Plan Benefits

Advicare Advocate combines all of the benefits of Medicare (Parts A/B), Medicare Part D and Healthy Connections Medicaid under a single Medicare-Medicaid Plan to make it easier to get the care you need.  Below is a very brief  summary of some of the benefits Advicare Advocate offers.  For a more detailed listing of benefits, including a complete list of premiums, cost-sharing and any applicable conditions and limitations, please read the Member Handbook.

Service

Cost with an In-Network Provider

Benefit Explanation

Ambulance Services

$0 You may go to any emergency room if you reasonably believe you need emergency care.

Chiropractic Services

  • Adjustments of the spine to correct alignment
$0

Diagnostic Radiology Services

  • Diagnostic test and procedures
  • Lab services
  • Outpatient x-rays
  • Therapeutic radiology services
$0

Doctor’s Visit

  • To treat an injury or illness
  • Specialist care
  • Annual physical
$0

Durable Medical Equipment

Examples include:

  • Oxygen
  • Walkers
  • Wheelchairs
$0 Prior authorization required.

Emergency Care

$0 Not covered outside the U.S. and its territories, except under limited circumstances. Contact plan for details.You may go to any emergency room if you reasonably believe you need emergency care.

Home Health Care

Examples include:

  • Physical Therapy
  • Speech Therapy
  • Skilled Nursing Services
  • Personal Care Services

$0 Prior authorization rules may apply.*Some personal services may require co-pay of $3.30

Inpatient Care

  • Including inpatient substance abuse services
  • Including inpatient mental health care
  • All other associated costs (lab tests, meals, therapies, etc.)
$0 Prior authorization rules may apply.

LTSS (Long-Term Care Services and Supports)

Examples include:

  • Adult Day Care
  • Home Delivered Meals
  • Occupational Therapy

 

 

$0 LTSS are available to members who are on certain waiver programs operated by the Community Long Term Care (CLTC) division of Healthy Connections Medicaid.  Those waivers include:

  • Community Choices waiver
  • HIV/AIDs waiver
  • Mechanical Ventilator Dependent waiver

Mental Health Services

Examples include:

  • Inpatient mental health care
  • Community mental health rehabilitation services
  • Crisis intervention and stabilization
$0

Transportation (Non-Emergency Travel)

  • Doctor’s visits
  • Drug Store
$0

Urgent Care

  • a non-emergency
  • a sudden medical illness
  • an injury
  • a condition that needs care right away

$0 Urgent care is not covered outside of the United States and its territories.If you require urgently needed care, you should first try to get it from a network provider or call our 24/7 Nurse Advice Call Line. However, you can use out-of network providers when you cannot get to a network provider.

Please be sure to read your Member Handbook. It contains lots of useful information about using your benefits with us, such as a complete listing of premiums and cost-sharing, including any conditions and limitations.

Drug Coverage

We’ve Got You Covered. As a member of Advicare Advocate, you will have access to an extensive list of both brand and generic medications.  The List of Covered Drugs (sometimes referred to as a formulary) lists all the drugs that are covered by Advicare Advocate.  You can search for your medication either by name (in alphabetical order in the index) or by condition (i.e. dermatology).

You can access the List of Covered Drugs here.

2016 Prior Authorization Grid

2016 Step Therapy Criteria

Mail-Order Services

For certain kinds of drugs, you can use Advicare Advocate’s network mail-order services. Generally, the drugs available through mail order are drugs that you take on a regular basis for a chronic or long-term medical condition. The drugs not available through our plan’s mail-order service are marked NM* on our drug list.

Our plan’s mail-order service allows you to order up to a 90-day supply. A 90-day supply has the same co-pay as a one-month supply.

To learn more about our mail-order service, please view our Member Handbook.

Medication Therapy Management Program

The Advicare Advocate Medication Therapy Management (MTM) program helps you get the greatest health benefit from your medications by:

  • Preventing or reducing drug-related risks
  • Increasing your awareness
  • Supporting good habits

Who qualifies for the MTM program?

We will automatically enroll you in the Advicare Advocate Medication Therapy Management Program at no cost to you if all three (3) conditions apply:

  1. You take eight or more Medicare Part D covered maintenance drugs, and
  2. You have three or more of these long term health conditions:
  • Asthma
  • COPD
  • Diabetes
  • Depression
  • Osteoporosis
  • Chronic Heart Failure
  • Cardiovascular Disorders such as High Blood Pressure, High Cholesterol
  • Coronary Artery Disease
  1. You reach $3,138 in yearly prescription drug costs paid by you and the plan.

Your participation is voluntary, and does not affect your coverage. This program is free of charge and is open only to those who qualify. The MTM program is not considered a benefit for all members.

What services are included in the MTM program?

