If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare.

If you get extra help, your monthly plan premium will be $0 for any of the plan(s) below. (This does not include any Medicare Part B premium you may have to pay.)

• MyTruAdvantage Select (HMO)
• MyTruAdvantage Select Plus (HMO)
• MyTruAdvantage Choice Plus (PPO)

MyTruAdvantage Medicare Advantage plan premiums include coverage for both medical services and prescription drug coverage. Since the Part D premium for MyTruAdvantage plans is $0, members receiving Extra Help will not see additional cost savings to their overall premium.

If you aren’t getting extra help, you can see if you qualify by calling:

• 1-800-Medicare or TTY users call 1-877-486-2048 (24 hours a day/7 days a week)
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call MyTruAdvantage Member Services at 1.844.425.4280 (TTY: 711). From October 1, 2023, through March 31, 2024, a Member Services representative will be available to speak to you from 8:00 a.m. - 8:00 p.m., local time, seven (7) days a week. On Thanksgiving and Christmas days, as well as weekends and holidays from April 1 through September 30, alternate technologies (for example, voicemail) will be used and a Member Services representative will return your call within one (1) business day.

What is Extra Help and am I Eligible

Medicare Extra Help
Medicare helps pay prescription drug costs for people who qualify.

What is Medicare Extra Help?
Medicare gives "extra help" to pay prescription drug costs for people with limited income and resources, like savings and stocks. If you qualify for Extra Help, you will get help paying for any Medicare drug plan's monthly premium, yearly deductible, and drug copays. This extra help will count toward your out-of-pocket costs.

How do I qualify for Extra Help?
Here are some ways you can qualify for Extra Help:

• If you receive full Medicaid benefits, you are automatically eligible for Extra Help—there is no need to apply separately. Medicare will mail you a letter with information about Extra Help when you qualify.
• If you receive any help from Medicaid paying your Medicare premiums or receive Supplemental Security Income, you will automatically get Extra Help and do not need to apply separately. However, you will need to enroll in a Medicare prescription drug plan.
• If you have limited income and resources and don’t get help from Medicaid, you can apply for Extra Help and enroll in a Medicare drug plan1. Call 1 (800) MEDICARE (1 (800) 633-4227), 24/7 (TTY 1 (877) 486-2048).

How do I prove I’m eligible for Extra Help?

The Centers for Medicare & Medicaid Services (CMS) started the Best Available Evidence (BAE) policy to deal with Extra Help eligibility. BAE makes sure that people getting Extra Help aren’t charged too much or have higher copayments than you’re supposed to.

According to CMS, all plan sponsors, like MyTruAdvantage, must accept BAE sent by someone applying for Extra Help if they are eligible, even if Medicare records don’t show it. Once you’ve sent BAE to MyTruAdvantage, we will ask CMS to change your status in their system.

Some acceptable forms of Best Available Evidence are:

• A copy of your Medicaid card (if you have one)
• A copy of a state document that shows you have Medicaid
• A print-out from a state electronic enrollment file or from your state's Medicaid systems that shows you have Medicaid
• A print-out from a state electronic enrollment file or from your state's Medicaid systems that shows you have Medicaid
• A screenprint from the State's Medicaid systems showing Medicaid status
• Any other document from your state that shows you have Medicaid
• A document from your state that shows you have Medicaid and are getting home- and community-based services
• Social Security Administration (SSA) Award Letter
• An "Application Filed by Deemed Eligible" (SSA publication HI 03094.605) confirming that the beneficiary is "automatically eligible for extra help"

See a sample notice of the Application filed
Go to CMS.gov to learn more about BAE Policy

Medicare and Social Security Info:

• 1-800-MEDICARE (1 (800) 633-4227), 24/7 (TTY 1 (877) 486-2048)
• The Social Security Office at 1 (800) 772-1213, 7 am to 7 pm, Monday through Friday (TTY users should call 1 (800) 325-0778)
• Your local State Medicaid Office

In our effort to contain costs and deliver quality care to you, MyTruAdvantage and our service partners have organized our drug list into tiers and placed requirements on some expensive drugs to target their availability to where they are most valuable. Below are terms you may see in the formulary. Please see the formulary to understand which drugs fall within each category below.

Formulary
Our formulary lists drugs that we have approved coverage for in advance and helps you and your doctor find treatment options that will address your needs, while also explaining the cost and any rules or usage requirements that may apply to certain medications.

