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Is My Drug Covered?

Is My Pharmacy In-Network?

Prescription Drug Claim Form

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Glossary

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Annual Election Period for Medicare Advantage and Medicare Prescription Drug Plans

The Annual Election Period occurs between October 15th to December 7th of each year. During this period, an individual can do the following:

Change to a Medicare Advantage Plan from Original Medicare and vice versa.
Change your Medicare Advantage Plan.
Join a Medicare Part D Plan.
Change your Medicare Prescription Drug Plan.
Opt out of Medicare Part D coverage completely.

Coinsurance

Splitting costs on a percentage basis. After you reach the set deductible amount in your Medicare Prescription Drug Plan, you will share costs with the plan and pay a predetermined coinsurance percentage.

Copayment

A cost sharing where you pay a preset flat amount for a service, and the plan pays the rest.

Creditable Coverage

Coverage that is, on average, at least as good as the coverage offered in a Medicare Prescription Drug Plan.

Formulary

A list of drugs that are covered by a Medicare Prescription Drug Plan.

Late Enrollment Fee

Late enrollment fee is a penalty imposed for not enrolling in a Medicare Prescription Drug Plan during the Open Enrollment Period. This will be at least 1% of your premium cost per month, for every month you delayed enrolling in a plan. There is no limit to the percentage, and it will last as long as you are enrolled in a Medicare Prescription Drug Plan. This penalty will not apply if you already have a plan that offers coverage as good as that offered in a Medicare Prescription Drug Plan.

Maximum Out-of-Pocket

The maximum out-of-pocket amount is the most that you pay for copayments and coinsurance during the calendar year for covered: Part A and Part B services.

Amounts you pay for your copayments, and coinsurance count toward your maximum out-of-pocket amount. Amounts you pay for your prescription drugs do not count toward your maximum out-of-pocket amount.

Premium

The monthly fee required to obtain coverage in an insurance plan.

Pharmacy Definitions

In-Network Pharmacies

Our “in-network pharmacies” are ones with which we have made arrangements to provide prescription drugs to our members. The two types of in-network pharmacies are “preferred” and “non-preferred.” You may go to either of these in-network pharmacies to receive your covered prescription drugs.

Preferred Pharmacies are those in our network where you pay a lower amount for covered prescription drugs than at non-preferred pharmacies. Preferred pharmacies offer the lowest copays.

Non-Preferred Pharmacies are also in our network, but there you will pay a higher amount for covered prescription drugs than at preferred pharmacies.

Non-Network (Out-of-Network) Pharmacies

Non-network pharmacies, sometimes referred to as out-of-network pharmacies, may only be used in limited, non-routine circumstances as described in your Evidence of Coverage. We have not made arrangements with non-network pharmacies to provide prescription drugs to our members. If you use a non-network pharmacy, you may have to pay the full cost of your prescription. You may submit a claim form for reimbursement, however even after you are reimbursed, you could pay more for the drug because a non-network (out-of-network) pharmacy’s price is higher than what an in-network pharmacy would have charged. You may only request reimbursement on a prescription filled at a non-network pharmacy up to three times per calendar year.

Evidence of Coverage

View a complete list of benefits for each plan by selecting the corresponding document below:

H5215_Website12 CMS Approved 12152011
Last Updated: 2/20/2012

Notice of Privacy Practices (2012)

Quality Initiatives (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages)
Financial Information | Site Map | Network Health Plan (by clicking on this link, you will be leaving the Network Health Medicare-specific web pages)

Network PlatinumPlus, Network PlatinumPremier and Network PlatinumSelect are Medicare Preferred Organizations (PPO) plans offered by Network Health Insurance Corporation, a Medicare Advantage plan with a Medicare Contract. Benefits, formulary pharmacy network, premium and /or copayments and co-insurance may change on January 1, 2013.The Network Health Insurance Corporation Contract is renewed annually, so enrollment in a plan cannot be guaranteed.

We also offer NetworkCares PPO SNP, a $0 premium full dual eligible Special Needs Plan. NetworkCares is a Coordinated Care Plan with a Medicare Advantage contract and contract with the Wisconsin Medicaid Program. This plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Part B premium unless otherwise paid for by Medicaid or by another third party. For information about this Special Needs Plan, please contact us at 1-800-983-7587 or 1-800-947-3529 Monday through Friday 8 a.m. - 8 p.m. For the hearing impaired, call TDD/TTY 1–800–947–3529.

Network Cares has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2013/2014. NCQA’s approval is based on a review of NetworkCares Model of Care and is an indicator of compliance with CMS requirements. NCQA’s approval is not an endorsement by CMS and/or NCQA of NetworkCares or the quality of services provided by NetworkCares. NetworkCares will still need to be approved each year by CMS in order to operate. If you have any questions regarding our approval by the NCQA, please contact us at 1-800-378-5234.

You may be eligible for extra help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week.
The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m. Monday through Friday. TTY users should all 1-800-325-0778; or
Your State Medicaid Office.

The benefit information provided here is a brief summary, not a comprehensive description of benefits. For more information, please contact the plan.

Network Health Insurance Corporation (NHIC) contracts with a network of providers within the 14 county service area to provide Medicare-covered benefits. Our Network Medicare Advantage plans are open to Medicare beneficiaries eligible by age or disability in the plan’s service area. Our Network Medicare Platinum Plans provide reimbursement for all covered benefits regardless of whether they were received in-network, as long as they are medically necessary. With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.

Individuals must have both Medicare Part A and Part B to enroll and continue to pay their Part B premiums, unless otherwise paid for by Medicaid or by another third party. Plan benefit maximum limitations, copayments and restrictions may apply. To qualify, you must be a resident of the service area and not have End Stage Renal Disease (ESRD).

Members may enroll only during certain times of the year. If you enroll in one of our Medicare Advantage Pharmacy plans, you must receive your Medicare prescription drug benefit through the plan. Eligible members must use network pharmacies to access their prescription drug benefit except under non-routine circumstances; quantity limitations and restrictions may apply. Our Network Medicare Advantage Pharmacy plans use a formulary, which is a list of preferred drugs covered by the plan.