The MTM Program provides you with a:

  • Comprehensive Medication Review (CMR)
  • Targeted Medication Review (TMR)
Comprehensive Medication Review (CMR)

A CMR is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

  • Prescription Drugs
  • Over-the-counter (OTC) medicines
  • Herbal Therapies
  • Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the drugs you take. If more information is needed, the pharmacist may contact your prescribing doctor. A CMR review takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will give you a Personal Medication List of the medications you discussed during your CMR.

You will also receive a Medication Action Plan. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

Targeted Medication Review (TMR)

A TMR is where we mail or fax suggestions to your doctor every three months about prescription drugs that may be safer, or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them.

How will I know if I qualify for the MTM program?

If you qualify, we will mail you a letter letting you know that you qualify for the MTM program. Afterward, you may receive a call from a partner pharmacy, inviting you to schedule a one-on-one medication review at a convenient time.

Will the MTM program pharmacist be calling from my regular pharmacy?

Yes, the MTM program pharmacist may be calling from your regular pharmacy if your regular pharmacy chooses to participate in the MTM Program as a service provider. You will be given the option to choose an in-person review or a phone review.

If your regular pharmacy does not participate in the program, you may be contacted by a Call Center pharmacist to provide your MTM review, and ensure that you have access to the service if you want to participate. Call center reviews are conducted by phone.

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

  • Discuss how your prescription drugs and OTC medications may affect each other.
  • Identify any prescription drugs and OTC medications that may cause side effects, and offer suggestions to help.
  • Help you get the most benefit from all of your prescription drugs and OTC medications.
  • Review opportunities to help you reduce your prescription drug costs.

How do I benefit from talking with a pharmacist?

  • Discussing your medications can result in real peace of mind knowing that you are taking your prescription drugs and OTC medications safely.
  • The pharmacy can look for ways to help you save money on your out-of-pocket prescription drug costs.
  • You benefit by having a Personal Medication List to keep and share with your doctors and health care providers.

How can I get more information about the MTM program?

To find out more about MTM, call Customer Care or visit the MTM Program Website. Our toll free number is 1-844-564-0143, 8:00 a.m. until 8:00 p.m., seven days a week.  Alternative technologies will be used on weekends and holidays. TTY users call 711 or 1-888-357-7188.

Medicare Part D and Medicaid Drugs

When you join Advicare Advocate, if you are taking any prescriptions that our plan does not cover, you will get a temporary supply.  We will help you get another drug or get an exception for Advicare Advocate to cover your drug, if medically necessary.

Part D Transition Policy

To learn more about how Advicare Advocate handles situations when you first join our plan where your Part D drug is either not included on our list of covered drugs or, is included on our formulary but  subject to certain limitations, please read our 2015 Part D Transition Policy.

Advicare MMP Transition Policy

List of Covered Drug (Formulary) Change Notices

Advicare Advocate may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, add prior authorization, quantity limits and/or step therapy restrictions on a drug or move a drug at a higher cost-sharing tier, we will notify you of the change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, in which case we will immediately remove the drug from our formulary.  The document below lists medications that have either been added or removed.  Please check back periodically to see if your drugs have been impacted.

Formulary Change Notice (November 2015)

Grievance (Complaint)

A grievance is a complaint about any matter besides a service that has been denied, reduced or ended. Grievances do not involve problems related to approving or paying for Medicare Part D drugs.  The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive.  Examples of problems that may lead to filing a grievance:

  • If you feel that you are being encouraged to leave (disenroll from) the plan.
  • If you disagree with our decision not to give you a “fast” decision or a “fast” appeal.
  • We don’t give you a decision within the required time frame.
  • We don’t give you required notices.
  • You believe our notices and other written materials are hard to understand.
  • Waiting too long for prescriptions to be filled.
  • Rude behavior by staff or providers

If you have any of these types of problems and want to make a complaint, it is called “filing a grievance.”

Advicare Advocate takes member complaints very seriously.  We want to know if you experience a problem so we can make it right and also makes our services better for everyone.  If you have a complaint, please let us know right away.  We will do our best to answer your questions or help resolve your concerns.  Filing a complaint will not affect your health care services or your benefits coverage.

Filing a Grievance with Advicare Advocate

You can file a grievance with our plan any time by phone, mail or fax.  You can call 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. You can mail a grievance to 531 South Main Street, Suite RL-1, Greenville, SC 29601; or, you can fax a grievance to 1-888-781-4316.

If you are making a complaint because we denied your request for a “fast coverage decision” or a “fast appeal,” we will automatically give you a “fast” complaint. If you have a “fast” complaint, it means we will give you an answer within 24 hours.

  • You may submit a written request for a Fast Grievance to: Advicare, Corp.  Attn: Appeals & Grievances Dept., 531 S. Main Street, Suite RL-1, Greenville, SC 29601, or
  • You may fax your written request to 1-888-781-4316; or
  • You may call us to file an expedited Grievance at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week.

