GEMCare Health Plan - Medicare Plus


only search this site

Medicare Plus | Physicians Choice Medicare Plus | Enrollment Meetings | Health Education Events | Promotional Events

Physicians Choice Medicare Plus HMO

Thank you for your interest in the Physicians Choice Medicare Plus (HMO) Plan by GEMCare Health Plan. Coverage in this plan begins January 1, 2012. You will find links to specific information outlining benefits, deductibles and cost-sharing information below.

Introduction

Physicians Choice Medicare Plus HMO is a Medicare Advantage Plan offered by GEMCare Health Plan Inc., a Medicare Advantage Organization that contracts with the federal government. You can join Physicians Choice Medicare Plus (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. Please note that individuals with End-Stage Renal Disease are generally not eligible to enroll in Physicians Choice Medicare Plus (HMO) unless they are members of our organization and have been since their dialysis began. Members receive all benefits offered by original Medicare and more.

You must continue to pay your Medicare Part B premiums if not otherwise paid for under Medicaid or by another third party. If you obtain routine care from out-of-plan providers neither Medicare nor GEMCare Health Plan will be responsible for the costs. Medicare beneficiaries may be enrolled in only one Part D plan at a time.

SAN LUIS OBISPO AND

SANTA BARBARA COUNTIES:

Below please find information Service Area: Physicians Choice Medicare Plus (HMO) – San Luis Obispo and Santa Barbara – Partial Counties. The following Zip Codes are approved for Physicians Choice Medicare Plus (HMO):

Approved Zip Codes

San Luis Obispo

93401, 93402, 93403, 93405, 93406, 93407, 93408, 93410, 93412, 93420, 93421, 93424, 93430, 93433, 93442, 93443, 93444, 93445, 93448, 93449, 93475 and 93483

Santa Barbara

93434, 93454, 93455 and 93458

Benefits, Premiums and Cost Sharing

For information regarding your Part C and Part D benefits, premiums, deductibles and cost-sharing for GEMCare Medicare Plus (HMO), you can review the Summary of Benefits document or for more detailed information you can review the Evidence of Coverage document. Both can be accessed by clicking on the appropriate links below.

Click Here for a Summary of Physicians Choice Medicare Plus (HMO) for San Luis Obispo and Santa Barbara County benefits.

Click Here to view the Evidence of Coverage for Physicians Choice Medicare Plus (HMO) for San Luis Obispo and Santa Barbara County benefits document for more detail on GHP benefits.

Enrollment in Physicians Choice Medicare Plus (HMO) by GEMCare Health Plan for San Luis Obispo and Santa Barbara County:

GHP Enrollment Form for San Luis Obispo & Santa Barbara Counties

Download, complete & return to GHP.

Online enrollment through Medicare.gov

Find a Provider or Pharmacy

2012 Medical Provider Directory

2012 Provider Directory Updates

Prescription Drugs

List of Medications (Formulary)

Copy of 2012 GHP Formulary for Covered Prescription Drugs

(San Luis Obispo / Santa Barbara Counties - Partial Counties)

Search the PTI Formulary Database:

2012 GHP Formulary for Covered Prescription Drugs (San Luis Obispo / Santa Barbara Counties - Partial Counties)

2012 Formulary Changes and Update Information

VENTURA COUNTY

Below please find information Service Area: Physicians Choice Medicare Plus (HMO) – Ventura County.

The following Zip Codes are approved for Physicians Choice Medicare Plus (HMO):

93001, 93002, 93003, 93004, 93005, 93006, 93007, 93009, 93010, 93011, 93012, 93015, 93016, 93030, 93031, 93032, 93033, 93034, 93035, 93036, 93060 and 93061

Benefits, Premiums, Deductibles and Cost-Sharing

Click here for a Summary of Physicians Choice Medicare Plus (HMO) for Ventura County benefits.

Click here to view the Evidence of Coverage for Physicians Choice Medicare Plus (HMO) for Ventura County benefits. document for more detail on GHP benefits.

