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

Contact Form & Info

ODS Advantage PPORX Select (2008) - 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 enhanced Prescription Drug benefits serving the State of Oregon.

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.

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, 2007 through December 31, 2007, 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, 2007 delayed enrollment in a Medicare Prescription Drug Plan until January 1, 2008 that member would have a penalty of 12%. This 12% is based on the twelve months from January 2007 through December 2007.

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

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 services.

ODS Advantage PPORX Select Benefits

Medical Benefits

ODS Advantage PPORX Select plan features a number of valuable medical and prescription drug benefits including:

Prescription Drug Benefits

Highlights

The ODS Advantage PPORX Select Summary of Benefits is a comparison of ODS Advantage PPORX, ODS Advantage PPORX Select and the Original Medicare Plan. The charts in this 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 Combined Annual Notice of Change - 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 2008 is $99.90. 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:

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:

If you qualify for the Medicare Part D premium subsidy and you choose ODS Advantage PPORX plan, you will have to pay the balance of the plan's Part D premium.

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 2008. 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 with questions about their extra help with Medicare Prescription Drug Plan costs should call:

If you qualify for the Medicare Part D premium subsidy and you choose ODS Advantage PPORX plan, you may 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. Section 9 and Section 10 in your Combined Annual Notice of Change -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 8 below for more information about a grievance and what to do if you would like to make one.

Section 8: How to file a grievance - This section is from your Combined Annual Notice of Change - Evidence of Coverage for the ODS Advantage PPORX Select plan.

Section 9: What to do if you have a complaint about your Part C medical services and benefits - Detailed information about how to make an appeal that involves your medical benefits. This section is from your Combined Annual Notice of Change - Evidence of Coverage for the ODS Advantage PPORX Select plan.

Pharmacy Information

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 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 Part D eligible 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

New members in our plan may be taking drugs that aren’t in our formulary or that are subject to certain restrictions, such as prior authorizations or quantity limits. Current members may also be affected by changes in our formulary from one year to the next.

For each of the drugs that aren’t on our formulary or that have coverage restrictions or limits, we will cover a temporary 30-day supply (unless the prescription is written for fewer days) when a new or current member goes to a network pharmacy (and the drug is a Part D eligible drug). After we cover the temporary 30-day supply, we generally will not pay for these drugs as part of our transition policy again. We will provide you with a written notice after we cover your temporary supply which explains the steps you can take to satisfy the coverage restrictions or limits on the drugs that you take.

If you are a resident or become a resident of a long-term-care-facility (like a nursing home) or have a level of care change, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). If necessary, we will cover more than one refill of these drugs during the first 90-days after you enroll into our plan.

Generally, if you are taking a drug on our 2008 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2008 coverage year except when a drug becomes an over-the-counter (OTC) drug, when the drug is no longer eligible to be a Part D drug, or when new adverse information about the safety or effectiveness of a drug is released.

Pharmacy Forms

Prescription Drug Appeal and Grievance Procedure

The following Section 10 below is what you can do if you have a complaint about your Part D Prescription drug benefits.

Section 10: What to do if you have complaints about your Part D Prescription drug benefits - This section is from your Combined Annual Notice of Change - 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 Part D eligible drug that is not on our formulary (a formulary 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 your receipt. 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:

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. Within 60 days of the fill date or when you return home (whichever is sooner), submit the receipt from the pharmacy with your name on it that lists the Pharmacy , the phone number of the pharmacy, your member ID number, 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 Combined Annual Notice of Change - 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:

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 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):

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.

Whether leaving the plan is your choice or not, Section 11: Ending your membership, from your Combined Annual Notice of Change - 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 Section 11.

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, collect premiums and reporting to Medicare, state and federal agencies as required by law.

Medicare and your Rights

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.

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H38134006PPORXS08A (10/2007)