Please be sure to include the words “fast”, “expedited” or “24 hour review” on your request.

Whether you call or write, you should contact Advicare Advocate right away. The complaint must be made within 60 calendar days after you had the problem you want to complain about, unless the complaint pertains to a quality of care issue in which case the 60 filing requirement does not apply. If possible, we will answer you right away. If your health condition requires us to answer quickly, we will do that. You will receive written acknowledgement within 5 business days. Most complaints are resolved in 30 calendar days.

If we need more information and the delay is in your best interest or if you ask for more time, we can take up to 14 more calendar days (44 calendar days total) to answer your complaint.

Who Can File a Grievance

You or someone you name may file a grievance. The person you name would be your “representative.” You may name a relative, friend, lawyer, advocate, doctor, or anyone else to act for you. Other persons may already be authorized by the Court or in accordance with State law to act for you.

If you want someone to act for you who is not already authorized by the Court or under State law, you and that person must sign and date a statement granting the person legal permission to be your representative. To learn how to name your representative, you can call Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays. You can also download the form here: Appointment of Representative Form.

To learn more about how to file a grievance, please read chapter 9 of your Member Handbook.

Coverage Determination

If your doctor or pharmacist tells you that we will not cover a prescription drug, you should contact us and ask for a coverage determination. An initial coverage decision about your Part D drugs is called a “coverage determination”, or simply put, a “coverage decision.” A coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your prescription drugs. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might decide a drug is not covered or is no longer covered by Medicare. If you disagree with this coverage decision, you can make an appeal.

If you request an exception, your doctor must provide a statement to support your request.  You can learn more about when you may want to ask for a coverage determination in chapter 9 of the Member Handbook.

For assistance in completing these forms, please call Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays.

Appeal

If we make a coverage decision and you are not satisfied with this decision, you can “appeal” the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.

When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.

To File an Appeal:

  • Write a letter describing your appeal, and include any paperwork that may help in the research of your case. Provide your name, your member identification number, your date of birth, and the drug you need. You may also request an appeal by downloading and mailing in the Redetermination Request Form. Please mail this form to the following address: 531 South Main Street, Suite RL-1, Greenville, SC 29601. You also have the option of faxing this form to 1-888-781-4316.
  • You must mail your letter within 60 days of the date the adverse determination was issued, or within 60 days from the date of the denial of reimbursement request. If you missed the 60-day deadline, you may still file your appeal if you provide a valid reason for missing the deadline.
  • The Appeals and Grievance Department will look into your case and respond with a letter within 7 calendar days of receiving your request. You’ll receive a letter with detailed information about the coverage denial.
  • The information on how to file a Level 1 Appeal can also be found in the adverse coverage decision letter.
  • To inquire about the status of an appeal, you can call 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week.

To learn more about how to file an appeal, please read chapter 9 of your Member Handbook.

Who may file your appeal of the coverage determination?

If you are appealing a coverage decision about a Medicare Part D drug, you, your authorized representative, or a prescriber (or his and her office staff) may file a standard appeal request or a fast appeal request.

How soon must you file your appeal?

You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.

How soon will we decide on your appeal?

For a standard decision regarding reimbursement for a Medicare Part D drug you have paid for and received and for standard appeal review requests for drugs you have not yet received:

  • We will give you our decision within 7 calendar days of receiving the appeal request.

For a fast decision about a Medicare Part D drug that you have not yet received.

  • We will give you our decision within 72 hours after receiving the appeal request.

To obtain an aggregate number of the plan’s grievances, appeals and exceptions please call 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week.

Behavioral Health

Behavioral health services offer a wide range of treatment options for individuals with a mental health or substance abuse disorder, such as Depression, Anxiety or Drug Addiction. These services aim to help individuals live in the community and help them to maintain the most independent and satisfying lifestyle possible.

What kind of services are available?

Services can range from counseling to hospital care, including day treatment and crisis services. Services can be provided in homes and the community, on a short or long term basis. You are encouraged to speak to a healthcare professional about your concerns and seek an evaluation if you are having trouble coping with feelings and thoughts.

How do I get behavioral health services?

As a member of Advicare Advocate, you will be assigned a Care Coordinator who will help you manage all of your doctors and health services. You can talk about the many behavioral health services available to you with your Care Coordinator or other members of your care team. Your Care Coordinator will help you in finding the help you need and help you schedule appointments or screenings.

For more information on behavioral health information, please read your Member Handbook. You can also call Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays. This call is free.

Vision

Advicare Advocate includes eye care benefits. A referral is not required to see an eye doctor. Advicare Advocate will pay for outpatient doctor services for the diagnosis and treatment of diseases and injuries of the eye. This includes treatment for age-related macular degeneration. Please note that in most cases, eyeglasses are not a covered benefit.

