2013 Akamai Advantage Select Plus

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• Contact Us

  8 a.m. to 8 p.m.
  Seven days a week
  1 (800) 620-4672
  TTY: 711
  
  HMSA Akamai Advantage
  P.O. Box 860
  Honolulu, HI 96808-0860

• Email: Akamai@hmsa.com
• Find a Doctor
• Attend a Medicare Session

Monthly Premium

$34.00* For residents of the City
and County of Honolulu

Do you want more comprehensive coverage to help you pay for the health care you need? Akamai Advantage Select Plus provides you with financial protection by offering a higher level of coverage and benefits at a great low monthly premium.

Plan Features

• Medical and prescription drug coverage with a $0 deductible.
• Low set copayments for doctor’s visits.
• Financial protection with annual out-of-pocket maximum.
• Vision coverage.
• SilverSneakers fitness program.
• Access to Akamai Advantage’s statewide network of doctors, specialists, and other health care providers including network pharmacies.
  (Download Provider Directory)
• Exclusive value-added discounts for dental services.
• Valuable discounts for vision, hearing, and other health care services.

Benefits

What you pay when you use Akamai Advantage Select

• More Information
• Marketing Brochure
• 2013 Plan Ratings
• Summary of Benefits
• Evidence of Coverage

Medicare-covered Services	You Pay
All plan benefits listed above are based on in-network services. 1. $0 copayment for additional hospital days. 2. Physician visit copayment may apply.
Physician visits	$7 Primary Care Physician $10 Specialist
Inpatient hospital care1	Days 1-5: $100 per day Days 6-90: $0
Outpatient services/surgery2	$15
Ambulance service	$50
Emergency room; urgent care facility	$50
X-rays (diagnostic)	$15

What you pay for vision

Benefit	You Pay
Annual routine eye exam	$10
Eyewear	$0 copayment for eyewear; maximum benefit of $100 every 2 years

SilverSneakers

An innovative health, exercise, and wellness program helping older adults live healthy, active lifestyles.

What you pay for prescription drugs

Medicare-covered Services	Phase	You Pay
$0 - $325	Annual Deductible	There is no deductible.
Up to $2,970 in total drug costs	Initial Coverage Period	Tier 1: $4 Tier 2: $30 Tier 3: $65 Tier 4: 25%
$2,970 in total drug costs to $4,750 in true out-of-pocket costs	Coverage Gap	All Tier 1: $4 All other Tiers: Generic: 79% Brand: 47.5%
$4,750 and higher in true out-of-pocket costs	Catastrophic Coverage Period	You pay the greater of 5% coinsurance or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.

You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances. Quantity limitations and restrictions may apply.

• The plan information provided here is effective Jan. 1, 2013. Benefits, formulary, pharmacy network, premium, and/or copayments/coinsurance may change on Jan. 1 of each year.
• Limitations, copayments, and restrictions may apply.
• With the exception of emergencies or urgent care, it may cost more to get care from out-of-network providers.
• The benefit information provided here is a brief summary, not a comprehensive description of benefits. For more information, contact the plan.
• Medicare beneficiaries may also enroll in Akamai Advantage Select Plus through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
• Plan performance Star Ratings are assessed each year and may change from one year to the next.

Eligibility

You are eligible to enroll in Akamai Advantage if you:

• Have Medicare Part A and are enrolled in Part B.
• Live in the City and County of Honolulu.
• Do not have end-stage renal disease (ESRD). HMSA members who have ESRD are allowed to enroll in Akamai Advantage if they also meet other enrollment eligibility requirements.

You may enroll in the plan only during specific times of the year. Contact HMSA for more information. Medicare open enrollment is Oct. 15 - Dec. 7.

Akamai Advantage is a Health plan with a Medicare contract.

Drug Tools

Formulary Search (Comprehensive)

HMSA’s formulary is a list of Medicare-approved drugs covered by your health or drug plan.

Find a Pharmacy

HMSA has a network of pharmacies. In most cases, prescriptions are covered only if they are filled at a network pharmacy.

Drug Comparison Tool

Find out if your drug is covered on HMSA's formulary, find available alternatives, and monitor your benefit status in relation to the Medicare Part D coverage gap (also called the "doughnut hole").

