If you have Medicare coverage and live in Clackamas, Clatsop, Columbia, Jackson, Josephine, Marion, Multnomah, Polk or Washington county, you are eligible to join CareOregon Advantage.

For CareOregon Advantage Plus HMOS-POS SNP, you may join any time during the year. For CareOregon Advantage Star HMO-POS, you may only join during certain times of the year. You will receive all your Medicare benefits, including Part A, Part B and Part D prescription drugs from CareOregon Advantage. Your starting date will likely be the first day of the month following the date when we receive your Enrollment Form.Please see the Apply Now page for more information on how to apply for Medicare coverage.

If you are a CareOregon Advantage Plus member, yes. Your ending date will likely be the first of the month following the date we receive your letter requesting to leave CareOregon Advantage. You won't lose your Medicare benefits, and you may choose another Medicare Advantage plan, if available in your area. Or you can access benefits through the traditional Medicare program. For CareOregon Advantage Star Medicare beneficiaries, there are certain times of the year during which you may join or leave a Medicare Advantage plan. Please contact Customer Service for more details.

CareOregon Advantage Plus has no plan premium for medical coverage (Part A and B services). You must continue to pay your Medicare Part B premium unless it's paid for you through your Medicaid coverage. Most medical services have no co-payment as long as you have Medicaid coverage through CareOregon. For Part D services, CareOregon Advantage has a premium of $35.30 per month for prescription drugs. This amount is usually paid for you by your Extra Help with Medicare Part D.

CareOregon Advantage Star has a plan premium of $35.30 for Part A and B medical services and Part D prescription drugs.

If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium will be lower. When you join CareOregon Advantage, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you aren't getting any extra help, you can see if you qualify by calling:

• 1-800-MEDICARE (1-800-633-4227).
  TTY/TDD users should call 1-877-486-2048
• Oregon State Division of Medical Assistance Programs (8AM - 5PM)
  Phone: 503-945-5772
  Phone: 800-527-5772
  TTY: 800-375-2863 
• The Social Security Administration at 1-800-772-1213 (7AM -7PM, Monday through Friday)
  TTY/TDD users should call 1-800-325-0778

An Online Application for Extra Help is also available.

 

CareOregon Advantage uses the most recent information (called “Best Available Evidence”) to determine how much extra help you get. If you would like more information about Best Available, call  Customer Service or visit the Medicare program web site.

Your cost for each prescription will vary depending on your income and whether you live in a nursing home or institution. See our Summary of Benefits for more information.
Or call us at 503-416-4279 in the Portland area, toll free at 888-712-3258 or TTY/TDD 800-735-2900.

CareOregon Advantage assigns a primary care provider (PCP) to each member. You can change your PCP by calling Customer Service at 503-416-4279 in the Portland area or toll free at 888-712-3258, daily, 8 a.m. to 8 p.m. TTY/TDD users should call 1-800-735-2900. Then, except for women's health and emergency care, your PCP will coordinate your care. See our Provider Directory or Provider Search  to find a specific doctor. Except for PCPs, Specialists, emergency care and out-of-area renal dialysis, you must use plan providers to receive benefits.

 

If you have questions about a specific health problem, need health care advice or are unsure if you need to see a doctor, CareOregon Advantage can help. Just call our free Registered Nurse (RN) Medical Advice Line - 24 hours a day, seven days a week.

 

Our RN Medical Advice Line is a free telephone medical advice line, 1-866-209-0905, available exclusively for CareOregon Advantage members.

We offer prescription drugs through the Medicare Part D program. We use a formulary – a list of drugs that we cover and choices of drugs within each drug class. You may view and print out our Formulary to see if a specific drug is covered. Our contract with Medicare requires us to provide members 60-days notice of changes to the formulary. Click here to view the most recent Formulary List and changes.

 

Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.

If we remove drugs from our formulary or add prior authorization, quantity limits and/ or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refi ll of the drug, at which time the member will receive a 60-day supply of the drug.

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, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

If any of the following situations occur, we will notify you by mail and include a list of changes so that you can update this formulary book:

• CareOregon Advantage removes formulary drugs or adds utilization restrictions due to any reason other than the Food and Drug Administration’s approval of a new generic or new safety or clinical guideline information.
• CareOregon Advantage increases cost sharing on formulary drugs that are unrelated to the Food and Drug Administration’s approval of a new generic or new safety or clinical guideline information.
• A drug is no longer eligible for coverage under Medicare Part D.

In most cases, your prescriptions are covered only if they are filled by the CareOregon Advantage plan's network pharmacies. A network pharmacy is a pharmacy that has a contract with the plan to provide you covered prescription drugs. Click to view and print our Pharmacy Directory or call us at 503-416-4279 in the Portland area, toll free at 888-712-3258, or TTY/TDD 800-735-2900 to request a copy.

You will also find more information about network pharmacy information in your Evidence of Coverage.

CareOregon Advantage Star HMO-POS, page 71

CareOregon Advantage Plus HMO-POS SNP, page 65

Certain members receive extra help with paying for their prescription drugs. This is usually referred to as Low Income Co-pay level or LIC level. View materials related to the CMS BAE policy.

A coverage determination is the first decision we make about your benefits and coverage or about the amount we will pay for your medical services or drugs.

There are several ways you, your representative, or your doctor can request a coverage determination or formulary exception:

• Call: 503-416-4279 or toll free at 888-712-3258. TTY/TDD users should call 1-800-735-2900.
• Fax: 503-416-8109.
• Write: CareOregon Advantage
315 SW 5th Ave, Suite 900
Portland, OR 97204
• E-mail: partdparequests@careoregon.org

Generally, CareOregon Advantage will only approve your request for a formulary exception if the alternative drugs on our formulary or additional use restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects. Your doctor must give us a statement supporting your request. This statement can be faxed or mailed to us, or your physician can call us and follow up in writing.

