Medical Member Service
503-265-4762 or
877-299-9062
800-433-6313 TTY
7:30AM-5:30PM,
Mon-Fri,
Pacific Time
Pharmacy Customer Service
503-265-4709 or
888-786-7509
800-433-6313 TTY
8:00AM-8:00PM,
Mon-Fri,
Pacific Time
ODS Advantage PPO RX Select (2007) - A PPO and enhanced Prescription drug plan with a Medicare contract
The ODS Advantage PPORX Select is a Medicare Advantage local PPO plan that includes an enhanced Prescription Drug serving the State of Oregon.
- Eligibility Requirements
- Enrollment
- Benefits
- Premium
- Medical Provider Network
- Pharmacy Information
- Disenrollment
- Administrative Information
- ODS Advantage Plan Member Guide (PDF)
Eligibility Requirements
The ODS Advantage PPORX Select plan is designed for those Medicare eligible people who wish to have one plan that includes both their medical coverage and their Part D prescription drug coverage.
- You must have both Medicare Part A and Part B to apply.
- You must reside in Oregon to apply for the ODS Advantage PPORX Select plan.
- You must continue to pay your Part B premium. (if not paid under Medicaid or third party)
- You cannot enroll if you have End Stage Renal Disease (ESRD). If you are currently enrolled in an ODS medical plan, you may be able to enroll even if you are having renal dialysis or have had a recent kidney transplant. Contact member services for more information.
- Prescription drug benefits are only available to members of this plan
Note: If you are already enrolled in another Medicare Advantage Prescription Drug plan, you must receive your Medicare prescription drug benefit through that plan.
Enrollment
Enrollment into a prescription drug plan is voluntary.
You can enroll in ODS Advantage PPORX Select beginning November 15, 2006 through December 31, 2006, when you are first eligible for Medicare, when you have a Special Election Period and each Annual Election Period.
If you do not join a prescription drug plan, you may have to pay more for your prescription drug coverage. There is a 1% per month penalty for each month during which you could have enrolled but did not. The 1% penalty is based on the Medicare Base premium and can change each year.
For Example: If a Medicare eligible person who could have enrolled January 1, 2006 delayed enrollment in a Medicare Prescription Drug Plan until January 1, 2007 that member would have a penalty of 6%. This 6% is based on the six months from July 2006 through December 2006.
The penalty applies for as long as the member is enrolled in a prescription drug plan.
Your coverage will generally be effective the first of the month following our receipt of a "Complete" enrollment form. If you have not completed the enrollment form we will contact you for more information. This can delay your effective date.
Warning: If you are enrolled in a Medicare Advantage plan (like the ODS Advantage PPO) and you apply for the ODS Advantage PPORX Select plan you will be disenrolled from your Medicare Advantage plan and may not be able to reapply until the next Medicare Annual Election Period, which is Nov. 15th through Dec 31st of each year.
Ways to Enroll
- Attend a Community Meeting for more complete information about the ODS Advantage PPORX Select plan. The Community Meeting Schedule is a list of ODS Advantage Community Meetings. A sales representative will be present with information and applications.
- Print the ODS Advantage PPORX Select Enrollment Form and Instructions and send it to us at the address on the form.
- Call member services to request an enrollment packet
For more information about when you can enroll in ODS Advantage PPORX Select, call member services.
If you need help completing the ODS Advantage PPORX Select Enrollment Form, please call ODS Advantage member service.