Formulary

• PA: Prior Authorization Applies
• PA NSO: PA for New Starts Only
• PA BvD: Part D vs. Part B Only
• PA-HRM: PA for High-Risk Meds
• QL: Quantity Limit Applies
• ST: Step Therapy Applies
• ST NSO: ST for New Starts Only
• CB: Capped Benefit
• GM: Male Only
• GF: Female Only
• AGE (Max x Years): Prior Authorization Age Edit
• AGE (Min x Years): Prior Authorization Age Edit
• AGE Min x Years and Max y Years): Prior Authorization Age Edit
• EX: Excluded Drug
• FF: First Fill (Generic Use Incentive)
• LA: Limited Access Drug
  • This prescription may be available only at certain pharmacies. For more information consult your Pharmacy Directory or call Pharmacy Member Services at (844) 283-2788, TTY users should call 711. 24 hours a day, 7 days a week or visit www.MyTruAdvantage.com.
• GC: Gap Coverage
• NDS: Non-Extended Days’ Supply
• NM: Non-Mail Order Drug
• HI: Home Infusion Drugs
• ENH: Enhanced Benefit

Part B vs Part D coverage (B/D)
Your cost for some drugs will vary depending on the purpose for which they are prescribed, and where you are taking them (sometimes referred to as the "setting", for example, in the hospital vs. at home). Please see the evidence of coverage for more information.

• Evidence of Coverage - Select (HMO)
• Evidence of Coverage - Select Plus (HMO)
• Evidence of Coverage – Choice Plus (PPO)
• Evidence of Coverage – Red, White and Tru (PPO)

Temporary Supply for Drugs not Covered

If your medication is not on our Formulary (Approved Drug List) or if your ability to get your prescription is limited, you may be able to fill a temporary supply (up to 30 days) of your drug at an in-network pharmacy.

What is a temporary supply or transition fill?
A temporary supply or a "transition fill" is generally a one-time refill of a current medication that gives you and your health care provider time to change to a different medication or to file a request to have it covered by MyTruAdvantage.

Eligibility
You are eligible for a temporary supply or transition fill of up to 30 days if you meet one of the following situations:

• If you're new to your Medicare plan and the drug you are currently taking is not on the MyTruAdvantage formulary or is restricted, you are eligible for a temporary supply. You have 90 days from the day your plan starts to receive a transition fill or temporary supply of a medication you’re currently taking
• If you're a current member of a MyTruAdvantage plan and the drug you have been taking is no longer on the plan's formulary or the drug you have been taking is now restricted in some way (See Section 5, Chapter 5 of your EOC for more information about restrictions), you are eligible for a temporary supply. You have 90 days from the day your drug’s status changes to get a transition fill or temporary supply.
• If you're a member of a MyTruAdvantage plan and live in a long-term care facility, you have 90 days from your admission date to the facility to get a transition fill or temporary supply

Call pharmacy member services at 877.406.6035 (TTY) for more details about receiving a temporary supply or transition fill of a medication.

MyTruAdvantage has implemented quality assurance policies, procedures and programs to help you get the best possible care now, to continuously improve the quality of care delivered by our plans, and to promptly address any issues our monitoring detects. Our goal is to ensure care is safe, accessible, reliable, patient-centered, timely, efficient and cost-effective.

Making sure you get quality care:
The MyTruAdvantage Quality Improvement Program is designed to objectively and systematically monitor and evaluate the quality and appropriateness of clinical and non-clinical care and services provided to MyTruAdvantage enrollees. By implementing a solid infrastructure, plan and provider performance are overseen throughout each year to ensure maximal quality experience and efforts toward our quality goals.

Our Standards
The Quality Improvement Program establishes a set of standards to which every plan entity and provider must strive to meet. These are developed from the regulations set by CMS as well as the values and initiatives of MyTruAdvantage. Our standards are based in:

• Strong organizational and Quality Improvement infrastructure with lines of authority
• Continuously striving for Quality Improvement through quality studies and improvement initiatives
• Provider participation in the Quality Improvement Program and relevant processes
• Appropriate access to care and services for enrollees
• Management of enrollee medications
• Privacy, protection, and maintenance of member rights and responsibilities
• Enrollee rights for grievance and appeals
• Provider participation in quality assurance monitoring including HEDIS measurement
• Assessment of enrollee satisfaction with care and service provided via information collected by CMS approved and endorsed surveys including CAHPS and HOS.

Institutional Structures
Organizational infrastructure is at the foundation of the Quality Program, with shared oversight from the Board of Directors and through the Executive Leadership team and the Quality Improvement Committee (QIC).

