Medical Member Service
503-265-4761 or
877-299-9061
800-433-6313 TTY
503-948-5577 Fax
7:30AM-5:30PM, Mon-Fri
Pacific Time

Pharmacy Customer Service
503-265-4709 or
888-786-7509
800-433-6313 TTY
800-207-8235 Fax
7AM-8PM, Mon-Fri
Pacific Time

Contact Form & Info

PERS ODS Advantage PPORX (2009) - A PPO and Prescription drug plan with a Medicare contract

The PERS ODS Advantage PPORX is an employer sponsored Medicare Advantage local PPO plan that includes Prescription Drug benefits serving the state of Oregon.

Eligibility Requirements

The PERS ODS Advantage PPORX 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

For information about when you can enroll or if you have questions about enrolling, please call PERS Health Insurance Program at 503-224-7377 or toll free 1-800-768-7377 or TTY 1-800-433-6313, Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time, to discuss your options.

PERS ODS Advantage PPORX Benefits

Medical Benefits

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

Prescription Drug Benefits

Highlights

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 PERS ODS Advantage PPORX Annual Notice of Change and Evidence of Coverage includes the benefits, the limitations, restrictions, appeal and grievance process, and other important information about the PERS ODS Advantage PPORX plan.

For more information about PERS ODS Advantage PPORX benefits, call member services.

Premium

Your premium is collected by the PERS Health Insurance Program and forwarded to ODS Health Plan, Inc. If you qualify for extra help from Medicare, called the Low-Income Subsidy or LIS, you may not have to pay for part of your monthly premium.

If you have any questions about your plan premiums or the payment program, please call the PERS Health Insurance Program Customer Service at 1-800-768-7377 or TTY 1-800-433-6313 Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time.

Low Income Subsidy

What do I need to know if I'm receiving extra help from Medicare to pay for my prescription drugs?

If you continue to qualify for the same amount of help next year, the table below tells you how your prescription costs will change.

If you pay this much this year 2008 You will pay this much next year 2009
$0 deductible $0 deductible

$1.05 for generics and brands that are treated as generics

$1.10 for generics and brands that are treated as generics

$3.10 for brand name drugs $3.20 for brand name drugs
$2.25 for generics and brands that are treated as generics
$2.40 for generics and brands that are treated as generics
$5.60 for brand name drugs $6.00 for brand name drugs
15% co-insurance for all drugs 15% co-insurance for all drugs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly 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.

If you aren’t getting extra help, you can see if you qualify by calling:

If you have any questions, please call member services.

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

Best Available Evidence (BAE)

Beneficiaries are “deemed” low income subsidy eligible if they are full benefit Medicare/Medicaid eligible, partial dual eligible, are receiving SSI or have applied and been awarded LIS by the Social Security Administration (SSA).  There is a new process for assisting individuals who do not have the required pieces of evidence but who claim to be eligible for the low income subsidy (LIS).   If you do not have the required evidence called “Best Available Evidence” (BAE) and believe you are LIS eligible please call member services.

The following link is to the section of Centers for Medicare and Medicaid Services (CMS) web site regarding BAE policy. You will be leaving the ODS site.

http://www.cms.hhs.gov/PrescriptionDrugCovContra/17_Best_Available_Evidence_Policy.asp

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. You may also call our member services at 1-877-299-9061 (TTY/TDD users should call 1-800-433-6313) Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time.

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 PERS ODS Advantage PPORX 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 special kind of complaint you make if you disagree with a decision to deny a request for health care services payment for services you already received. You may also make a complaint if you disagree with a decision to stop services that your are receiving. For example, you may ask for an appeal if our Plan doesn’t pay for an item or services you think you should be able to receive. See Section 5 below for more information 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 4 below for more information about a grievance and what to do if you would like to make one.

Section 4: How to file a grievance - This section is from your Annual Notice of Change and Evidence of Coverage for the PERS ODS Advantage PPORX plan.

Section 5: Complaints and Appeals about your Part D Prescription Drug(s) and Part C Medical Care and services - Detailed information about how to make an appeal that involves your medical benefits. This section is from your Annual Notice of Change and Evidence of Coverage for the PERS ODS Advantage PPORX plan.

