CareOregon Advantage

CareOregon Advantage (COA) has two health plans for people who qualify for Medicare and who live in one of these Oregon counties: Clackamas, Clatsop, Columbia, Jackson, Josephine, Marion, Multnomah, Polk or Washington. ¹

• CareOregon Advantage Plus for people who qualify for both Medicare and Medicaid/Oregon Health Plan
• CareOregon Advantage Star for all Medicare beneficiaries

• How do I join?
• Can I change health plans if I want to?
• How much do I pay?
• Which doctors can I see?
• What prescription drugs are covered, and how can I get them?
• How do I request a coverage determination (e.g., prior authorization) or formulary exception?
• How do I submit a grievance or appeal a decision not to cover a drug that my provider or I requested?
• Which drug management programs does CareOregon Advantage offer?
• How do I appoint an authorized representative to help me make medical decisions?

Community Meetings

Join us at a community meeting in your neighborhood to learn about how CareOregon Advantage can help you with your Medicare health plan needs. Click here to find the meeting nearest you.

How do I join?

View map of statewide service area

1. Print out the Instructions and Enrollment Form and send it to the address listed on the form.
2. Click the following button to enroll on-line.
3. Call Member Services at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m., to have an Enrollment Form and other plan benefit information sent to you. TTY/TDD users should call 1-877-416-4161. Or, visit our office at 315 SW Fifth Avenue, Suite 900, Portland, Oregon, 97204, Monday through Friday, 8 a.m. - 5 p.m.
4. If CareOregon is your Medicaid plan through the Oregon Health Plan, contact your State of Oregon case worker for a special Enrollment Form.

Can I change health plans if I want to?
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.

How much do I pay?
CareOregon Advantage Plus has no plan premium for medical coverage (Part A and B services). You must continue to pay your Part B premium unless it's paid for you through your Medicaid coverage. Most medical services have no copayment as long as you have Medicaid coverage through CareOregon. For Part D services, CareOregon Advantage has a premium of $30.10 per month for prescription drugs.

CareOregon Advantage Star has a plan premium of $44 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, or
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778.

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 503-416-4100, 800-224-4840 or TTY/TDD 877-416-4161.

Which doctors can I see?
CareOregon Advantage assigns a primary care provider (PCP) to each member. You can change your PCP by calling Customer Service at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m. TTY/TDD users should call 1-877-416-4161. Then, except for women's health and emergency care, your PCP will coordinate your care. See our Provider Directory or Search to find a specific doctor. Except for 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 available exclusively for CareOregon Advantage members. Click here for a more detailed description of this service.

What prescription drugs are covered, and how can I get them?
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 or Search for a specific drug to see if it 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 changes (Posted: 09/29/08).

We contract with 80 pharmacies at 275 locations in our service area, and you can go to any of them for your prescriptions. Except for emergency care, members must use plan pharmacies to receive benefits. Click here to view and print our Pharmacy Directory or call us at 503-416-4100, 800-224-4840 or TTY/TDD 877-416-4161 to request a copy.

We also offer mail order pharmacy benefits through Wellpartner, Inc. and Walgreens. By getting your prescriptions through mail order, you can receive a 90-day supply for the cost of one copay per prescription. For more information on mail order pharmacy services, call us at the numbers above or:

• Click here to go to the Wellpartner, Inc. web site, or click here to print a Wellpartner Mail Order Form, or call them at 877-935-5797.
• Click here to go the Walgreens Mail Order website, or click here to print a Walgreens Mail Order Form, or call them at 503-643-8511 or 800-635-3070.

More questions?

• Questions and Answers about CareOregon Advantage Prescription Drug Coverage

How do I request a coverage determination (e.g., prior authorization) or formulary exception?
Call Customer Service at 503-416-4100 in the Portland area or toll free at 800-224-4840, daily, 8 a.m. to 8 p.m. TTY/TDD users should call 1-877-416-4161. You can also fax us at 503-416-1428. When you mail or fax an exception request, also send a written statement from your physician supporting your request.

Generally, CareOregon Advantage will only approve your request for an exception if the alternative drugs included on the plan's formulary or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.

If you would like a Coverage Determination/Exception Request Form, call Customer Service or print the form here.

How do I submit a grievance or appeal a decision not to cover a drug that my provider or I requested?
You have the right to make a complaint if you are unhappy with benefits or services you receive from either CareOregon Advantage or a CareOregon Advantage provider. For a full description of your rights, click here.

Which drug management programs does CareOregon Advantage offer?
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.

Drug Utilization Reviews
We do utilization reviews for all of our members to make sure they are receiving safe and effective drug therapy. During reviews, we look for potential medication problems such as:

• Additive toxicity. (Combinations of drugs may cause more serious side effects than would happen with either drug alone.)
• Duplicate drugs that are unnecessary because you are taking another drug to treat the same medical condition
• Drugs that are inappropriate because of your age, gender or disease
• Possible harmful drug interactions (two or more medicines react with each other to cause unwanted effects)
• Drug dosage errors
• Drug therapy adherence (e.g., late refills or failure to refill)

If we identify a medication problem during a drug utilization review, we work with you and your doctor to correct the problem.

Medication Therapy Management Program (MTMP)
This program is especially helpful for members who take several drugs for chronic medical conditions, such as asthma, coronary artery disease, hypertension, hyperlipidemia, diabetes, heart failure and/or depression.

What does MTMP do?
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
• Receive current information on proven medical practices to help you and your provider determine the most effective treatment
• Understand your conditions and medications, so you can take an active role in managing your health

How can MTMP help me?
CareOregon Advantage pharmacists and clinicians may communicate with you and your provider to help you understand your condition and the prescriptions you take, if they are right for you, and if you are taking them according to your provider's directions. Participating in MTMP participation may help improve your overall health and reduce your risk for serious medication reactions, hospitalization and emergency room visits.

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 join 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 503-416-4100 or toll free at 1-800-224-4840. TTY/TDD users should call 1-877-416-4161.

How do I appoint an authorized representative to help me make medical decisions?
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 following address.

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 the completed form to:
CareOregon Advantage
Attn: Member Services
315 SW Fifth, Suite 900
Portland, OR, 97204

If you have questions about the authorized representative procedure, call 503-416-4100 in Portland, OR, or toll-free at 1-800-224-4840 (TTY/TDD 1-877-416-4161).

1. 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.

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