If you would like a Coverage Determination/Exception Request Form, call Customer Service at the numbers listed above or print the form here. You can also use the Request for Medicare Prescription Drug Coverage Determination form provided by Medicare.

 

You have the right to make a complaint if you are unhappy with the benefits or services you receive from a CareOregon Advantage provider. For a full description of your rights, click here.

You can also file a complaint or grievance directly to Medicare by filling out the Medicare Complaint Form found on the Medicare website.

Finally, members can contact CareOregon Advantage in writing or by phone to make a complaint. Members can also obtain a summary of the total number of grievances, appeals, and exceptions filed with the plan. To contact us by telephone, call Customer Service daily during the hours of 8 a.m. to 8 p.m. toll-free at 503-416-4279 or toll free 888-712-3258. TTY/TDD users can call toll-free at 1-800-735-2900.

More Questions? We list Questions and Answers about CareOregon Advantage Prescription Drug Coverage.

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. Except when you request a filing time extension, the request must be filed within 60-calendar days from the date of notice of the coverage determination denial. For a full description of your rights, click here.

You will also find information about your appeal rights in Chapter 9 of your Evidence of Coverage.
• CareOregon Advantage Plus HMO-POS SNP Evidence of Coverage

• CareOregon Advantage Star HMO-POS Evidence of Coverage
There are several ways you, your representative, or your doctor can request an appeal:
• Call: 503-416-4279 or toll free at 888-712-3258. TTY/TDD users should call 1-800-735-2900.
• You can fill out the Request for Redetermination form and fax, mail or e-mail the completed form to us.
o Fax: 503-416-1428
o Write: CareOregon Advantage
315 SW 5th Ave, Suite 900
Portland, OR 97204.
o E-mail: partdappeals@careoregon.org

CareOregon Advantage is committed to ensuring that our members have access to high quality, safe and effective prescription drug therapy. We use various tools and methods to achieve this goal.

The CareOregon Advantage Formulary

The formulary is created by a team of practicing doctors and pharmacists who carefully evaluate the available scientific evidence. For some prescription drugs, the team has recommended additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs safely and effectively.

Programs to help you use drug safely

We conduct drug use reviews for our members to help make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one provider who prescribes their drugs.

We do a review each time you fill a prescription. We also review our records to look for potential problems such as:

• Possible medication errors.
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition.
• Drugs that may not be safe or appropriate because of your age or gender.
• Certain combinations of drugs that could harm you if taken at the same time.
• Prescriptions written for drugs that have ingredients you are allergic to.
• Possible errors in the amount (dosage) of a drug you are taking.

 

If we see a possible problem in your use of medication, we will work with your doctor to correct the problem.

 

Medication Therapy Management Program (MTMP)
This program is especially helpful for members who take several medications for chronic medical conditions, such as hypertension, hyperlipidemia, diabetes, and heart failure.

What does MTMP do?

MTPT pharmacists may contact you to talk about all of the medications you are taking, including over-the-counter medications or natural supplements. They will make sure you understand what they are for and how to take them safely. The pharmacist will also work with your providers to make sure you are taking the safest and most effective medications.

How can MTMP help me?
When you take multiple drugs, it is a challenge to make sure they all work well together. With the Medication Therapy Management Program, we can help you:

• Reduce the risk of medication errors, especially if you have chronic conditions, take several medications or see more than one care provider
• Understand your conditions and medications, so you can take an active role in managing your health

Is there a cost for MTMP?
No. There is no extra cost for the program.

Am I eligible for MTMP?
We contact members who qualify for this program. If we contact you, we hope you will participate so that we can help you manage your medications. Remember, there is no charge to participate in MTMP. If you have questions about the CareOregon Advantage MTMP, please call Customer Service at 503-416-4279 in the Portland area or toll free at 888-712-3258. TTY/TDD users should call 1-800-735-2900.

You can choose a friend, family member or other person to be your authorized representative. As your authorized representative, this person can help you make decisions about your Medicare coverage, such as joining or leaving a plan, and filing appeals and grievances. If you would like to appoint an authorized representative, fill out an appointment of representative form and mail it to the address below.

However, an authorized representative cannot make decisions about your medical care. You may complete an advance directive form to tell your doctor what kind of care you want if you cannot make medical decisions.
Mail completed forms to:

If you have questions about the authorized representative procedure, call 503-416-4279 in the Portland area or toll free at 888-712-3258 (TTY/TDD 1-800-735-2900).

Note: COA's Medicare contract with the federal government is renewed annually. Coverage beyond the end of the current year is not guaranteed. If the contract is not renewed or the service area reduced, COA must provide affected members with 90-day notice and a written description of members' rights and responsibilities, including alternatives for obtaining Medicare services.

The Centers for Medicare & Medicaid Services require us to send all CareOregon Advantage members a packet of printed publications each year—unless you tell us you don’t want them. You can see them on the web instead in our Medicare Plans section.

If you want to opt out of the annual CareOregon Advantage mailing, you can call our customer service to let us know, at 503-416-4279 in the Portland area or toll free at 888-712-3258 or TTY/TDD users can call 1-800-735-2900.

The annual publications are:

• Evidence of Coverage
• Pharmacy Directory
• Formulary
• Privacy practices
• Provider Directory

 

Even if you opt out of receiving these, we will still need to send you a Low Income Subsidy letter and Annual Notice of Change.

We hope you will choose to use the web site, rather than mail, and we look forward to hearing from you.