Plan details

These plans are available for business to offer their Medicare-eligible employees and retirees. The Summary of Benefits, Evidence of Coverage, and other information below explain the details about each plan:

• Benefits 
  • Summary of Benefits
  • Evidence of Coverage
• Prescription drug information 
  • Formulary and pharmacies
  • Forms
  • Requirements
  • Extra help for prescription drug costs
• Provider and pharmacy directories 
• Your privacy, rights, and procedures for grievances, appeals, and exceptions
• How to enroll 

Benefits

Summary of Benefits — These booklets explain general information about the plans we have for employer groups and compares them to original Medicare. They also include information about premiums, cost sharing, out-of-network coverage, any limitations, and more.

  Group POS/Plus A Summary of Benefits — H1099_MPINFO2761 (09/2011)

  Group Plus B Summary of Benefits — H1099_MPINFO2830 (11/2011)

  Group Basic A Summary of Benefits — H1099_MPINFO2829 (11/2011)

 Delta Dental Summary of Benefits — H1099_MP2764 CMS Approved 11042011)

Evidence of Coverage —These documents contain the most detailed information about the Group plans:

 Group POS Evidence of Coverage — H1099_MPINFO2720 (09/2011)

•  Delta Dental Evidence of Coverage for Group POS —
  H1099_MP2722 CMS Approved 09302011

 Group Plus A Evidence of Coverage — H1099_MPINFO2721 (09/2011)

•  Delta Dental Evidence of Coverage for Group Plus A —
  H1099_MP2722 CMS Approved 09302011

 Group Plus B Evidence of Coverage — H1099_MPINFO2722 (09/2011)

•  Delta Dental Evidence of Coverage for Group Plus B —
  H1099_MP2722 CMS Approved 09302011

 Group Basic A Evidence of Coverage — H1099_MPINFO2723 (09/2011)

•  Delta Dental Evidence of Coverage for Group Basic A —
  H1099_MP2722 CMS Approved 09302011

Prescription drug information

Health First Health Plans has contracts with pharmacies that equal or exceed CMS requirements for pharmacy access in your area. We have more than 100 network pharmacy locations in our local area, and more than 65,000 nation-wide.

Formulary and pharmacies

 Comprehensive formulary — a complete list of covered drugs (H1099_MPINFO2639 (09/2011)

 Participating pharmacies — listed in the provider/pharmacy directory (H1099_MP2621 CMS Approved 09072011)

Forms

Mail order prescriptions from Health First Family Pharmacy

Mail order prescriptions from MedVantx

Prescription reimbursement form

Requirements

 Prior authorization requirements 
(H1099_MP2596_19611 CMS Approved 07182011)

Transition policy (H1099_EL2798 File and Use 11072011)

Medication therapy management, and drug and/or utilization management  (H1099_EL2842 File & Use 12172011)

Extra help for prescription drug costs

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week;
• 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; or
• Your State Medicaid Office.

Assistance with Best Available Evidence for Low Income Subsidy

Provider/pharmacy directories

Search for physicians

 Printable provider (physician/pharmacy) directory — includes information about authorizations, our network of doctors, ancillary services like labs, fitness centers, etc., and also pharmacies (H1099_MP2621 CMS Approved 09072011)

 Delta Dental provider directory
(H1099_MP2811 CMS Approved 11182011)

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Your privacy, rights, and procedures for grievances, appeals, exceptions

Part D prescription drug prior authorizations, exceptions, appeals and grievances

Medical prior authorizations, appeals, and grievances

 Notice of privacy practices

Please refer to your Evidence of Coverage (EOC) for more details about these topics, as well as your rights and responsibilities upon disenrollment:

 Group POS Evidence of Coverage  — H1099_MPINFO2720 (09/2011)

 Group Plus A Evidence of Coverage — H1099_MPINFO2721 (09/2011)

 Group Plus B Evidence of Coverage  — H1099_MPINFO2722 (09/2011)

 Group Basic A Evidence of Coverage — H1099_MPINFO2723 (09/2011)

For more information about our quality assurance policies and procedures or to obtain an aggregate number of the our grievances, appeals, and exceptions, contact customer service.

How to enroll

If your employer (or former employer) offers Health First Medicare Plans as part of their employee or retiree benefits, check with them for details on how and when to enroll. They may prefer you send your completed enrollment form (and premium payment if necessary) to them. If they ask you to contact us directly to enroll, please follow these instructions.

 Enrollment form (H1099_MP2623 CMS Approved 09082011)

H1099_MP2760 CMS Approved10212011
Last updated: 5/1/2012