ODS Advantage PPORX Select Benefits
Medical Benefits
ODS Advantage PPORX Select plan feature a number of valuable medical and prescription drug benefits including:
- Annual out-of-pocket maximum of $1,500
- No medical deductible
- Copayments and coinsurance amounts are the same for both in and out of network services. ODS Advantage pays up to the limiting charge for Medicare covered services
- Annual physical
- See any Medicare provider in or out-of-network
- Travel and visitor coverage for up to 12 months
- Worldwide coverage for urgent and emergent medical services
Prescription Drug Benefits
- Open formulary covering all Part D eligible drugs
- $0 Yearly deductible then you pay
- 25% Coinsurance until your yearly drug costs reach $2400 (paid by both you and your plan) then
- You pay 100% of your Brand name drug costs from $2400 until your yearly out-of pocket drug costs reach $3850 (TrOOP)
- You pay 25% coinsurance for Generic drugs from $2400 until your yearly out-of-pocket drug costs reach $3850
- You pay 100% of costs from $2400 to $3850 (True Out of Pocket (TrOOP))
- TrOOP Maximum $3850
- After your yearly out-of-pocket drug costs reach $3850. You pay the greater of:
- $2.15 for generic (including brand drugs treated as generic) and $5.35 for all other drugs
OR - 5% coinsurance
- $2.15 for generic (including brand drugs treated as generic) and $5.35 for all other drugs
Highlights
- Access to in-network pharmacies in Oregon, Washington and across the USA
- Access to Mail Order Pharmacy
- 90-day supply through Retail or Mail Order
- ODS Advantage Formulary includes all eligible Part D drugs
- Generic : A Generic drug has the same active-ingredient formula as the brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs.
- Brand: Brand name drugs that are as therapeutic as newer and more costly drugs. The brand drugs may include a rebate that is used to offset program costs.
- Special/Injectables: Biotech drugs, drugs that require medical management, drugs that are dispensed in a limited quantity, drugs that are injected, some compound drugs and drugs that require special handling.
- You generally pay less for a generic drug than for a Brand drug.
The ODS Advantage PPORX Select Summary of Benefits is a comparison of ODS Advantage PPORX, ODS Advantage PPORX Select and Original Medicare Plan. The charts in the booklet list some important health benefits. For each benefit, you can see what our plans cover and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.
The ODS Advantage PPORX Select Evidence of Coverage includes the benefits, the limitations, restrictions, appeals and grievances process, and other important information about the ODS Advantage PPORX Select plan.
For more information about ODS Advantage PPORX Select benefits, call member services.
Premium
The monthly premium for 2007 is $99.50. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You can pay your Medicare plan directly for your monthly premium, or have the monthly premium automatically deducted from your Social Security check. If you choose to pay directly, you can pay by mail or by electronic funds transfer (EFT). Generally you must stay with the option you choose for the rest of the year.
Payment may be made:
- Directly to ODS Health Plan, Inc.
- Through Electronic Fund Transfer from your bank
- Deducted from your monthly Social Security check
If you have questions about any of these options, call member services.
Beneficiaries interested in qualifying for extra help
Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call:
- 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.
- Your State Medicaid Office or
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week), or
If you qualify for the Medicare Part D premium subsidy and you choose an ODS Advantage plan, you will have to pay the balance of the plan's Part D premium if you don't qualify for the 100% subsidy.
Low Income Subsidy
If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you aren't getting any extra help, you can see if you qualify by calling: 1-800-MEDICARE (1-800-633-4227) for this information. TTY/TDD users should call 1-877-486-2048. They are available 24 hours a day, 7 days a week.
You may receive (or may have received) a letter from Medicare or the Social Security Administration (SSA) about your eligibility for extra help in 2007. Read this important information carefully. If you don't know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227) for this information. TTY/TDD users should call 1-877-486-2048. They are available 24 hours a day, 7 days a week.
Beneficiaries interested in qualifying for extra help with Medicare Prescription Drug Plan costs should call:
- 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1- 877-486-2048 , 24 hours a day/7 days a week ), or
- Your State Medicaid Office or
- 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.
If you qualify for the Medicare Part D premium subsidy and you choose an ODS Advantage plan, you will have to pay the balance of the plan's Part D premium.
Medical Provider Network
The ODS Advantage Provider Network is a network of doctors, specialists and hospitals. You can use any provider who is part of our network. You may also go to Medicare providers outside of our network. The providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or visit the link below. Or call our member services at 1-877-299-9062 (TTY/TDD users should call 1-800-433-6313).
