members. We’ll be at health fairs, senior expos and other events ready to educate and talk with our current members and others throughout the community. Led by our team of liaisons, we’re excited to build relationships with the people we serve.
What is care coordination? A care coordination team is made up of many providers,
Find helpful resources.
Care for yourself to help prevent illness and hospital stays.
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Set and reach health and wellness goals.
Use your health benefits to save money.
Understand and manage health issues, like diabetes and asthma.
Coordinate your care when you have complicated health conditions.
Understand your coverage when you travel. Going to the doctor is probably one of the last things on your mind while traveling. But if sickness or injury strikes, you have coverage for any emergency room, urgent care center (also called convenient care or a walk-in clinic) or ambulance at the in-network, cost-share amount. And you’ll be covered if you’re admitted to the hospital through the emergency room. POS plans offer out-of-network coverage for routine care, including physical therapy or doctor’s visits, but with an HMO, any routine care you receive while out-of-network won’t be covered. Some services, like physical therapy, may be covered if they’re deemed medically necessary for you to be able to return home.
How You’re Covered
Helpful Travel Reminders
• Break
You have a virtual health coverage benefit included with your plan, talk to a board-certified doctor or counselor by phone or secure video through the Hally™ app, 24/7.
your ankle while hiking? Your emergency care is covered both in and out of network, and so is any emergency surgery you need as a result. • Need routine physical therapy? You’re covered on a POS plan, but you may have to pay more for being out-ofnetwork. You’re not covered on an HMO. • Take a tumble and need physical therapy in order to return home? You’re covered at the in-network level regardless of where you get your care. • Come down with a cold or flu? Urgent care, convenient care and walk-in clinics are covered both in and out of network. • Need a routine physical? You’re covered on a POS plan, but you may have to pay more for being out of network. You’re not covered on an HMO. • If you have questions about other situations, give us a call at the number on the back of this guide.
You can also call our 24-hour Anytime Nurse Line to get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away. Help is just a phone call away with Assist America when you travel 100 miles or more from home. And remember, no matter where you are, urgent or emergency care is covered at the in-network benefit level.
Guide
Assist America Global Emergency Services Have peace of mind on your dream vacation with Assist America global emergency services. No matter where you’re traveling, when you’re 100 miles or more from home, help is just a phone call away, 24 hours a day and 365 days a year. Assist America can connect you to prompt medical attention and help make sure you’re admitted to reliable hospitals when needed. Plus, it can even help in some situations that are not health related.
Here are just some of its many features: • Prescription
assistance if you need medication or left your prescription behind. • Compassionate visit from someone close to you if you need to be hospitalized for more than a week. • Return of mortal remains. • Medical referrals. • Emergency medical evacuation. • Help returning home if you need medical care to travel. • Lost luggage assistance. • Interpreter and legal referrals. All Assist America benefits apply on all of our Medicare Advantage plans, but when you’re out-of-network, our HMO plans cover only emergency and urgent care. Assist America will not pay you back for ambulance and other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.
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Total care from start to finish. We offer plenty of perks and programs to help guide you toward better health.
Anytime Nurse Line
Be Fit
Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.
Get fit at the fitness center of your choice. You choose where you want to work out, and we pay you back up to $360 per year for gym membership or fitness class fees. If your fees are more than $360 per year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover services that require additional fees, like personal trainers or personal equipment. It applies to only standard fitness class and gym membership fees at non-residential commercial or community facilities. Guide
Comprehensive Dental Coverage We cover up to $200 a year for use on dental services. You pay the dentist and then send us the receipt. If your dentist submits the claim for you, you don’t need to send us the receipt. Some plans may have higher coverage.
• Search
functions. • Quick access to virtual visits. • Doctor match and cost estimates. Hally is your ally in all things health.
Disease Management Programs Get help staying on track if you have asthma, diabetes or high blood pressure. We connect you to resources, support and reminders.
Hearing Benefit Through TruHearing®, you can get one routine hearing exam for a $45 copayment and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.
Get your yearly flu shot. Help prevent getting or spreading the flu with your flu shot. The viruses that cause the flu can change yearly, so it’s important to get your shot every year. You can get your shot for no extra cost at any in-network provider or pharmacy that offers it. You may have an office visit copay if you get it at the doctor’s office.
Preventive Care Here are just some of the many services we cover: • Yearly wellness visit. • Routine screenings (like mammograms or colorectal cancer screenings). • Flu shot.
Quit For Life
®
Get help ending your tobacco use with: • One-on-one coaching from a quit coach. • Quit plan made just for you. • Helpful tools, like Text2Quit®. • Web Coach®, an online learning and support community.
Hally™ App Manage your health plan and get the care you need anytime, anywhere. • All your account activities in one place. • Virtual ID card access. •
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Visit the Apple® App Store® or Google Play® to download the Hally™ app. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
Virtual Health Coverage Get care when and where you need it with virtual health coverage. If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. You don’t even need to leave the comfort of your home. You can also get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S. Whether at home or traveling, you can talk to a board certified doctor or counselor by phone or secure video through the Hally™ app or hally.com at any time of the day, any day of the year.
Vision Coverage Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider.
Online Access Get instant access to your coverage anytime at OSFMedAdvantage.org. Our secure member website stores important plan information in one easy place. You can also find information about our member app on our website.
