Frequently Asked Questions

Frequently Asked Questions (FAQs):

• Coverage Gap
• Diabetic Supplies
• Fitness Benefit
• ID Card
• Prescriptions
• Referrals
• Urgently Needed Care
• Vision Benefit

Durable Medical Equipment - FAQs:

• Getting Started
• Diabetic Supplies
• Vendors
• Delivery
• Costs
• Visitor/Travel Benefits
• Refills
• Repair/Replacement
• Other Questions

Frequently Asked Questions (FAQs):

Coverage Gap

Q: What is the coverage gap*? When does it begin and end?
A: Most Peoples Health Medicare plan members have a coverage gap*, which is sometimes called the “doughnut hole.” This is the phase in the prescription drug cycle in which plan members become responsible for paying the full cost for certain drugs.

Phase 1 is the standard coverage phase. During this phase, you pay your standard copay or coinsurance amounts until your total drug costs (which include the amount Peoples Health pays and the amount you pay for your Medicare-covered drugs, combined) reach $2,830. You can check your monthly Explanation of Benefits to find out how close you are to hitting the coverage gap.

Phase 2 is the coverage gap*. Peoples Health covers some drugs through this phase, but you must pay for 100 percent of the cost for drugs that are not covered until your total out-of-pocket costs (what you alone have paid since January 1) reach $4,550. Peoples Health covers generic and preferred brand drugs for Choices 65 (HMO) and Choices Plus (HMO-POS) plan members, and generic drugs only for Choices Select (HMO-POS) plan members through the coverage gap*. After you have paid a total of $4,550 in out-of-pocket costs, you will reach Phase 3.

Phase 3 is the catastrophic coverage phase. During this phase, you pay reduced costs for your prescription drugs: the greater of 5 percent coinsurance or $2.50 for generic drugs (or drugs that are treated like generics) and $6.30 for all other drugs. Peoples Health pays the
rest until the prescription drug cycle starts over again on January 1.

*Excludes Peoples Health Group Medicare (HMO-POS) and Secure Health (HMO) plan members, as well as certain individuals who receive “extra help.”

[Back to top of page ^]

Diabetic Supplies

Q: How do I get diabetic supplies?
A: You have several options to receive your free diabetic supplies (lancets, test strips and syringes). Your first option is to order these supplies through the Peoples Health mail-order service. This option requires your physician to send his or her order for DME to Peoples Health, and your supplies will be delivered to your door at no charge. Your second option is to bring your order for DME to be filled at a network retail pharmacy. Please refer to your Provider Directory or call Member Services at the numbers listed on the back of this document for a list of network retail pharmacies. Remember, you must have a current order for diabetic supplies from your physician in order to receive these supplies. If your physician changes your diabetic supplies or the number of times you need to test your blood sugar each day, he or she will need to write a new order for DME.

[Back to top of page ^]

Fitness Benefit

Q: My gym says I need to register with Silver&Fit to work out there. Is that true?
A: Yes. Peoples Health works with a company called Silver&Fit to administer our fitness benefit. You can choose from over 120 fitness facilities or work out in the comfort of your home using Silver&Fit’s at-home exercise kit. Whichever option you choose, you will need to register with Silver&Fit. Registration is easy and free.

Have your Peoples Health member ID card ready and visit www.SilverandFit.com and follow the instructions to register. Or, call Silver&Fit toll-free at (877) 427-4788, Monday through Friday, from 7 a.m. to 8 p.m. TTY/TDD telephone device for the hearing impaired users may call toll-free at (877) 710-2746. A Silver&Fit respresentative will describe the program and will be able to answer any questions you may have about the program. Remember to consult your physician before you begin any physical fitness program.

[Back to top of page ^]

ID Card

Q: I recently changed my primary care physician (PCP). When will I get my new ID card? When can I start seeing my new PCP?
A: Requests for PCP changes that are received by the 20th day of the month will become effective the first day of the following month. For example, if you request a new PCP on January 19, you can begin seeing your new PCP on February 1. If you request a new PCP on January 23, you can begin seeing your new PCP on March 1. Keep in mind that seeing your new PCP before the effective date will result in higher out-of-pocket costs. You should receive your new ID card within two weeks of requesting your PCP change. If you do not receive your new ID card within this timeframe, please call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

[Back to top of page ^]

Prescriptions

Q: How can I save money on prescriptions?
A: There are several ways you can save money on your prescriptions.

Consider switching to generic or preferred brand-name prescriptions.
Some prescriptions (called “maintenance drugs”) are available in a 90-day (three-month) supply, which may help you save money and can be filled either through our mail-order service or through a Peoples Health network pharmacy. A list of network pharmacies can be found on the Network Pharmacies page.
If you have limited income and resources, you may qualify for extra help. Contact Member Services at the numbers listed on the back of this document for more information.