The ODS Advantage Network Provider Directory (Acrobat PDF) is a printable version of the ODS Advantage Network Provider Directory for the entire state of Oregon.
If you need help finding an ODS Advantage Network provider please call member services.
Medical Appeal and Grievance Procedure
As an ODS Advantage PPORX Select member, you have the right to file a complaint if you have concerns or problems with any part of your benefits, care and service.
There are two types of complaints:
- Appeal
-
An appeal is a type of complaint you make when you want us to reconsider and change a decision we have made about what services are covered for you or what we will pay for a service. Sections 10 and 11 in your Evidence of Coverage explain about appeals, including the process involved in making an appeal.
- Grievance
-
A grievance is a type of complaint you make about us or one of our plan providers, including a complaint concerning the quality of your care. This type of complaint does not involve payment or coverage disputes. See Section 10 below for more information about a grievance and what to do if you would like to make one.
Section 10: How to file a grievance - This section is from your Evidence of Coverage for the ODS Advantage PPORX Select plan.
Section 11: Information on how to make a complaint about Part C medical services and benefits - Detailed information about how to make an appeal that involves your medical benefits. This section is from your Evidence of Coverage for the ODS Advantage PPORX Select plan.
Pharmacy Information
Note: Due to a change in Medicare most Medicare prescription drug plans will no longer cover erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, Edex, Muse, Yohimbine and Caverject starting January 01, 2007. ODS Advantage prescription drug plans will no longer cover ED drugs beginning January 01, 2007.Formulary
The ODS Advantage Comprehensive Formulary includes generic and BRAND drugs. Generic drugs are listed in lower-case italics (e.g. furosemide) and BRAND drugs are in upper case capital letters (e.g. CELEBREX) by therapeutic category followed by an alphabetic list by drug name. We have not listed all strengths for all drugs.
If you do not find your drug in the formulary it may still be a covered drug. Please call ODS Advantage Pharmacy customer service.
You may request a hard copy Formulary in the Abridged Formulary version (drugs by classification and an alphabetic list but not all covered drugs are listed) or the Comprehensive Formulary version (drugs by classification and an alphabetic list but may not include all of the changes that have been made this past year or be as up to date as the version on this web site) by calling ODS Advantage Pharmacy customer service.
The ODS Advantage Formulary Updates will be made monthly. Changes are made based on new drugs entering the market, drugs that were BRAND drugs being offered as generic drugs, FDA rulings that take a drug off of the market, FDA rulings that change the approved usages for drugs, Medicare rule changes, and ODS Advantage Pharmacy and Therapeutics Committee recommendations.
These updates can result in a change in the cost share you pay for specific drugs. These updates can result in drugs that were covered being excluded or excluded drugs may now be covered. If you have any questions about the status of the drugs that you use, please call ODS Advantage Pharmacy Customer Services at the numbers listed in customer service.
Transition Policy
The ODS Advantage General Transition Notice will explain what a new or continuing member in our plan can do if a current prescription drug is not on our formulary or their ability to get a drug is limited. This transition notice will also explain that if you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days).
Generally, if you are taking a drug on our 2007 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2007 coverage year except when a drug becomes an over-the-counter (OTC) drug or when new adverse information about the safety or effectiveness of a drug is released.
Pharmacy Forms
- Appointment of Representative
This form is used to name a relative, friend, advocate, doctor or anyone else to be your appointed representative. This appointed representative may request a coverage determination or file a grievance or appeal on your behalf. If you want someone to act for you, then you and that person must sign the Appointment of Representation form which will give the person legal permission to act as your appointed representative. - Coverage determination and Exception Request
This form is used to request a coverage determination and a formulary exception request. Note: This form cannot be used to request barbiturates, benzodiazepines, fertility drugs, drugs for weight loss or weight gain, drugs for hair growth, over-the-counter drugs, or prescription vitamins (except prenatal vitamins and fluoride preparations). - Coverage Determination Form (Physicians)
This form is used by the prescribing physician to request a coverage determination. A coverage determination includes a prior authorization, an exception request, and an expedited review. This form cannot be used to request Medicare non-covered drugs including barbiturates, benzodiazepines, fertility drugs, drugs prescribed for weight loss, weight gain or hair growth, over-the-counter drugs or prescription vitamins (except prenatal vitamins and fluoride preparations). - Prescription Drug Redetermination Request
This form is used to request an appeal or redetermination of a denied service or coverage determination. Note: You must receive a denied coverage determination before requesting a redetermination.
