Frequently Asked Questions (FAQ’S):

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1. Where are PUP's plans available?

In 2010, our plans are available in the following 15 Florida counties: Brevard, Broward, Hillsborough, Lake, Manatee, Marion, Miami-Dade, Orange, Osceola, Pasco, Palm Beach, Pinellas, Polk, Seminole, and Sumter counties. You must live in one of these counties to join the plan. If you are in prison, you can’t join this plan.

2. Who is eligible to join Physicians United Plan?

A. You can join Physicians United Plan (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in our service area. Individuals with End Stage Renal Disease are not eligible to enroll in Physicians United Plan.

3. Can I choose my doctors?

Physicians United Plan (HMO) (PUP) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. When you join PUP, you will choose a primary care provider/doctor from our network of participating providers. Your primary care provider (PCP) will provide or arrange for all your care, including giving you referrals to specialists. Generally, you may ask your PCP to refer you to any specialist in our network. Some PCPs are affiliated with a medical group that also includes specialists, and will only refer you to a specialist within that medical group. Of course, if there is no specialist within that medical group that can deal with your condition, your PCP will refer you to another specialist within the PUP(HMO) network. Our provider directory shows who these PCPs are. Please be aware our network may change from time to time.

4. What happens if I go to a doctor who’s not in your network?

A. If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither PUP nor Original Medicare will pay for these services. There are some exceptions: emergencies, urgently-needed care and out-of-area renal dialysis.

5. Does my plan cover Medicare Part B or Part D drugs?

All our plans cover Medicare Part B drugs.
All except one of our plans cover Part D outpatient prescription drugs.
TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact Physicians United Plan (HMO) for more details.
Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
Injectable Drugs: Most injectable drugs administered incident to a physician’s service.
Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.

• Some Oral Cancer Drugs: If the same drug is available in injectable form.
• Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
• Inhalation and Infusion Drugs provided through DME (durable medical equipment).

6. Where can I get my prescriptions if I join this plan?

You must use a network pharmacy or mail-order service to fill your prescriptions. We have over 60,000 pharmacies across the United States, including some national chain pharmacies.

7. What is a prescription drug formulary?

PUP uses a formulary. A formulary is a list of covered drugs selected by PUP in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. PUP will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage.

8. How can I get extra help with prescription drug plan cost?

Medicare provides “Extra Help” to pay prescription drug costs for people who have limited income and resources. Resources include your savings and stocks, but not your home or car. If you qualify, you get help paying for any Medicare drug plan’s monthly premium, yearly deductible, and prescription copayments. This Extra Help also counts toward your out-of-pocket costs. Low income subsidy, or extra help, is a Medicare program to help people with limited income and resources pay Medicare prescription drug program costs, such as premiums, deductibles, and coinsurance. People with limited income and resources may qualify for Extra Help. Some people automatically qualify for Extra Help and don’t need to apply. Medicare mails a letter to people who automatically qualify for Extra Help.
To see if you qualify for getting extra help, call:

• 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week;
• 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; or
• Your State Medicaid Office.

9. What are my protections in this plan?

All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of PUP, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with FMQAI, the Quality Improvement Organization (QIO) for Florida.

As a member of PUP, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug.

10. What is a Medication Therapy Management (MTM) program?

A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact PUP for more details.