Enrollment in Physicians Choice Medicare Plus (HMO) by GEMCare Health Plan for Ventura County:

GHP Enrollment Form - Download, complete & return to GHP

Online enrollment through Medicare.gov

Find a Provider or Pharmacy

2012 Medical Provider Directory

2012 Valley Care Provider Directory

2012 Provider Directory Updates

Prescription Drugs

List of Medications (Formulary)

2012 GHP Formulary for Covered Prescription Drugs - (Ventura County - Partial County)

Search the PTI Formulary Database:

2012 GHP Formulary for Covered Prescription Drugs
(Ventura County - Partial Counties)

2012 Formulary Changes and Update Information

GENERAL INFORMATION FOR PHYSICIANS CHOICE MEDICARE PLUS (HMO)

Conditions and Limitations

For information about conditions and limitations of benefits and coverage, click on the Evidence of Coverage documents listed above for you appropriate county.

Potential for Contract Termination: GEMCare Health Plan has a contract with Medicare and CMS to offer its plan in the approved service area. This contract between GHP and the Centers for Medicare & Medicaid Services (CMS) is reviewed annually, so the availability of coverage beyond the end of the current contract year can not be guaranteed.

Potential for Contract Termination

There is the possibility that at some time GEMCare Health Plan may terminate, refuse to renew, or modify its contract with Medicare and vice-versa. In the event that any of these events occur, your rights are protected. You will be notified in writing of any and all changes in a timely manner and provided with instructions as to how to proceed and the options available to you. Once you are notified in writing that we are leaving the Medicare program or the area where you live, you may enroll in another plan.

If the contract is terminated, your membership in Physicians Choice will end, and you will need to enroll in another MA-PD Plan in order to continue your health care and prescription drug coverage.

Disenrollment Rights

In the event you decide to end your membership in Physicians Choice, you should be aware of your rights related to the disenrollment. For more information about disenrollment and your rights click and refer to Chapter 10 of the EOC Document.

Frequently Asked Questions About Medicare Advantage Plans:

What is Medicare Advantage?

Medicare Advantage is s Medicare program gives Medicare beneficiaries more options to consider as they choose a Medicare health plan. Anyone who has Medicare Parts A and B is eligible, except those who have End-Stage Renal Disease (certain exceptions may apply). Medicare Advantage plans (MA-PD) cover Medicare Parts A & B services and Part D (Pharmacy).

Medicare Part A is traditional Medicare hospital insurance that pays for inpatient hospital admissions, care in a skilled nursing facility, hospice care, and some home health care.

Medicare Part B is traditional Medicare medical insurance that helps pay for doctors, outpatient hospital care, durable medical equipment, and some medical services not covered by Part A.

Medicare Part D is the Medicare insurance that helps pay for pharmacy and medication services.

Why would I want to choose a Medicare Advantage (MA-PD) plan?

The advantages to choosing a Medicare Advantage Plan are:

There are more plan choices to consider;
Most MA-PD plans offer benefits not paid for by traditional Medicare;
There is usually a reduction in out-of-pocket costs through lower premiums, lower co-pays, and lower deductibles;
MA-PD plans generally are more proactive in keeping its members healthy;
MA-PD plans cover prescription drugs, with lower premiums and co-pays; and,

MA-PD plans have programs that improve the quality of care provided to its members.

If I am covered by an employer sponsored health plan, would I benefit from joining a Medicare Advantage plan?

It is possible that you could lower your out of pocket expenses for health care by joining an MA-PD plan. You should contact your employee benefits manager to find out more information about whether a Medicare Advantage plan would benefit you.

What are some potential disadvantages of the new program?

Some of the potential drawbacks to joining an MA-PD plan include:

Services provided in MA-PD plans are “managed”, resulting in a system of care that is not as flexible for the member as is traditional Medicare;
Not all medical providers are contracted with the MA-PD plan, limiting you to physicians in the plan’s network;
Your current physician may not have a contract and is not in the network;
You are not free to self refer to any “out of network” provider without prior authorization; if you go out of network without prior health plan approval, you will be responsible for those expenses;
Referrals generally require an approved authorization from your primary physician and the plan;
Sometimes all the “rules” for getting services can be confusing and frustrating for the member;
If a hospital or health care provider does not participate in the Medicare program, you can not be referred to that provider; and,

Once you have chosen an MA-PD plan, you are “locked” into the plan and can not change plans until the next benefit year.

Do Medical Management rules apply to Medicare Advantage Plans?

Generally, Medical Management rules regarding referrals apply. Providers are encouraged to obtain an Authorization Determination for selected services outlined by the Plan. Authorization Determinations are performed to review benefit coverage, medical necessity, and appropriateness before services are rendered. Claims submitted for services that were not approved are reviewed retrospectively for appropriateness and coverage. Except for emergencies, it is important to contact the health plan to determine requirements prior to receiving non-emergency services.