Prescription Drug Appeal and Grievance Procedure
The following Section 12 below is what you can do if you have a complaint about your Part D Prescription drug benefits.
Section 12: What to do if you have complaints about your Part D Prescription drug benefits - This section is from your Evidence of Coverage for the ODS Advantage PPORX Select plan.
If you have questions or need help with your appeal, coverage determination, exception request, redetermination or grievance, please call member services.
If you would like a report on the number of ODS Advantage PPORX Select grievances, appeals and exceptions, call member services.
Coverage Determination
The plan sponsor has made a coverage determination when it makes a decision about the prescription drug benefits you can receive under the plan, and the amount that you must pay for a drug.
Exception
A type of coverage determination that, if approved, allows you to obtain a drug that is not on our formulary (a formulary exception), or receive a non-preferred drug at the preferred cost-sharing level (a tiering exception). You may also request an exception if we require you to try another drug before receiving the drug you are requesting, or the plan limits the quantity or dosage of the drug you are requesting (a formulary exception).
Pharmacy Network
The ODS Advantage pharmacy network contracts with over 600 pharmacies in the state of Oregon . ODS Advantage PPORX Select has contracts with pharmacies that equal or exceed the CMS requirements for pharmacy access in your area.
ODS Advantage offers a wide range of choices when it comes to where and how you can order prescription drugs. The ODS Advantage Pharmacy Network includes Retail, Home Infusion, Long-Term Care and Indian Health Service pharmacies, and for your convenience a majority of national mail-order pharmacies. You can also fill up to a 90-day supply of maintenance medications at your local retail pharmacy.
The ODS Advantage Network Pharmacy Directory (Acrobat PDF) is a printable version for Oregon and Washington.
You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies. If you use an out of network pharmacy, you may need to pay for your prescriptions and mail your receipt to ODS Advantage for processing. You will have to pay any difference between the out of network pharmacy's charge and the plan's allowable charge.
If you have any questions about access, mail order services, or need help finding a pharmacy, please call ODS Advantage Pharmacy customer service.
Out of Network Pharmacy Access
Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. Before you fill your prescription in these situations, call customer service to see if there is a network pharmacy in your area where you can fill your prescription. If you do go to an out-of-network pharmacy for the reasons listed below, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription. You can ask us to reimburse you for our share of the cost by submitting a claim form. However, even after we reimburse you for our share of the cost, you may pay more for a drug purchased at an out-of-network pharmacy because the out-of-network pharmacy's price is higher than what a network pharmacy would have charged. You should submit a claim to us if you fill a prescription at an out-of-network pharmacy, any amount you pay, consistent with the circumstances listed above, will help you qualify for catastrophic coverage. To learn how to submit a paper claim, please refer to the paper claims process described next.
We will cover your prescription at an out-of-network pharmacy if at least one of the following applies:
- If you are unable to obtain a covered drug in a timely manner within our service area because there is no network pharmacy within a reasonable driving distance that provides 24-hour service.
- If you are trying to fill a prescription drug that is not regularly stocked at an accessible network retail or mail order pharmacy (including high cost and unique drugs).
- If you are getting a vaccine that is medically necessary but not covered by Medicare Part B and some covered drugs that are administered in your doctor's office.
How do I submit a paper claim?
When you go to a network pharmacy, your claim is automatically submitted to us by the pharmacy. However, if you go to an out-of-network pharmacy for one of the reasons listed above, the pharmacy may not be able to submit the claim directly to us. When that happens, you will have to pay the full cost of your prescription . When you return home, submit the receipt from the pharmacy with your name on it that lists the Pharmacy , the phone number of the pharmacy, the prescription filled and the prescriber to the following address:
ODS Health Plan, Inc.