Q: My pharmacy wouldn’t refill my prescription because they said it was too early. When can I refill my prescription?
A: You must use 80 percent (24 days) of a 30-day prescription and 90 percent (81 days) of a 90-day prescription before we can refill your medications. Refills are not available for controlled substances; these medications are only available with a new prescription.

[Back to top of page ^]

Referrals

Q: Do I need a referral from my primary care physician (PCP) to see a specialist?
A: Peoples Health does not require you to get referrals to see a specialist. You can keep your costs lowest by seeing a specialist in your physician team (Choice 1). For a slightly higher cost, you can see any physician in the Peoples Health network (Choice 2). Members of Choices Plus (HMO-POS), Choices Select (HMO-POS) and Peoples Health Group Medicare (HMO-POS) also have the option to access care from providers outside of the Peoples Health network (Choice 3). This option costs more than Choices 1 and 2.

[Back to top of page ^]

Urgently Needed Care

Q: What are urgent care centers and why should I use them?
A: Urgent care centers are ideal for accessing medical care when your health condition is not life-threatening, or when you are unable to see your primary care physician (PCP) during nights, weekends or holidays. Urgently needed care visits are less expensive than emergency department visits. For a list of Peoples Health urgent care centers in your area, visit our Ancillary Service Providers page. You can also contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

[Back to top of page ^]

Vision Benefit

Q: Why am I sometimes charged different copays for seeing my eye doctor?
A: Routine vision care is different than medical vision care, and each has a different copay. Routine vision care is provided by a network of optometrists and optical shops, and should be used when you have a routine eye exam or need a new prescription for glasses or contacts. These exams are associated with a routine vision copay and must be performed by a Vision Benefits Network provider. These providers are listed in the back of your Provider Directory, in the “Ancillary Services” section.

Medical vision care is provided by a doctor called an ophthalmologist to diagnose problems with your eyes that may require medication or surgery. These exams are associated with a medical copay for a doctor’s office visit. These doctors are listed under your physician team name in your Provider Directory.

If you aren’t sure which eye doctor to use, contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

[Back to top of page ^]

Durable Medical Equipment - FAQs:

Getting Started

Q: What items, services and supplies are considered DME?
A: DME is equipment needed for medical reasons and is sturdy enough to be used many times without wearing out. Examples include canes, crutches, walkers, commode chairs, bath or shower chairs, transfer benches for a tub, raised toilet seats, wheelchairs and hospital beds. It also includes diabetic supplies and breathing equipment.

Q: I’m a new member who needs DME. How do I get it?
A: New members receive a call from one of our nurses shortly after enrolling with Peoples Health. We attempt to contact our new members three times. If we are unable to reach you, we send you a letter asking you to contact us. It’s important that we speak with you to make sure that you continue getting any medical services or supplies you need without interruption. If your old DME vendor is not a Peoples Health vendor, we can help you pay the lowest costs for your DME by switching you to a Peoples Health vendor.

If you have not spoken with a Peoples Health nurse about your DME needs, please call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979. They can put you in touch with one of our nurses who can help you switch to a Peoples Health DME vendor.

Q: I spoke to a Peoples Health nurse but haven’t gotten my DME yet. Why?
A: You may need to set an appointment with your physician so he or she can write you an order for DME. Peoples Health cannot supply you with DME without a physician’s order.

Q: I have been prescribed DME for the first time. What do I need to do?
A: If your physician orders canes, crutches, walkers, commode chairs, bath or shower chairs, transfer benches for a tub, raised toilet seats, wheelchairs, hospital beds or equipment that helps you breathe, there is nothing you need to do. Your physician will fax an order for this equipment to Peoples Health. After we process the order, we will contact our DME vendor. The Peoples Health vendor will then contact you to schedule a delivery of this equipment to your home. If your order is for diabetic supplies, you need to decide how you want to receive these supplies. You can sign-up to have them delivered to your home through our mail-order service, or you can fill your order at a network retail pharmacy.

Q: Do I rent or own my DME?
A: It depends on the type of DME you have. Wheelchairs and hospital beds are rental items only, so you will always have to pay for this equipment. Your monthly copay/coinsurance helps you purchase the following DME: canes, crutches, walkers, commode chairs, bath/shower canes, crutches, walkers, commode chairs, bath/shower chairs, transfer benches for a tub and raised toilet seats. Members pay a copay/coinsurance for this equipment for 13 months. As of the 14th month, you own this equipment and no longer have to pay for it. If you are not sure how long you have been paying for this equipment, call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979..

