What is TrOOP (True Out-of-Pocket costs)?

The actual prescription drug expenses paid by a Medicare Part D beneficiary throughout the plan year, which count when determining what stage of the basic Part D coverage the beneficiary is at. Payments by a beneficiary’s family members or a charity on behalf of a beneficiary also count toward TrOOP. It does not include the premium. A beneficiary must always satisfy TrOOP to reach catastrophic coverage level. Current members may call HealthSpring Member Services 365 days a year for TrOOP information.

What counts toward my out-of-pocket limit?

Your deductible; your co-payments; what you spend on drugs out of pocket during the gap; and any payments for your drugs made by a family member or friend, a charitable group or a state pharmacy assistance program. In all cases, only payments for drugs your plan covers, including any "exceptions" you receive, count toward the limit.

What does not count toward my limit?

Your premiums; payments for drugs not covered by your plan; payments made by your plan, by an employer, union, federal agency or other group insurer; and any drugs bought from Canada or other foreign countries.

Are any drug categories not included in Medicare prescription drug coverage?
 
Yes.  Certain drugs are excluded, which means they can't be provided as part of standard Medicare prescription drug coverage.  Some examples of excluded drugs include benzodiazepines, barbiturates, drugs for weight loss or gain, and erectile dysfunction drugs. 

Is there a limit on the number of drugs a plan will cover in a given year?

No. There is no limit on the amount of drugs that can be covered. However, each Medicare drug plan will have a list of the specific prescription drugs that it will cover (called a formulary), and not all plans will cover exactly the same drugs. If your doctor thinks you need a drug that is not on the plan’s list, you can ask the plan for an “exception” to its list. Plans may cover both generic and brand-name prescription drugs. These drugs must be approved by the FDA (Food and Drug Administration) as safe and effective.

How can I get help with my drug plan costs?

Medicare beneficiaries with low or limited income and resources may qualify for additional assistance. If you qualify, your Medicare prescription drug plan costs, the amount of your premium and your drug costs at the pharmacy will be less. Once you have enrolled in HealthSpring Prescription Drug Plan, Medicare will tell us how much assistance you are receiving, and we will send you information on the amount you will pay. If you are not receiving this additional assistance, you should contact 1-800-MEDICARE to see if you might qualify.

Where can I get my prescriptions?

Prescriptions filled at out-of-network pharmacies will be allowed when you cannot fill your prescription within our network. Pharmacies outside the United States will not be allowed. Coverage rules and/or limitations will apply.

Please note that HealthSpring is contracted nationally with major chain pharmacies (i.e. Walgreens, CVS, Wal-Mart).  Before you fill your prescription out-of-network, please call Customer Service to see if there is a network pharmacy in the area where you can fill your prescriptions.

When drugs are purchased at an out-of-network pharmacy, the cost sharing at a network pharmacy will apply plus the difference between the out-of-network pharmacy price and in-network pharmacy price.

Out-of-Network pharmacy access is allowed for the following instances:

1. You travel outside the plan’s service area and run out of or lose covered Part D drugs, or become ill and need a covered Part D drug and cannot access a network pharmacy.
2. You are unable to obtain a covered Part D drug in a timely manner within the service area because, for example there is no network pharmacy within a reasonable driving distance that provides 24/7 service.
3. You are filling a prescription for a covered Part D drug and that particular drug is not regularly stocked at an accessible network retail or mail order pharmacies.
4. The Part D drugs are dispensed by an out-of-network institution-based pharmacy while in an emergency facility, provider based clinic, outpatient surgery, or other outpatient setting.

How do I join?

You can join this plan if you are entitled to Medicare Part A and/or enrolled in Medicare Part B and live in the service area. Annual Enrollment is October 15 to December 7 for a January 1 effective date. 

Plan rating information

The Medicare Program rates how well Medicare Prescription Drug Plans perform in different categories (for example, customer service, drug pricing, patient safety).

Where is HealthSpring’s Prescription Drug Plan available?

HealthSpring’s Prescription Drug Plan service area includes all 50 states within the United States.

How do I disenroll from the plan?

Between January 1– February 14, 2011, if you’re in a Medicare Advantage Plan, you can leave your plan and switch to Original Medicare. If you switch to Original Medicare during this period, you will have until February 14 to also join a Medicare Prescription Drug Plan to add drug coverage. Your coverage will begin the first day of the month after the plan gets your enrollment form.

During this period, you can’t do the following:

• Switch from Original Medicare to a Medicare Advantage Plan.
• Switch from one Medicare Advantage Plan to another.
• Switch from one Medicare Prescription Drug Plan to another.
• Join, switch, or drop a Medicare Medical Savings Account Plan.