Can I use any hospital or provider for services?

If you have an emergency medical condition, you may seek treatment at the nearest hospital or emergency room, regardless of the plan coverage. For non-emergency care use hospitals and health care providers in your area that are contracted with your plan.

Will I have the same hospital benefits with Medicare Advantage that I had with traditional Medicare?

The hospital services covered under traditional Medicare will be the same. However, there may be limits on which hospitals, doctors, or pharmacies you use. Out of pocket expenses are usually less than with traditional Medicare. You may even have additional coverage for dental and vision, depending on the plan you choose. It is important to check with your MA-PD plan to see what benefits and limitations you may have.

When you receive emergency or urgently needed health care services from a provider who is not part of our network, you are responsible for paying your cost sharing amount. You should instruct the provider to bill our health plan for the balance of the payment they are due. If you have received a bill from the provider, please send that claim to GEMCare Health Plan, 4500 California Avenue, Ste. 100, Bakersfield, CA 93309 to the attention of the Member Services Department, so we can reimburse the provider what they are owed.

What services can I receive without getting an authorization approved?

Most services are provided or arranged by your primary physician. You may get the following services without a referral or approval in advance. You will still be responsible for all co-pays or your share of any non-covered expenses.

You may self refer to a gynecologist for a routine annual woman’s examination. This examination includes a breast exam, a pelvic examination and a PAP smear.
Routine screening mammograms are covered, depending on age and history, and require a referral slip to an approved radiology service, but not prior approval.
Flu shots and pneumonia vaccinations (Pneumovax) are covered provided you obtain them from a contracted plan provider.
Emergency and urgently needed services are covered and do not require prior authorization (see above).
Kidney Dialysis services outside the Plan’s service area are covered without authorization. If possible, please call us before you leave the service area so we can help arrange for you to have maintenance dialysis while outside the service area

When you receive care outside the service area without approval, you will be responsible for all expenses. You will usually pay a higher cost for the care since you will get your care from non-contracted providers. If you have questions about your care and medical cost responsibilities when you travel, please call Member Services at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

Are Hearing Services covered?

Except in unusual cases, you pay 100% of the costs for routine hearing exams and hearing aids. If you require a diagnostic hearing exam, you pay a $10 co-payment for each Medicare covered diagnostic hearing exam.

How do I complain or file a Grievance?

If you have a complaint or a concern, you or your representative may call member services at the numbers listed above and verbally state your concern or complaint. At the time of the call every attempt will be made to resolve the issue while you are on the phone.

In the event that your concern or complaint is related to quality of care or if the complaint can not be resolved over the phone, then we will ask you to formally file a grievance. This process can be done over the phone or by mail. You will be given instructions about filing the grievance and an explanation of the process and the time lines for resolution of your complaint.

What types of problems or concerns might lead to filing a grievance?

Common problems that lead to filing a grievance include:

Issues related to the service you receive by providers;
Rude behavior by providers or staff;
Problems related enrollment or disenrollment;
Disagreements with a denial for requested services;
Prescription and pharmacy issues;
Problems with access to doctors and appointments;
Problems with waiting;
Problems with your understanding of what is happening

What do I do if I need financial assistance?

People with limited income and resources may qualify for extra help. The amount of assistance depends on your financial circumstances. There are 2 situations where you can obtain assistance:

You automatically qualify for assistance if:

You have full coverage from a state Medicaid (Medi-Cal) program;
You are receiving assistance from Medicaid in paying your Medicare premiums (Medicare Savings Program); or,
You are receiving Medicare Supplemental Security Income benefits.

You may apply to qualify for extra help if:

You believe you have a low yearly income; and,
You believe you do not have enough financial resources.

If you think you may qualify and wish to apply for assistance, call Social Security at 1-800-772-1213 (TTY users should call 1-800-325-0778), visit your local Social Security Office, or visit the web site www.socialsecurity.gov. You may also apply at your State Medical Assistance (Medi-Cal) office.

GHP OUT OF NETWORK COVERAGE GUIDELINES

OUT OF NETWORK MEDICAL SERVICES

GEMCare Health Plan (GHP) has created a group (network) of providers and places of service that will care for GHP members. If medical care is given outside that network, the member may be responsible for those charges. If there is a question about what is covered, the best place to look is in the Evidence of Coverage document or by calling GHP’s Member Services department at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

Note: If a member has a medical emergency, needs urgent care, or if the out of network services were pre-approved by a primary care physician (PCP) or authorized specialist, GHP will cover the costs as noted in the Evidence of Coverage.

