This is benefit information for coverage beginning January 1, 2014.
*The products and services described above are neither offered nor guaranteed under our contract with the Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding these products and services may be subject to the grievance process.
Here are some helpful documents to understand our coverage better:
If you have Regence MedAdvantage + Rx Classic or Regence MedAdvantage + Rx Enhanced, the prescription drug coverage outlined below applies to you.
We have contracts with almost 63,000 pharmacies that equal or exceed CMS requirements for pharmacy access in your area. Our pharmacy network includes 90-day supply, retail, mail order and specialty, chain, home infusion, long-term care and Indian Health Service/Tribal/Urban Indian Health Program pharmacies. Please see the Formulary or your Evidence of Coverage for more information relating to quantity limitations and requirements for mail-order drug service. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply.
Covered Prescription Drugs (Formulary)
Search for a prescription drug.
Help with prescription drug premiums and costs if you have Part D prescription drug coverage: You may be able to get Extra Help paying for your prescription drug premiums and costs. To see if you qualify for extra help, call any of the following:
works hard to provide quality programs for our members. We're here to help ensure that medication options for our members are appropriate, safe and effective. We have concurrent drug utilization review and safety initiatives geared to give our members the best possible health benefits from their medications, while lowering risks for adverse events, medication errors, drug interactions or therapy duplications. Our medication policies and procedures are based on careful review of scientific information and input from practicing physicians. Our ultimate goal is to enhance health outcomes with improved medication use for our members.
Medication Therapy Management
is a covered service offered to members of our Medicare Part D prescription drug plans. MTM is a voluntary program that is offered to our members, with limited eligibility requirements, to assist with controlling chronic disease. The MTM program is not actually a plan benefit, it is an educational program offered to members.
The MTM program is designed to help members who meet the below criteria to get the most from their medications:
For additional information about the program and eligibility, members should contact us at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.
A grievance is any complaint you make about us or one of our plan providers. This does not involve payment or coverage disputes.
Examples of grievances include:
Grievances must be filed within 60 days of the event or incident. You may send a complaint to us in writing or by calling Customer Service at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and send it to us along with your grievance. We must notify you of our decision about your grievance within 30 calendar days after receiving your grievance.
Contact: Medicare Advantage/Medicare Part D
Appeals and Grievances S5D
PO Box 12625
Salem, OR 97309-0625
Number to call for oral coverage decision request:
1 (800) 541-8981
Number to call to request or check the status of a redetermination (appeal):
1 (866) 749-0355
Fax number for appeals and grievances:
1 (888) 309-8784
Fax number for prescription coverage decisions:
1 (888) 335-3016
Contact: Medicare Part D Prior Authorization
200 SW Market St, Ste 600
Portland, OR 97201-1249
Download helpful forms that will aid you in the coverage decision, appeal and grievance process.
A coverage decision is a decision we make about what we'll cover or the amount we'll pay for your medical services or prescription drugs.
Examples of coverage decisions include:
Pharmacy Coverage decisions will be responded to within 72 hours for standard requests and 24 hours for expedited requests.** Medical Coverage decisions are responded to within 14 days for standard requests and 72 hours for expedited requests. Coverage decisions can be submitted by you or your prescribing physician by calling us or faxing your request. Download helpful forms. If you wish to appoint someone to act on your behalf, you must fill out completely an Appointment of Representative form and return it to us, along with your Coverage Determination form.
*If you are asking for a formulary or tiering exception, your prescribing physician must provide a statement to support your request. You cannot ask for a tiering exception for a drug in our Specialty Tier. In addition, you cannot obtain a brand name drug at the copayment that applies to the generic drugs.
**If you, or your prescribing physician, believe that waiting for a standard decision (which will be provided within 72 hours) could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescribing physician asks for a faster decision for you, or supports you in asking for one by stating (in writing or in a telephone call to us) that he or she agrees that waiting 72 hours could seriously harm your life, health or ability to regain maximum function, we will give you a decision within 24 hours. If you do not obtain your physician's support, we will decide if your health condition requires a fast decision.
An appeal is any complaint you make when you want us to reconsider a decision we have made about your medical or Part D prescription drug benefits.
Examples of appeals include:
Appeals must be filed within 60 days of the payment or coverage denial. You must send an appeal to us in writing, including a signature. If you wish to appoint someone to act on your behalf, you must fill out an Appointment of Representative form and return it to us, along with your appeal. We must notify you of the outcome of your appeal within seven calendar days after receiving your Part D appeal. Additional information about the medical and prescription appeal process may be found by referring to the Evidence of Coverage in the section titled "What to do if you have a problem or complaint."
For more information, you may contact Customer Service at 1 (800) 541-8981. Our telephone hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. From October 1 through February 14, Customer Service is available from 8:00 a.m. to 8:00 p.m., seven days a week. TTY users should call 711.
Rights and Responsibilities
Your rights and responsibilities upon disenrollment:
Our rights and responsibilities upon your disenrollment
We will let you know, in writing, the date your coverage ends. We have the right to disenroll you for the following reasons:
To obtain information on the aggregate number of grievances, appeals and exceptions filed with the plan, call Customer Service at 1 (800) 541-8981.
Contacting Medicare Directly
You can also submit feedback about your Medicare health plan or prescription drug plan directly to Medicare. The Centers for Medicare & Medicaid Services values your feedback and will use it to continue to improve the quality of the Medicare program.
is a Health plan with a Medicare contract. Enrollment in depends on contract renewal. Medicare renews this contract annually. Your Medicare Advantage plan may not be available next year because by law, CMS may refuse to renew our contract, or can choose not to renew our contract with CMS, or can choose to reduce its service area, which would result in your plan's termination or renewal.
The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. You must continue to pay your Medicare Part B premium. Limitations, co-payments and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year.
It may cost more to get care from out-of-network providers, except in an emergency or urgent care situation.
If you have to go to an out-of-network pharmacy due to non-routine circumstances, you may have to pay more. Quantity limitations and restrictions may apply.
Certain eligibility periods and requirements apply.
Individuals must have both Part A and Part B to enroll in a Medicare Advantage plan.
Stand-alone Medicare Part D plans are offered by our affiliates.
Current members can find .
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Last updated 03/20/2014