Frequently Asked Questions
Medicare can be confusing. Which Medicare option is right for you and meets your needs? The questions below will assist you in making the right healthcare choice.
- How do Private Fee-for-Service Plans like AveraAdvantage work?
- Can I use the same doctors and hospitals that I use now or do I need to use a network of physicians?
- Do I have to use a primary care doctor like in HMOs?
- What if my provider won’t accept the AveraAdvantage plan?
- Does AveraAdvantage cover everything that Original Medicare covers?
- Do I need to continue to pay my Part B premium with AveraAdvantage?
- Are my doctors permitted to bill me for services?
- Where can I get my prescription drugs?
- What drugs are excluded from the Medicare Advantage Prescription Drug Plans?
- What if I already have prescription drug coverage through a Medicare Part D Prescription Drug Plan?
- What if I would like my current Medicare Advantage Private Fee-for-Service (PFFS) plan to include prescription drug coverage?
- What is the difference between a Medicare Advantage (MA) and a Medicare Advantage Prescription (MAPD) plan?
- What is the coverage gap?
- How will I know if the prescription drugs I currently take will be covered?
1. How do Private Fee-for-Service Plans like AveraAdvantage Work?
AveraAdvantage plans provide more coverage than Original Medicare alone, including health and wellness benefits and prescription drug benefits (if applicable to your plan). Because we’re a Private Fee-for-Service plan, you’re free to visit any doctor that is willing to provide care and accepts AveraAdvantage’s terms and conditions. And although you’re free to go any hospital you’d like, you’ll save more money when you choose an AveraAdvantage network hospital.
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2. Can I use the same doctors and hospitals that I use now or do I need to use a network of physicians?
You can see any licensed provider in the U.S. who can be paid by Medicare and who is wiling to accept the plan’s terms and conditions of payment. You will not be locked into a network of providers. However, a provider may at any time decide that he or she does not want to accept the AveraAdvantage plan. If this happens, you will need to find another provider who will accept your plan. To make sure this doesn’t happen, you should verify in advance of receiving services that a particular provider is willing to see you. Although you’re free to go to any hospital you’d like, you’ll save more money when you choose an AveraAdvantage network hospital.
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3. Do I have to use a primary care doctor like in HMOs?
No, under AveraAdvantage, you can receive care from any licensed provider who can be paid by Medicare and is willing to accept the plan’s terms and conditions of payment.
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4. What if my provider won’t accept the AveraAdvantage plan?
Providers are not required to furnish services to members of AveraAdvantage. If your provider does not want to participate in AveraAdvantage, then you must seek care from another provider who is willing to furnish services to AveraAdvantage members. If the provider does provide services to you, he/she will be considered a deemed provider and AveraAdvantage will pay for the covered healthcare services. You must pay the appropriate copayments or coinsurance. Remember that AveraAdvantage network hospitals have agreed to accept our plan's terms and conditions.
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5. Does AveraAdvantage cover everything that Original Medicare covers?
Yes. AveraAdvantage must provide enrollees with the same benefits they would receive under Original Medicare. This includes all medically necessary services covered under Medicare Part A and Part B, plus additional benefits not covered by Original Medicare. In addition, you can choose an AveraAdvantage Basic Plus, Value Plus or Premier Plus Plan that includes prescription drug coverage.
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6. Do I need to continue to pay my Part B premium with AveraAdvantage?
Yes. You must continue to pay your Part B premium to participate in AveraAdvantage.
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7. Are my doctors permitted to bill me for services?
No. AveraAdvantage does not allow doctors, hospitals, and other providers to bill you for more than the plan pays for services.
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8. Where can I get my prescription drugs?
With our agreement with Member Health LLC, you will have access to more than 63,000 pharmacies nationwide.
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9. What drugs are excluded from the Medicare Advantage Prescription Drug Plans (MAPD)?
The drugs that are excluded by Medicare are:
- Medications used to treat anorexia, weight loss, or weight gain
- Medications used to promote fertility
- Medications used for cosmetic purposes or hair growth
- Medications used to treat erectile dysfunction
- Prescription vitamins and mineral products, except prenatal vitamins and fluoride preparation
- Non-prescription drugs
- Outpatient medications for which the manufacturer requires that associated tests or monitoring services be purchased exclusively from the manufacturer as a condition of sale.
In addition, if a medication is covered by Medicare Parts A or B, it cannot be covered under Part D (Medicare Advantage Prescription Drug Plan). Some examples of Parts A or B medications include: diabetic test strips, injectables solely administered in the physician’s office and medications administered in the hospital. Also, each Medicare Advantage Prescription Drug plan may have its own specific exclusions.
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10. What if I already have prescription drug coverage through a Medicare Part D Prescription Drug Plan?
You may elect to drop your Prescription Drug Plan (Part D) and enroll in an AveraAdvantage Medicare Advantage or AveraAdvantage Medicare Advantage Prescription Drug Plan between November 15, 2007 and December 31, 2007. We have three plan options that include both medical benefits and prescription drug coverage: AveraAdvantage Basic Plus, Value Plus, and Premier Plus plans.
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11. What if I would like my current Medicare Advantage Private Fee-for-Service (PFFS) plan to include prescription drug coverage?
You may change your plan to add Part D prescription drug coverage during the Annual Enrollment Period, November 15, 2007 and December 31, 2007.
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12. What is the difference between a Medicare Advantage (MA) and a Medicare Advantage Prescription (MAPD) Plan?
AveraAdvantage offers two types of Medicare Advantage plans—Medicare Advantage (MA) plans and Medicare Advantage Prescription Drug (MAPD) plans. MA plans provide comprehensive medical benefits including doctor visits, hospital coverage, preventive services and more. MAPD plans – our “Plus” plans -- offer an integrated healthcare package of all the same medical benefits plus Part D prescription drug coverage. All plans from AveraAdvantage offer generous health and wellness benefits.
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13. What is the coverage gap?
The coverage gap is sometimes called the “donut hole.” This is the amount you pay with a Medicare Advantage Prescription Drug Plan (MAPD) after you reach the initial coverage limit of $2,010, and until your total out-of-pocket costs for prescription drugs reach $4,050. Some plans, like our Premier Plus plan, offer important coverage on generic drugs during the coverage gap. For more information on the coverage gap, call 1-800-MEDICARE, 24 hours a day, 7 days a week (TTY users 1-877-486-2048). Or visit www.medicare.gov.
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14. How will I know if the prescription drugs I currently take will be covered?
Our plans with prescription drug (Part D) coverage include a comprehensive list of drugs in their formularies. You can find both the Abridged and Comprehensive formularies on our website. You can also call AveraAdvantage at 1-800-944-8400 (TTY/TDD for the hearing impaired 1-800-888-9680), 8 AM-11 PM EST, 7 days a week.
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