The QIC is supported by the following subcommittees who perform assigned routine quality management activities and report up to the QIC on a regular basis.

• Health Services Committee
• Medical Peer Review and Credentialing Committee
• Therapeutics Committee
• Grievance and Appeals Committee

Commitment to Continuous Improvement
All parties accountable to the Quality Improvement Program are constantly comparing metrics to ensure consistency and maximal experience to enrollees; while deviations are considered new opportunities for improvement. Through annual review and evaluation of ongoing special studies, improvement projects, and the qualify plan, MyTruAdvantage is regularly looking for ways to improve. This is a fundamental effort supported throughout the organization from all Quality Improvement Program participants to the Board of Directors.

Federal and state laws protect the privacy of your medical records and personal health information. We protect your personal health information as required by these laws.

• Your "personal health information" includes the personal information you gave us when you enrolled in this plan as well as your medical records and other medical and health information.
• The laws that protect your privacy give you rights related to getting information and controlling how your health information is used. We give you a written notice, called a "Notice of Privacy Practice," that tells about these rights and explains how we protect the privacy of your health information.

How do we protect the privacy of your health information?

• We make sure that unauthorized people don’t see or change your records.
• In most situations, if we give your health information to anyone who isn’t providing your care or paying for your care, we are required to get written permission from you first. Written permission can be given by you or by someone you have given legal power to make decisions for you.
• There are certain exceptions that do not require us to get your written permission first. These exceptions are allowed or required by law. For example, we are required to release health information to government agencies that are checking on quality of care. Because you are a member of our plan through Medicare, we are required to give Medicare your health information including information about your Part D prescription drugs. If Medicare releases your information for research or other uses, this will be done according to Federal statutes and regulations.

You can see the information in your records and know how it has been shared with others
You have the right to look at your medical records held at the plan, and to get a copy of your records. We are allowed to charge you a fee for making copies. You also have the right to ask us to make additions or corrections to your medical records. If you ask us to do this, we will work with your healthcare provider to decide whether the changes should be made. You have the right to know how your health information has been shared with others for any purposes that are not routine. If you have questions or concerns about the privacy of your personal health information, please call Member Services (phone numbers are printed on the back cover of this booklet).
See also: Notice of Privacy Practices

Advance Directives

The term “advance directive” refers to your spoken and written instructions about your future medical care and treatment. By stating your health care choices in an advance directive, you can help your family and health care providers understand your wishes about your medical care if you are unable to make those decisions for yourself due to an accident or illness.

There are different types of advance directives. From a living will, to power of attorney, to choosing a health care representative and more, advance directives can be used in different situations to make sure your health care wishes are known. Indiana law pays special attention to advance directives and has specific laws in place regarding them.

Advance directives are not required and no one may discriminate against you if you do not sign one. While physicians and hospitals often encourage patients to complete advance directive documents to gain information about your health care choices, they cannot require you to have an advance directive.

Information about how to choose a health care representative is provided below. You can also visit the Indiana State Department of Health advance directive resource center for additional information on advance directives, including links to forms, contact information and more.

You or your appointed representative (someone you name to act for you) may file a grievance. You can name a relative, friend, attorney, doctor, or someone else to act for you. You may have someone already authorized under state law to act on your behalf or an individual appointed with power of attorney, for example.

If you wish to appoint someone to represent you, download the Appointment of Representative form required by the Centers for Medicare and Medicaid Services (CMS). This form is valid for one (1) year from the date of the last signature on the form, unless the form is revoked. For example, if the enrollee signs the form on January 1, 2024 and the representative signs on January 3, 2024 (or vice versa), the form is effective for one year starting on January 3, 2024. This form can also be used for appeals, coverage decisions, or grievances.

Filing a Claim for Reimbursement

Use this form to file a claim for reimbursement for your Medicare drugs and services.

Click here to download a Claims Form

Prior Authorization

MyTruAdvantage provides prior authorization services to ensure members receive services that are medically and clinically necessary, and that the services are appropriate for your condition or diagnosis.

Every year, Medicare evaluates health plan quality based on a 5-star rating system. A health plan's Star Rating can vary each year based on how well it performs in various categories. MyTruAdvantage is too new to receive a star rating. Please review the MyTruAdvantage Star Ratings document for more details.

In the event of a public health emergency within our service area, cost shares may be modified to ensure members have complete access to needed services, as allowed by CMS. In the event of a public health emergency, members can check back here at www.MyTruAdvantage.com for updated information or call Member Services at 844-425-4280.