EMERGENCY / URGENT CARE SITUATION:

Emergency: If you think you are having a medical emergency immediately contact 911 and go to

the nearest emergency room. Members are covered worldwide for these services. Within 24vhours of the emergency visit, call your medical group to let them know about your emergency visit; also call GHP at our member service number listed above.

A “medical emergency” is when you reasonably believe that your health is in serious danger –when every second counts. A medical emergency includes severe pain, a bad injury, a serious illness, or a medical condition that is quickly getting much worse.

Urgent Care: If your provider’s office is closed or your provider is unavailable, go to the nearest urgent care facility. Members are covered worldwide for these services. Within 24 hours of the visit, call your medical group to let them know about your visit; also call GHP at our member service number listed above.

“Urgently needed care” is when you need medical attention right away for an unforeseen illness or injury, and it is not reasonable given the situation for you to not get medical care from your PCP or other plan providers. In these cases, your health is not in serious danger.

Submitting Claims (bills) for emergency/urgent care:

You can submit claims (bills) to the following address:

GEMCare Health Plan

P.O. Box 752

Bakersfield, CA 93302

OUT OF NETWORK PHARMACY SERVICES

Prescriptions received by a network pharmacy are covered under the plan. Since GHP offers, through Pharmacy Technology, Inc. (PTI), a large network of pharmacies, finding a network pharmacy should not be a problem. However, if there is an emergency, urgent situation, or unusual pharmaceutical situation, there are exceptions.

For example:

1. prescriptions related to caring for a medical emergency or urgent care

in this situation, you may have to pay the full cost (rather than paying just your co-payment) when you fill your prescription and you will receive reimbursement when you submit the claim (bill);

2. if the network pharmacy does not regularly stock a high cost or unique drugs); or 3. if you are getting a medically necessary vaccine that is not covered by Medicare Part B or receiving a covered drug administered in your doctor's office. Please call the member services department listed below prior to obtaining an “exception” prescription unless in an emergency situation at the number

below:

Pharmacy/Pharmacist: For participating pharmacies, call 800-546-5677 or log onto www.ptinps.com and register in NPS to search pharmacies and access other pharmacy options. You can always contact our Member Services at

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

Submitting Claims (bills) for prescriptions:

You can submit claims (bills) to the following address:

PTI

Attn: Claims

P.O. Box 407

Omaha, NE 68010

General Prescription Drug Transition Policy:

What if my current prescription drugs are not on the formulary or are limited on the formulary?

New Members:

As a new member in our plan, you may currently be taking drugs that are not on our formulary or are on our formulary but your ability to get them is limited. In instances like these, you need to talk with your doctor about appropriate alternative therapies available on our formulary. If there are no appropriate alternative therapies on our formulary, you or your doctor can request a formulary exception. If the exception is approved, you will be able to obtain the drug you are taking for a specified period of time. While you are talking with your doctor to determine your course of action, you may be eligible to receive an initial 30 days transition supply of the drug anytime during the first 90 days you are a member of our plan.

For each of your drugs that is not on our formulary or for situations where your ability to get your drugs is limited, we will cover a temporary 30-day supply (unless you have a prescription written for fewer days) when you go to a network pharmacy. After your first 30-day transition supply, we may not continue to pay for these drugs under the transition policy. Also, due to a change in Medicare Regulations, erectile dysfunction (ED) drugs like Viagra, Cialis, Levitra, and Caverject will no longer be covered under most Medicare Drug Plans. You are reminded to discuss with your doctor appropriate alternative therapies on our formulary and if there are none, you or your doctor can request a formulary exception.

If you are a resident of a long-term care facility, we will cover a temporary 31-day transition supply (unless you have a prescription written for fewer days). We will cover more than one refill of these drugs for the first 90 days you are a member of our plan. If you need a drug that is not on our formulary or your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover a 31-day emergency supply of that drug (unless you have a prescription for fewer days) while you pursue a formulary exception

Current Members with a change in their level of care

Exceptions are available for beneficiaries who have experienced a change in the level of care they are receiving which requires them to transition from one facility or treatment center to another.