Healthy Connections Medicaid covers the following services:

  • Treatment for an illness or injury to the eye
  • Initial replacement of the lens due to cataract surgery

For people at high risk of glaucoma, the plan will pay for one glaucoma screening each year.

To learn more about the eye care benefits included in your plan, please read your Member Handbook, or call Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays. The call is free.

Dental

Advicare Advocate provides non-routine dental care benefits. Additionally, Healthy Connections Medicaid provides additional coverage including, oral evaluations and x-rays, preventive care, restorative care and surgical care. The services provided by Healthy Connections Medicaid are covered on a fee-for-service basis with a $3.40 copay. Please contact your Care Coordinator for more information. You can also learn more about your dental benefits by reading your Member Handbook, or by calling Member Services at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays. The call is free.

Nurse Advice Hotline

Our free 24/7 Nurse Advice Call Line will connect you with a nurse who can answer your health questions. The nurse can help you decide if you need to go to the Emergency Room (ER) or urgent care center, or if you should wait to see your Primary Care Provider (PCP). If you think you have an urgent problem and your doctor cannot see you right away, call the Nurse Advice Call Line for help at 1-844-564-0143 (TTY 711 or 1-888-357-7188), 24 hours a day, 7 days a week. During the hours of 8:00 am to 5:00 p.m., Monday through Friday, your Care Coordinator is available to assist you with your questions and care needs. We encourage you to contact your Care Coordinator during these hours for assistance

Transportation Services

Transportation services are provided by Healthy Connections Medicaid. Non-emergency medical transportation is available to and from any medical appointment with a $0 copay. The type of assistance will depend of the member’s medical situation.

Trips must be for medical reasons only. Logisticare is the transportation broker that can provide a ride for your non-emergent medical appointments at no cost to you. Note: For emergency care, dial 911.

To get non-emergent transportation services you may call Logisticare. They are available Monday through Friday, 8:00am to 5:00pm.
Logisticare offers rides when you have no other way to get to:

  • A doctor’s visit
  • A visit with other health care providers
  • A dental visit
  • A pharmacy after a provider visit

Logisticare’s contact information is as follows, based on the county where you live:

Region 1 (1-866-910-7688) – Abbeville, Anderson, Edgefield, Greenville, Greenwood, Laurens, McCormick, Oconee, Pickens, Saluda, Spartanburg.

Region 2 (1-866-445-6860) – Allendale, Bamberg, Barnwell, Calhoun, Chester, Clarendon, Fairfield, Kershaw, Lee, Lexington, Newberry, Orangeburg, Richland, Union.

Region 3 (1-866-445-9954) – Berkeley, Charleston, Chesterfield, Colleton, Dillon, Dorchester, Hampton, Marion, Marlboro, Williamsburg.

TTY (1-866-288-3133), for all regions.

When calling to schedule a ride, make sure you have the following:

  • Healthy Connections Medicaid ID Number
  • Pick-up address and phone number
  • Appointment date and time
  • Doctor’s name, address, and phone number

If you need assistance or have problems getting your ride scheduled with LogistiCare, call Member Service at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. Alternative technologies will be used on weekends and holidays. The call is free.

Call 911 if you need emergency transportation. You do not need prior approval in an emergency.

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Disclaimer

Advicare Advocate (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. This information is available in other formats, such as Braille, large print, and audio. This information is also available for free in other languages.  Please call our customer service number at 1-844-564-0143 (TTY/TDD 711 or 1-888-357-7188), 8:00 a.m. until 8:00 p.m., seven days a week. The call is free.

Esta información está disponible de forma gratuita en otros idiomas. Por favor llame a nuestro número de atención al cliente al 1-844-564-0143 (TTY/TDD 711 o 1-888-357-7188), 8:00 a.m. hasta las 8:00 p.m., los siete días de la semana. La llamada es gratuita.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations, copays and restrictions may apply.  For more information, call Advicare Advocate Member Services or refer to the Advicare Advocate Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks, and/or copayments may change from time to time throughout the year and on January 1 of each year.

H7542_MMPwebsite v115 Approved

Plans are available in the following counties: Abbeville, Aiken, Allendale, Anderson, Bamberg, Barnwell, Berkeley, Beaufort, Calhoun, Charleston, Cherokee, Chester, Chesterfield, Clarendon, Colleton, Dillon, Dorchester, Edgefield, Fairfield, Florence, Georgetown, Greenville, Greenwood, Hampton, Jasper, Kershaw, Laurens, Lee, Lexington, Marion, Marlboro, McCormick, Newberry, Oconee, Orangeburg, Pickens, Richland, Saluda, Spartanburg, Union,Williamsburg.

Page Last Updated: January 21, 2016