As a MyTruAdvantage member, you have certain rights and responsibilities when it comes to your plan and your health. It's important to understand your rights and responsibilities to ensure you get the most out of your MyTruAdvantage plan.

You can find a complete list of your rights and responsibilities as a member in Section 8 of the Evidence of Coverage (EOC) document for your plan.

Your Rights as a Member
As a MyTruAdvantage plan member, you have the right to:

• Information about us, our services, our providers, and your rights and responsibilities as a member
• Privacy and confidentiality regarding your medical care and records. Records pertaining to your healthcare will not be released without your, or your authorized representative's, written permission, except as required by law
• Discuss your medical record with your provider and receive, upon request, a copy of that record. Be informed of your diagnosis, treatment choices, including non-treatment and prognosis in terms you can reasonably expect to understand, and to participate in decision-making about your healthcare and treatment
• Collaborate with physicians and other health care providers when making decisions about the care you receive
• Expect reasonable access to medically necessary healthcare services, regardless of race, national origin, religion, physical abilities or source of payment
• File a formal complaint, as outlined in the plan's grievance procedure, and expect a response to that complaint within a reasonable period of time
• Be treated with courtesy and respect, with appreciation for your dignity and protection of your right to privacy
• Receive our "Notice of Privacy Practices"
• Expect your personal information to be kept secure and used appropriately for payment and health plan operations
• Expect MyTruAdvantage to adhere to all privacy and confidentiality policies and procedures

Your Responsibilities as a Member
As a MyTruAdvantage plan member, you are responsible for:

• Reading the coverage documents that explain your health plan and the accompanying member materials
• Understanding and complying with the terms and conditions of your plan
• Obtain and carefully consider all information you may need or desire in order to give informed consent for a procedure or treatment
• Calling us with questions
• Express opinions, concerns or complaints in a constructive manner
• Using participating/in-network health care providers for all services and supplies not requiring prior approval, or, if your plan allows you to use non-participating/out-of-network providers, then understanding the costs of services you choose to get from them
• Getting prior approval for medical services when required by your plan and complying with the limits of any approval of services
• Contacting participating health care providers to arrange for medical appointments and notifying them in a timely manner if an appointment must be canceled
• Paying copayments and any premiums by the date they are due
• Presenting your MyTruAdvantage member ID card to a health care provider before you receive a service
• Collaborating with your doctors and other health care providers to make informed decisions about the care you receive and to understand your health problems and health risks
• Following the instructions and working toward the treatment goals that you and your doctor or other health care provider agree upon. You may participate in developing your treatment goals when possible. MyTruAdvantage or your health care providers may ask you to agree to a written treatment plan to ensure you understand it
• Supplying your doctors, other health care providers and MyTruAdvantage with the complete and accurate information needed to ensure you receive proper care
• Notifying health care providers and us if you have other health insurance coverage
• Providing complete and accurate information on your enrollment form and in any other information provided to us
• Notifying us when your address or phone number changes, even if these changes are temporary
• Notifying us if your MyTruAdvantage membership card is stolen
• Cooperating with us to prevent the unauthorized use of your MyTruAdvantage membership card and to prevent anyone from using your benefits in your place
• Follow healthcare facility rules and regulations affecting patient care and conduct.
• Treating health care providers and their staff with respect
• Be considerate and cooperative in dealing with health care providers and their staff and respect the rights of fellow plan members

Here is information to cancel or disenroll from your MyTruAdvantage plan.

When can I cancel?
Cancellation occurs when you request to leave your MyTruAdvantage plan before its effective date. You can cancel your plan:

• any time before the plan’s effective date
• within 7 days of receiving your Enrollment Verification letter

When can I disenroll from my plan?
Disenrollment occurs when you request to leave your MyTruAdvantage plan after its effective date. You can generally disenroll from your plan during the following times:

• Medicare Annual Election Period (AEP) October 15–December 7
  • This election period applies for all Medicare plan types (Medicare Advantage plans, Prescription Drug plans, etc.)

• Medicare Advantage Open Enrollment Period (OEP) January 1–March 31
  During OEP, you have a one-time opportunity to enroll in another Medicare Advantage plan or disenroll from your current Medicare Advantage plan and return to Original Medicare (with or without a stand-alone Part D plan).

  When disenrolling from your Medicare Advantage plan during OEP, the termination date is the end of the month in which the disenrollment request is received if returning to Original Medicare.