Pharmacy Information

Formulary

The PERS 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. PERS ODS Advantage plans use reference based pricing for certain drugs on the formulary.  Those drugs are in the Brand name column and marked with an asterisk (Amoxicillin*) in the PERS ODS Advantage Comprehensive Formulary.  See below “What is reference based pricing?” for an explanation of reference based pricing.

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 PERS ODS Advantage 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 PERS ODS Advantage Pharmacy customer service.

The PERS 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 PERS ODS Advantage Pharmacy customer service.

What is reference based pricing?

Our plan uses reference based pricing for certain drugs on our formulary. If you request a brand name drug when a generic drug is available, and your physician has not specifically prohibited use of a generic medication, you are required to pay the coinsurance plus the difference in cost between the brand name drug and its generic equivalent. Your additional expense to cover the difference in cost between the brand and the generic medication will not apply toward your $150 (30-day supply) or $450 (90-day supply) out of pocket maximum for each prescription you have filled. Unless you or your physician requires the use of a brand name drug, your prescription will be filled with a generic when available and permissible by state law. Please see the PERS ODS Advantage Comprehensive Formulary for a list of those formulary drugs impacted by reference based pricing. These drugs are in the Brand name column and marked with an asterisk (Amoxicillin*) in the PERS ODS Advantage Comprehensive formulary. You can call PERS ODS Advantage customer service for more information on reference based pricing and the impact it may have on drugs you are taking.

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 2009 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2009 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

Section 4: How to file a grievance - This section is from your Annual Notice of Change and Evidence of Coverage for the PERS ODS Advantage PPORX Plan.

The following Section 5 below is what you can do if you have a complaint about your Part D Prescription drug benefits.

Section 5: Complaints and Appeals about your Part D Prescription Drug(s) and Part C Medical Care and services – Detailed information about how to make an appeal that involves your prescription drug benefits. This section is from your Annual Notice of Change and Evidence of Coverage for the PERS ODS Advantage PPORX 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 PERS ODS Advantage PPORX grievances, appeals and exceptions, call member services.

Coverage Determination
A decision from your Medicare drug plan about whether a drug prescribed for you is covered by the Plan and the amount, if any; you are required to pay for the prescription. In general, if you bring your prescription to a pharmacy and the pharmacy tells you the prescription isn’t covered under your plan, that isn’t a coverage determination.  You need to call or write to your plan to ask for a formal decision about the coverage if you disagree.
Exception
A type of coverage determination that, if approved, allows you to obtain a Part D eligible drug that is not on your plan sponsor’s formulary (a formulary exception). You may also request an exception if your plan sponsor requires 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. PERS ODS Advantage PPORX 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 PERS ODS Advantage within 60 days of the fill date 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 PERS 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

You may print out the Pharmacy paper claim form, complete the form,  attach your receipt and mail to the above address.

If you have any questions about submitting your receipt, please call PERS ODS Advantage Pharmacy Customer Service at 1-888-786-7509 or TTY 1-800-433-6313 Monday through Friday from 7 a.m. to 8 p.m., Pacific time.

Upon receipt, we will make an initial coverage determination on the claim. Please refer to your Annual Notice of Change and 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

PERS ODS Advantage PPORX is sponsored by PERS Health Insurance Program. Disenrolling from the PERS ODS Advantage PPORX may disenroll you from PERS. You may want to call PERS Health Insurance Program at 503-224-7377 or toll free 1-800-768-7377 or TTY 1-800-433-6313, Monday through Friday from 7:30 a.m. to 5:30 p.m. Pacific time, to discuss your options. If you leave the PERS Health Insurance Program you may not be able to return to the PERS Health Insurance Program.

Whether leaving the plan is your choice or not, Section 6: Ending your membership, explains your Medicare coverage choices after you leave and the rules that apply. This section is from your Annual Notice of Change and Evidence of Coverage for the PERS ODS Advantage PPORX plan.

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 PERS 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.

PERS ODS Advantage PPORX is a PPO and a Prescription drug plan with a Medicare contract.

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H38134006EGPPORX09A (10/2008)