HMSA My Account – Drug Tools

Register and log on to HMSA My Account to:

• Find out if there are lower cost alternatives to the medications you’re currently taking.
• See a list of all your prescriptions and how much you’ve spent on medications.
• See the possible side effects and adverse reactions of medications.
• Order prescriptions and refills online and have them delivered to your home through our Mail Order Prescription Drug Program.

Extra Help

Extra Help, also known as Low Income Subsidy, is a program that can help you pay for your prescription drug premiums and copayments.

Coverage Determination

Coverage Decision (also called Coverage Determination) - EOC Chapter 9, Sec. 6.4

You may call or write to your plan to request a formal decision or exception about prescribed drug coverage, quantity limits, prior authorization, step therapy and tiered cost sharing.

Exceptions & Appeals
Exceptions - EOC Chapter 9, Sec 6.2
Appeals - EOC Chapter 9, Sec 6.5

You can make an appeal if you disagree with a decision that denies your request for prescription drugs or payment of drugs you received.

Prior Authorization, Step Therapy and Quantity Limits

With Akamai Advantage, prior authorization is required for certain prescription drugs. To help manage our members’ health care costs, Akamai Advantage providers must contact HMSA before prescribing certain drugs. Step-therapy requirements and quantity limits also apply for some drugs. You can review a list of your plan’s drug prior authorizations, step therapy requirements, and quantity limits.

Transition Process
Transition Process - EOC Chapter 5, Sec 6.2

Under certain circumstances, HMSA can offer a temporary supply of a prescription drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider and figure out what to do.

Medication Therapy Management (MTM) Program

To help you better manage your medication and optimize the therapeutic outcomes, the Medication Therapy Management Program is offered to those meet the eligibility criteria at no cost. Click on the link to get more information about the program.

Member Resources

Contact HMSA

For help or more information about Akamai Advantage.

Akamai Advantage Dental Discount Program

Members receive exclusive value-added discounts for dental services.

HMSA365

Valuable discounts for vision, hearing, and other health care services.

Visitor/Travel Program

Coverage while traveling on the Mainland through the Blue Medicare Advantage PPO Network.

Dues Payment Service/EFT

HMSA’s Dues Payment Service is a simple, convenient way to save the time and expense of mailing monthly payments. With your authorization, HMSA will work directly with your local financial institution to transfer monthly dues payments to HMSA for your health plan and prescription drug coverage.

Ending your membership in the plan (Disenrollment) – EOC Chapter 10

Akamai Advantage and our members have rights and responsibilities when a member leaves our plan.

Appointing a representative

You can name another person to act as your representative for certain health care decisions.

Akamai Advantage Change form

Current Akamai Advantage members can use this form to choose a different Akamai Advantage plan. Contact us for more information.

Interpretive services

HMSA offers interpreter services at no charge. If you need an interpreter, please call Customer Service or visit your nearest HMSA office Monday through Friday, 8 a.m. to 4 p.m.

Organization determination

Coverage decisions (also called Organization Determinations) - EOC Chapter 9, Sec. 5.2

Contact HMSA if you have a question about whether a medical service is covered under your plan or how much it will cost you.

Exceptions and appeals
Appeals - EOC Chapter 9, Sec 5.3

You can make an appeal if you disagree with a decision to deny a request for health care services or payment of services you received.

Grievance
Grievances - EOC Chapter 9, Sec 10.3
Important Phone Numbers and Resources - EOC Chapter 2

HMSA provides a process if you need to make a complaint about quality of care, waiting times, customer service, or other concerns that are not related to benefits, coverage or payment.

Member card

Akamai Advantage members receive HMSA membership cards that contain important health plan information. Take your card with you whenever you receive medical and prescription drug services.

Prior authorization

With Akamai Advantage, prior authorization, also known as precertification, is required for certain medical services. To help manage our members’ health care costs, Akamai Advantage providers must contact HMSA before providing or ordering certain medical services. Please review the Evidence of Coverage to learn more about your plan’s specific prior authorizations.

To obtain an aggregate number of grievances, appeals, and exceptions filed with Akamai Advantage, contact Customer Service.