• Special Enrollment Period (SEP)
  You can also disenroll during a Special Enrollment Period (SEP) if you qualify for SEP. Circumstances that may qualify you for a Special Enrollment Period (SEP) are:
  • moving out of a plan’s service area
  • losing group Medicare employer coverage
  • qualifying for a low-income subsidy
  • newly qualifying for a Special Needs Plan due to a chronic health condition
  • eligibility for both Medicare and Medicaid (dual eligibility)

Members who elect to drop their Medicare Advantage plan coverage during AEP or OEP are not guaranteed the ability to obtain a Medicare Supplement policy. You can disenroll from Medicare Supplement plans at any time. However, MyTruAdvantage must receive your disenrollment request by the last day of the month in which you wish to disenroll or before the end of the election period. The termination date is the end of the month for the month of the requested termination, or as indicated in the policy.

How do I cancel or disenroll?
The most convenient way to cancel your plan before the effective date is to call MyTruAdvantage Member Services. The MyTruAdvantage Member Services team will guide you through the cancellation process. If you prefer, you can fax or mail a signed written request to cancel your plan.

Call MyTruAdvantage Member Services: 844.425.4280 (TTY: 711)
Our hours are 8 a.m. to 8 p.m. Local Time, 7 days a week. On Thanksgiving and Christmas Day, as well as on weekends and holidays from April 1 through September 30, alternate technologies (for example voice mail) will be used and we will return your call within one (1) business day.

To disenroll from your plan, you must send MyTruAdvantage a signed, written disenrollment request. You can print the simple disenrollment form here.

After you fill the form out and sign it, you can fax or mail it to MyTruAdvantage. If you prefer, you can write and sign your own disenrollment request.

Include the following information in the written request

• Member’s name
• MyTruAdvantage member ID number
• Plan name: MyTruAdvantage Select (HMO), MyTruAdvantage Select Plus (HMO), MyTruAdvantage Choice Plus (PPO) or MyTruAdvantage Red, White and Tru (PPO)
• Statement that you want to disenroll from your plan
• Requested disenrollment date
• Signature
• Reason for disenrolling

Note: Please reference the above Disenrollment Form link for a list of viable reasons to disenroll, based on your plan type

Submit the disenrollment form or a written cancellation or disenrollment request to:

MyTruAdvantage
PO Box 428
Columbus IN, 47201

Or fax to:
812.373.8717

If you have additional questions about cancellation or disenrollment, call MyTruAdvantage Member Services: 844.425.4280 (TTY: 711)

Our hours are 8 a.m. to 8 p.m. Local Time, 7 days a week. On Thanksgiving and Christmas Day, as well as on weekends and holidays from April 1 through September 30, alternate technologies (for example voice mail) will be used and we will return your call within one (1) business day.

Who can complete a disenrollment request?
Only the member or the member’s healthcare power of attorney (POA) or legal guardian can complete a disenrollment request.

What are my options during disenrollment?
There are options with disenrollment. When you disenroll from your plan, you can enroll in another carrier’s plan or return to Original Medicare.

Prescription drug plans (PDPs) are only available through private companies. If you do not maintain prescription drug coverage through Medicare Part D or other coverage that is at least as good as the Medicare drug benefit, you may incur a late enrollment penalty (LEP) that will be due as part of your monthly premium for the duration of any future PDP enrollment.

MyTruAdvantage notifies you of your disenrollment effective date after CMS approves the disenrollment. Until your disenrollment is effective, continue to fill your prescriptions at MyTruAdvantage network pharmacies to receive your prescription benefits.

If you’re making a plan change as part of your disenrollment, you can call our sales department at 1-833-213-6731 (TTY: 711), 8 a.m. to 8 p.m., 7 days a week. On Thanksgiving and Christmas Day, as well as on weekends and holidays from April 1 through September 30, alternate technologies (for example voice mail) will be used and we will return your call within one (1) business day. If you have a valid election to change plans, our sales department can assist you in making a plan change.

If the Governor of your state, the U.S. Secretary of Health and Human Services, or the President of the United States declares a state of disaster or emergency in your geographic area, you are still entitled to care from your plan.

If you cannot use a network provider during a disaster, your plan MTA will allow you to obtain care from out-of-network providers at in-network cost sharing. If you cannot use a network pharmacy during a disaster, you may be able to fill your prescription drugs at an out-of-network pharmacy. Please see the Evidence of Coverage for more information.