Examples of situations in which beneficiaries would be eligible for the one-time temporary fill exception when they are outside of the three month effective date into the Part D program are as follows:

i. For example if a beneficiary was discharged from the hospital and was provided a discharge list of medications based upon the formulary of the hospital.

ii. Beneficiaries who end their skilled nursing facility Medicare Part A stay (where payment s include all pharmacy charges) and who need to revert back to their Part D plan formulary

iii. Beneficiaries who give up Hospice Status to revert back to standard Medicare Part A and B benefits

iv. Beneficiaries who are discharged from Chronic Psychiatric Hospitals with medication regimens that are highly individualized.

All of these situations would warrant a temporary one-time fill exception regardless of if the beneficiary is in their first ninety (90) days of program enrollment.

If you have any questions about our transition policy or need help asking for a formulary exception, call Customer Services:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

Pharmacy and Part D

Frequently Asked Questions - FAQ's

What is the GEMCare Health Plan’s Medicare Part D Program?

The Part D program is a GHP and Medicare Prescription Drug Coverage insurance program designed to help you save money on prescriptions and protect you from catastrophically high drug bills. Part D Pharmacy coverage is part of the GEMCare Health Plan.

I keep hearing about coverage “phases” and the “donut hole”. Explain, please.

First, you need to understand that the cost of your medications is paid by both GEMCare Health Plan and you. As you fill prescriptions throughout the year, the amount of dollars spent to pay for your medications increases. As the total amount of dollars paid for drugs increases, the responsibility for payment will shift between you and GHP, depending on the amount of dollars expended. Throughout the year, GHP keeps track of all payments made for prescriptions by both you and GHP.

There are 3 “phases” of coverage for the Pharmacy Part D Benefit:

Initial Coverage Phase: In this phase of coverage you are responsible for co-payments or a percentage of the cost for prescriptions while GHP picks up the balance of the costs. When the total costs paid by you and GHP for prescriptions reaches a total of $2,930 in 2012, you then enter the “coverage gap” phase.
Coverage Gap Phase (aka the “donut hole”): When the total costs reach $2,930 in 2012, you are now responsible for the full cost of medications until your total out of pocket costs (what you alone have paid) reaches $4,700 in 2012. At this point, you enter the “catastrophic phase”.
Catastrophic Phase: When your total out of pocket costs have reached $4,700 in 2012, your responsibility is now reduced and you pay $2.60 for generic drugs (including brand drugs treated as generic) and $6.50 or 5% (whichever is greater) for all other drugs.

When the New Year begins, the process begins again. Based upon Medicare requirements and the costs for drugs for the previous year, the benefit and payment rules may change.

What is TROOP?

“TROOP” is a term used to indicate the total amount of money a member has paid out of pocket for the current year (the total true out-of-pocket (“TROOP”) expense). It is the sum total of all co-pays, all coinsurance payments, and all expenditures made by the member in the coverage gap (“donut hole”).

Explain formulary drug tiers, please

For 2012, medications on the GHP formulary are organized into 5 different tiers or groups. Your co-payments or coinsurance varies with the drug tier of your medication. The 5 tiers and co-pays for each medication received while in the network for a one-month period are:

Tier 1 – Preferred Generic; Co-pay = $0.00
Tier 2 – Non-Preferred Generic; Co-pay = $12.00
Tier 3 – Preferred Brand; Co-pay = $45.00
Tier 4 – Non-Preferred Brand; Co-pay = $90.00
Tier 5 – Specialty Drugs; Coinsurance = 33% of cost

What do I pay out of pocket if I am a member in GHP’s Part D Program?

For GHP in 2012, there is no separate insurance premium or deductible for Part D for GHP members. Your out of pocket expenses include responsibility for:

All co-payments in all coverage phases – Co-payments do vary with the Tier level and the coverage phase you are in;
All coinsurance costs in all coverage phases for Tiers 5– Coinsurance is reduced to 5% in catastrophic phase;
All medication costs in the coverage gap phase (“donut hole”).

What happens when my prescription is not on the formulary?

If your prescription is not on the formulary, you should do the following:

To confirm that your prescription is not on the formulary, contact Member Services at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

If Member Services confirms that your medication is not covered on the formulary, you should call your doctor to see if you can safely switch to another drug that is on the formulary;
If you or your physician feels that your requested medication has no alternatives, then you or your physician can request that GHP grant an “exception” or make a “coverage determination” to allow you to have the medication covered. The request is reviewed and the request can either be granted or denied.

