Frequently Asked Questions (FAQs)

If you enroll in our plan, you will not lose Original Medicare coverage. You’re just choosing to allow a private company to administer your benefits instead of the federal government. You do not lose your Medicare benefits and you must continue to pay your Part B premiums.

Your premium will stay the same every month during the calendar year. The only way your premium will change is if you receive a Part D Late Enrollment Penalty (LEP) from the Social Security Administration.

It will take a minimum of 90 days to start or stop automatic withdrawal from Social Security checks.

Advantage MD offers both HMO and PPO products. With an HMO plan, you must select a primary care provider (PCP) from our network who will coordinate your care. Your PCP will refer you to specialists or hospitals if you require additional care. You must get your care from providers that are in the Advantage MD network; if you go
to a provider outside of our network, you will be responsible for the entire cost.

With a PPO plan, you have the freedom to choose physicians and specialists from within our network, or seek care
out of network. If you choose to see a provider that is not in the Advantage MD network, your out-of-pocket costs
will be higher.

If you use providers that are not in our network, the plan will not pay for these services. For more information, review your Evidence of Coverage.

Yes, our HMO plan requires referrals for specialist visits. Your primary care provider will help to coordinate your
care with any specialists you may require.

Advantage MD recommends verifying your provider’s network status regularly and strongly recommends verifying your provider’s status before receiving services. It is important to verify your provider’s status because providers can opt out of the plan at any time throughout the year.

No, it is always best to verify the network status of your specific provider. Providers may have permission to practice at a facility, but may not be contracted with Advantage MD, which can impact the use of your benefits and your out-of-pocket costs.

You can find the premium for the optional supplemental dental benefit in the Summary of Benefits or Evidence of Coverage (EOC). It has a one-time, six-month waiting period before benefits begin.

The late enrollment penalty is assessed by the Social Security Administration and is added to your Medicare Part
D monthly premium. You may owe a late enrollment penalty if, for any continuous period of 63 days or more after your Initial Enrollment Period is over, you go without one of these:

• A Medicare Prescription Drug Plan (Part D)
• A Medicare Advantage Plan (Part C) (like an HMO or PPO)
• Another Medicare health plan that offers Medicare prescription drug coverage
• Creditable prescription drug coverage

The donut hole, or coverage gap, starts when your total drug costs—including what you and your plan have paid
for drugs—reaches $3,750 for the calendar year of 2018. When you enter the donut hole, the amount you pay for your prescriptions will increase. Because of this, you are eligible for discounts to help you pay for your drugs. You will pay 44% for preferred generics and 35% for all other drugs. Discounts vary depending on the drug and your
plan’s formulary.

If your total out-of-pocket spending on prescriptions reaches $5,000 for 2018, and the year’s not over, you move into the catastrophic phase for the rest of the calendar year. You pay very little for your prescriptions — either 5% or $3.35 per generic or $8.35 per brand — whichever is higher. The costs that help you reach catastrophic coverage also include most of the discount on brand-name drugs that you received in the coverage gap. The amount your drug plan paid for your drugs in your initial coverage period also does not count. If someone else pays for your drugs on your behalf (i.e. family members, most charities, State Pharmaceutical Assistance Programs, AIDS Drug Assistance Programs and the Indian Health Service) this will also count toward getting you out of the coverage gap. You must continue to pay your drug plan’s monthly premium during the gap, but the premium does not count toward the out-of-pocket limit.

If the President of the United States, the Governor of the State of Maryland, or the United States Secretary of Health and Human Services declares a state of emergency or disaster in your geographic area, you may obtain care from out-of-network providers and facilities that accept Medicare patients at in-network cost sharing rates. You also will not have to follow the prior authorization rules before you get care. You may have to pay the full cost at the time of your visit (rather than your normal share of the cost) and then ask us to reimburse you for our share of the cost. Please see Chapters 3 and 7 of your Evidence of Coverage for more information.

If you cannot use a network pharmacy during a state of emergency or disaster in your geographic area, you may fill your prescriptions at an out-of-network pharmacy. You will generally have to pay the full cost (rather than your normal share of the cost) at the time you fill your prescription and then ask us to reimburse you for our share of the cost. Please see Chapter 5, Section 2.5 of your Evidence of Coverage for more information.

Once the President of the United States, the Governor of the State of Maryland, or the United States Secretary of Health and Human Services declares the disaster or emergency over, or after 30 days have passed when there is no end date declared, you will need to use the plan provider and pharmacy network to receive services. The normal prior authorization requirements and cost sharing will resume as described in your Evidence of Coverage.

Original Medicare provides basic medical and hospital benefits, and only pays for 80% of covered services. Advantage MD provides comprehensive benefits and covers your doctor, specialist and hospital care, as well as many other medical services. Advantage MD also covers prescription drugs, preventive dental, routine vision and routine hearing care.

No. With Advantage MD, you have the freedom to use any doctor or hospital you want. When you choose one of our participating providers, your savings will be even greater.