Q: What is prior authorization and why do I need it?
A: All DME requires prior authorization, which is approval in advance from Peoples Health to get this equipment. Prior authorization is our way of making sure that DME is medically necessary.

[Back to top of page ^]

Diabetic Supplies

Q: How can I get my diabetic supplies?
A: You have several options to receive your free diabetic supplies (lancets, test strips and syringes). Your first option is to order these supplies through the Peoples Health mail-order service. This option requires your physician to send his or her order for diabetic supplies to Peoples Health, and your supplies will be delivered to your home at no charge. Your second option is to bring your order for diabetic supplies to be filled at a network retail pharmacy. Please refer to your Provider Directory or call Member Services for a list of network retail pharmacies. You can contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

Remember, you must have a current order for diabetic supplies from your physician to receive these supplies. If your physician changes your diabetic supplies or the number of times you need to test your blood sugar each day, he or she will need to write a new order for your diabetic supplies.

Note: The $0 copay does not apply to wound care, colostomy or urostomy supplies.

[Back to top of page ^]

Vendors

Q: Who are my Peoples Health DME vendors?
A: For a list of Peoples Health DME vendors, visit the Ancillary Service Providers page. You can also contact Member Services for the name and contact information of your Peoples Health DME vendor. You can contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

Q: Can I use different vendors than the ones contracted with Peoples Health?
A: The following Peoples Health Medicare plan members have the option to use providers not contracted with Peoples Health and will pay higher out-of-pocket costs for using these providers: Choices Plus (HMO-POS), Choices Select (HMO-POS) and Peoples Health Group Medicare (HMO-POS). All other Medicare plan members must use Peoples Health contracted DME vendors to receive DME benefits through Peoples Health.

[Back to top of page ^]

Delivery

Q: How can I get DME delivered to my home?
A: If your physician writes you an order for DME, he or she needs to send the order to Peoples Health. The order takes up to three days to process. Once it does, Peoples Health will contact the appropriate vendor to schedule delivery of your DME to your home*. The vendor will make three attempts to call you to set up a delivery time. Most companies require someone to be home to accept deliveries. If the vendor is unable to reach you, they will call Peoples Health to make sure they have your correct information on file.

*Your copay for wound care supplies and nebulizer medications must be prepaid before the vendor will ship these items to you.

[Back to top of page ^]

Costs

Q: What do I pay for DME?
A: Please refer to your plan Evidence of Coverage or call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979..

Q: Who do I pay for DME?
A: You will get a bill from your DME vendor. You are responsible for sending payment directly to your DME vendor (not Peoples Health).

[Back to top of page ^]

Visitor/Travel Benefits

Q: What if I’m away from the plan service area and need DME?
A: You can access your DME benefit when you travel outside of your plan’s service area. If you have questions about your DME costs when you travel, please call Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

Q: Can I pre-order my DME before traveling out of the service area?
A: In some cases, yes. Please call Member Services as soon as you know you must leave the service area to make arrangements for getting your DME. You can contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

[Back to top of page ^]

Refills

Q: What kind of DME supplies can I get refilled?
A: You can get refills on DME supplies that you use once, such as diabetic supplies.

Q: How can I get refills on my DME supplies?
A: Refills for DME supplies require a physician’s order. Contact your physician to request these refills, or ask your physician to give you additional refills when writing an order for your DME.

Q: I ran out of DME supplies. Why won’t my physician give me refills?
A: Physicians write orders for DME based on how often you should use these supplies. If you run out of supplies early, you may be using your DME supplies too often. For example, if you have diabetes and your physician tells you to test your blood sugar three times a day, but you test it six times a day, you will run out of test strips too soon. Peoples Health cannot give you refills without an order from your physician, and your physician may want to meet with you to discuss how to use your DME supplies before giving you a refill.

[Back to top of page ^]

Repair/Replacement

Q: My DME needs repair. What should I do?
A: That depends whether you rent or own your DME.

• If you rent your DME: You will need to call your DME vendor to repair the equipment. Call Member Services to request vendor contact information. You can contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

• If you own your DME: Peoples Health will cover the cost of repairs as needed. Please call Member Services to request DME repairs. You can contact Member Services toll-free at (800) 631-8443, ext. 2, Monday through Friday, from 8 a.m. to 8 p.m. Telephone device for the hearing impaired users may call (888) 631-9979.

Q: My DME needs to be replaced. How can I get new equipment?
A: If your DME is five years of age or older, you may qualify for new DME. This requires a new order for DME from your physician. Please contact your physician to make this request.

[Back to top of page ^]