Rules to Know for Medicare Advantage Plans

1. Your Medicare-covered dependent and you can each choose a different medical plan or both of you can be covered under the same plan. You are not required to be covered under the same plan.
   
   
2. If your dependents are not eligible to participate in these plans, they may continue coverage under their current HMO or PPO medical plan.
   
   
3. If you decide not to join a new plan during this enrollment, you may join later. The plan will become effective the first of the month after the Benefit Division receives your form. To pay the lower premium when you are first covered, the Benefits Division must receive your application by the third of the month prior to the month that you want coverage to start. If you want to pay the lower premium on May 1, the Benefits Division should receive your form by April 3. If we don’t, you will receive a refund for the higher premium for May 1 on the next pension check.
   
   
4. You may disenroll from TexanPlus or Texas HealthSpring effective the first of any month by submitting a disenrollment form. You must continue getting your medical services through TexanPlus or Texas HealthSpring until you are notified by the plan that your coverage has ended.
   
   
5. You may re-enroll in your previous city medical plan if you disenroll from a Medicare Advantage plan. You should request re-enrollment at the same time that you apply to disenroll from TexanPlus or Texas HealthSpring. If you do not apply for the city plan within 31 days after your coverage ends in TexanPlus or Texas HealthSpring, you will lose the opportunity to re-enroll.
   
   
6. You must select a primary care physician to coordinate your medical care, just as in the HMO. Check TexanPlus and Texas HealthSpring’s provider directory. Your physician might be in one of their networks.
   
   
7. All monthly premiums will be deducted from your pension check.
   Texas HealthSpring provides an outpatient prescription drug benefit with a copayment structure identical to the HMO and PPO: $10/generic, $30/brand, $45/nonpreferred brand. However, certain drugs used for catastrophic illnesses require you to pay 15 percent of the cost until your 15 percent reaches $1,000 in a calendar year; then they are covered at 100 percent.
   
   
8. TexanPlus provides an outpatient prescription drug benefit with a copayment structure identical to the HMO: $10/generic, $30/brand/ $45/non-preferred brand. However, certain drugs used for catastrophic illnesses require you to pay 20% of the cost.
   
   
9. Under both TexanPlus and Texas HealthSpring’s outpatient prescription drug programs, your annual benefit is $4,000 for preferred brand and nonpreferred brand prescription drugs. After you reach the limit, you will pay 100% of the discounted rate that TexanPlus or Texas HealthSpring has negotiated with the pharmacy. The $4,000 annual benefit is made up of the amount that TexanPlus or Texas HealthSpring pays the pharmacy for your prescriptions, not your copayments.
   
   
10. You may enroll your covered dependents in the new Medicare Advantage plans on the first of the month after they become eligible; they become covered under Medicare Part A and Part B; and/or, they reside in the service area of TexanPlus or Texas HealthSpring.
    
    
11. If you prefer to keep your HMO or PPO plan for yourself and your covered dependents, you should not do anything. Your medical coverage will remain the same.
    
    
12. You can change from HMO Blue Texas HMO to the PPO or vice versa during this enrollment. You may also add eligible dependents to your coverage.