How do you fill a prescription through the mail-order pharmacy service?

The GHP mail-order service is available to fill prescriptions for any drug on the formulary. The process is as follows:

For First Time Users: For your first order, Integrated HMO Pharmacy (IHMO) requires that you fill out the order form and include the original prescriptions from your doctor. This initial order form must include information about you, including the current medications, any known drug allergies, and chronic medical conditions. If you have any questions, contact IHMO at 1-800-633-7928.

For Ordering Refills: You should order refills when you have 14-21 days supply left. To reorder medications, you have options:

You can call 1-800-633-7928;
You can fill out the order form enclosed with each order you receive, or,
You can order your refills online at the IHMO web site:

http://ihmo.pti-nps.com.

Note: Remember to include your payment with your refill order to avoid possible delays in processing your prescription order.

When you order prescription drugs by mail-order you must order at least a 60-day supply, and no more than 90-day supply of the drug. Please allow 14-21 days to process and ship your order. If mail order is delayed, you can always obtain a prescription from a local network pharmacy. Please call Member Services at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

You can also get an extended supply of medication through all retail network pharmacies. Please call Member Services at the above numbers to find out which retail pharmacies off an extended supply.

Do I qualify for financial assistance with medications?

People with limited income and resources may qualify for extra help. The amount of assistance depends on your financial circumstances. There are 2 situations where you can obtain assistance:

You automatically qualify for assistance if:

You have full coverage from a state Medicaid (Medi-Cal) program;
You are receiving assistance from Medicaid in paying your Medicare premiums (Medicare Savings Program); or,
You are receiving Medicare Supplemental Security Income benefits.

You may apply to qualify for extra help if:

You believe you have a low yearly income; and,
You believe you do not have enough financial resources

If you believe you have a low income subsidy, but you are currently paying regular co-pays for your Part D prescription drugs, you should contact GEMCare Health Plan Member Services at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

For more detailed information, you can go to this Medicare Website http://www.cms.hhs.gov/prescriptiondrugcovcontra/17_best_available_evidence_policy.asp.

What do I need to know if I qualify for extra help (the low-income subsidy, or LIS) from Medicare to pay for my prescription drugs?

If you continue to qualify for the same amount of extra help next year, the table below tells you how your prescription costs will change. If you don’t know what level of extra help you qualify for, you can call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

If you qualify for extra help, you pay a reduced monthly premium (for both medical services and prescription drug benefits). If you continue to qualify for the same amount of extra help in 2012, please see Chapter 6 in the Evidence of Coverage booklet to find out how much you will pay for a monthly premium. This doesn't include any Medicare Part B premium you may have to pay. If you don’t know your level of extra help, call Member Services.

Low Income Subsidy Level	You Pay This Much for 2012
LIS 1	$2.60 for generics and brands that are treated as generics $6.50 for brand name drugs
LIS 2	$1.10 for generics and brands that are treated as generics $3.30 for brand name drugs
LIS 3	$0 for all
LIS 4	15% coinsurance for all drugs

What is the LEP or Late Enrollment Penalty?

The LEP is applied to members who did not join a Medicare drug plan when they were first eligible, or for some reason were without prescription drug coverage for a continuous period of 63 days or more.

If an LEP applies to you, the GHP drug plan will inform you as to the amount. The LEP is added to the monthly premium you pay. The penalty amount is adjusted each plan year and must be paid as long as you have Medicare prescription drug coverage. If you qualify for financial assistance, you may not be required to pay the LEP.

For more questions, call Member Services at:

San Luis Obispo County / Santa Barbara County:

1-877-744-2668 (TTY/TTD users call 1-888-833-9312)

Ventura County:

1-877-744-2709 (TTY/TTD users call 1-888-833-9312)

Physicians Choice Medicare Plus HMO is a Medicare Advantage Plan offered by GEMCare Health Plan Inc., a Medicare Advantage Organization that contracts with the federal government. GEMCare Medicare Plus is available to persons who reside in the service area and are entitled to Medicare Part A and enrolled in Part B, including those with Medicare based on entitlement to Social Security Disability Benefits. You must continue to pay your Medicare Part B premiums if not otherwise paid for under Medicaid or by another third party. If you obtain routine care from out-of-plan providers neither Medicare nor GEMCare Health Plan will be responsible for the costs. Medicare beneficiaries may be enrolled in only one Part D plan at a time.