Wellness Rewards Take steps toward better health while working your way toward a $50 gift card. Have a yearly wellness visit or physical, plus complete two other activities outlined at OSFMedAdvantage.org to qualify for your $50 gift card.
Appeals and Grievances We want you to feel at home with your plan, so we help you understand the protections we have in place. Our OSF MedAdvantage plans offer safeguards to make sure you’re treated fairly and have the chance to voice your opinion if you think you’ve been mistreated. appeal is a type of complaint you can file if you disagree with the plan’s decision to not cover healthcare services you’re trying to get or have already gotten.
• An
Manage your health plan and get the care you need anytime, anywhere. • All your account activities in one place. • Virtual ID card access. • Search functions. • Quick access to virtual visits. • Doctor match and cost estimates. The Hally app is your ally in all things health.
You must file an appeal in writing within 60 days of the decision or as soon as you can. grievance is a type of complaint you can make about your plan. Some examples are poor quality of care, bad customer service or feeling like an employee is encouraging you to leave the plan.
• A
You can file a grievance by calling Member Services at (877) 933-8480 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. You can also email MemberServices@HealthAlliance.org.
Guide
Enrollment We make enrollment simple with multiple options to choose from and helpful customer service along the way. 2021 OSF Med Advantage
Timelines and Requirements The Centers for Medicare & Medicaid Services (CMS) sets certain times during the year when people can enroll in a Medicare Advantage or prescription drug plan. Annual Enrollment Period
Special Enrollment Period
From October 15 to December 7, you can enroll in Medicare Advantage or a stand-alone prescription drug plan, or you can switch plans. If you enroll during this period, your coverage begins January 1 of the following year.
You can enroll in a new plan or change your plan in certain situations. Here are some examples: • Permanent address change. • Loss of coverage due to employment change. • Becoming eligible for a low-income subsidy.
Initial Enrollment Period
Contact us for other situations that qualify.
You have a seven-month initial enrollment period to enroll in Original Medicare, Medicare Advantage or a prescription drug plan. It starts three months before the month you turn 65, includes the month of your 65th birthday and ends three months after the month you turn 65. • If you enroll one to three months before your 65th birthday, your coverage begins the first day of the month you turn 65. • If you enroll during your birth month, your coverage begins the first day of the following month. • If you enroll one to three months after the month you turn 65, your coverage begins the first day of the month after you enroll.
Who is eligible for our plans? • You
must have Medicare Parts A and B and live in the service area. • You must continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.
Enrollment in the plan will automatically disenroll you from any other Medicare Advantage plan. Enrollment in the plan won’t automatically disenroll you from a Medicare Supplement plan. You must contact that plan to disenroll.
From January 1 to March 31, you can switch from one Medicare Advantage plan to another or join a standalone prescription drug plan.
Guide
Enrollment Process How to Enroll Online
Broker
Visit OSFMedAdvantage.org to get started.
If you attend a learning event, the person presenting can schedule an appointment to help you enroll.
By Phone
After You Enroll
Call (877) 633-2531 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.
If you enroll in a Medicare Advantage plan during the 2021 Annual Enrollment Period, your coverage will begin January 1, 2021.
By Mail Fill out and mail us the enrollment form in the back of this guide. You can also download it from OSFMedAdvantage.org.
OSF MedAdvantage Application Processing Center 3310 Fields South Dr. Champaign, IL 61822
In the meantime, we’ll help you get settled with the following: • Member materials, which we’ll mail to you. • Member ID card to use instead of your red, white and blue Medicare card at the doctor, hospital and pharmacy.
OSF MedAdvantage is administered by Health Alliance Medicare – a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Medicare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Every year, Medicare evaluates plans based on a 5-star rating system.
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2021 Star Ratings Health Alliance Medicare - H1463 2021 Medicare Star Ratings Every year, Medicare evaluates plans based on a 5-star rating system. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans. The two main types of Star Ratings are: 1. An Overall Star Rating that combines all of our plan's scores. 2. Summary Star Ratings that focus on our medical or our prescription drug services. Some of the areas Medicare reviews for these ratings include: How our members rate our plan's services and care; How well our doctors detect illnesses and keep members healthy; How well our plan helps our members use recommended and safe prescription medications. For 2021, Health Alliance Medicare received the following Overall Star Rating from Medicare. 4 Stars We received the following Summary Star Ratings for Health Alliance Medicare's health/drug plan services: Health Plan Services:
4 Stars
Drug Plan Services:
3.5 Stars
The number of stars shows how well our plan performs. 5 stars - excellent 4 stars - above average 3 stars - average 2 stars - below average 1 star - poor Learn more about our plan and how we are different from other plans at www.medicare.gov. You may also contact us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time at 877-633-2531 (toll-free) or 711 (TTY), from October 1 to March 31. Our hours of operation from April 1 to September 30 are Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Current members please call 877-933-8480 (toll-free) or 711 (TTY). Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next.
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. MDMKOS21-OSFstarrtgfl-1020
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Call us at (877) 633-2531 (TTY 711), Daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. OSFMedAdvantage.org MDMKOS21-guidebk-0320_DIGITAL H1463_21_86022_M