Attn: Pharmacy Claims
P.O. Box 40327
Portland , OR 97240-0327
If you have any questions about submitting your receipt, please call ODS Pharmacy Customer Service at 1-888-786-7509 or TTY 1-800-433-6313 Monday through Friday from 8:00 a.m. to 8:00 p.m., Pacific time.
Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Evidence of Coverage or call Customer Service for more information on initial coverage determinations.
ODS Advantage Pharmacy Quality Assurance
ODS Advantage has a number of quality assurance programs to assure that you are receiving the highest quality care and service at network pharmacies and by ODS.
We conduct drug utilization reviews for all of our members to make sure that they are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
- Possible medication errors
- Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
- Drugs that are inappropriate because of your age or gender
- Possible harmful interactions between drugs you are taking
- Drug allergies
- Drug dosage errors
If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
The ODS Advantage Medication Therapy Management Program (MTMP)
We offer a free medication therapy management programs for members who have multiple medical conditions, who are taking many prescription drugs, and have high drug costs. These programs were developed for us by a team of pharmacists and doctors. We use these medication therapy management programs to help us provide better coverage for our members. For example, these programs help us make sure that our members are using appropriate drugs to treat their medical conditions and help us identify possible medication errors.
We offer a medication therapy management program for members that meet specific criteria. We may contact members who qualify for these programs. If you are selected to join a medication therapy management program we will send you information about the specific program, including information about how to access the program. Remember, you do not need to pay anything extra to participate.
Disenrollment
As a member of ODS Advantage PPORX Select, you may want to leave our plan or there are a few situations where you would be required to leave our plan. "Disenrollment" from ODS Advantage PPORX Select means ending your membership in ODS Advantage PPORX Select. Disenrollment can be voluntary (your own choice) or involuntary (not your own choice):
- You might leave ODS Advantage PPORX Select because you have decided that you want to leave. You can do this for any reason. However, as we explain in this section, there are limits to when you may leave and how often you can make changes, and what your other choices are for receiving Medicare services, and how you can make changes.
- There are also a few situations where you would be required to leave. For example, you would have to leave ODS Advantage PPORX Select if you move out of our geographic service area or if ODS Advantage PPORX Select leaves the Medicare program. We are not allowed to ask you to leave the plan because of your health.
Until your membership officially ends, you should keep getting your Medicare services through ODS Advantage PPORX Select or you will have to pay more for your services
If you leave ODS Advantage PPORX Select, it may take some time for your membership to end and your new way of getting Medicare to take effect (we discuss when the change takes effect later in this section). While you are waiting for your membership to end, you are still a member and should continue to get your care as usual through ODS Advantage PPORX Select.
Whether leaving the plan is your choice or not, Section 13: Leaving ODS Advantage PPORX Select and your choices for continuing Medicare after you leave, from your Evidence of Coverage explains your Medicare coverage choices after you leave and the rules that apply. A disenrollment form is located at the end of this Section.
Administrative Information
Potential for Contract Termination
ODS Health Plan, Inc.'s contract with the Center for Medicare and Medicaid Services (CMS) may not be renewed each calendar year by CMS or by the plan. The services under the plan may change from year to year and the plan's service areas may also change. You will be notified in advance of any changes that may occur. Coverage beyond the end of the current contract year is not guaranteed.
ODS Advantage Privacy Notice
At ODS Advantage we understand that it is our responsibility to protect your private information. We will not share your private information except as allowed by law to conduct the business of providing you with your pharmacy benefits, collection premiums and reporting to Medicare, state and federal agencies as required by law.
ODS Health Plan, Inc. contracts with the Federal government.
ODS Advantage PPORX Select is a PPO and a Prescription drug plan with a Medicare contract.
H3813003
H38134006PPORXS07A (01/2007)