1. 2010 Univera Healthcare Medicare Plans Workshop
Welcome
2010
Univera Healthcare
Medicare Plans Workshop
(Sales Rep’s Name)
Medicare Sales Consultant
Univera Healthcare contracts with the Federal Government and is a Medicare Advantage Organization with a Medicare contract.

2. Our Vision
“…to be a best in class Medicare Program, providing Medicare beneficiaries with a range of products and services that meet their needs for health coverage at an affordable price.”
Good (morning/afternoon/evening) ladies and gentlemen and thank you for coming today. My name is ______ and I have been a proud employee of Univera Healthcare for ____ years. (add any other personal info that audience might find interesting)
I am certain that you will find the next hour to be a worthwhile use of your time. Please sit back and relax and know that I am here to assist you in making the best possible choice for you regarding your Medicare health insurance coverage.

3. Agenda Medicare Basics Plan Options & Benefits Valuable Extras
Enhanced Web Tools
Questions
So, what will we be covering today? I will go over Medicare Basics, including the 4 parts of Medicare, Medicare Supplement plans, and I will provide you with a full overview of our Univera Healthcare Medicare plan options for We offer Medicare Supplement plans A, B, C, F, F+ and H, our Medicare Advantage HMO plans - SeniorChoice Value, SeniorChoice Value Plus, SeniorChoice Secure, SeniorChoice Select; and, our Medicare Advantage PPO plan - Univera Medicare PPO 102.
I’m sure you will be as pleased as I am with the various Medicare coverage options we are offering this year and that you now have available to you to fit your needs.
I’ll also tell you about some of the additional benefits offered as part of our Medicare Advantage Plans, such as our Active Anytime Flexible Fitness Benefit and our 24 hour Personal Health Coaching Line.
We have also updated our Web site with enhanced tools to make everything from comparing plans to ordering ID cards faster and easier.
And, of course, I will make sure that you have all your questions answered before we wrap up today!
Here’s what you have in front of you to reference: (Explain what they have been given; product brochure, etc)

4. There are two parts to Original Medicare: Part A and Part B
Medicare Basics
There are two parts to Original Medicare: Part A and Part B
Part A
Helps cover inpatient care in hospitals.
Helps cover skilled nursing facility, hospice and home health care.
You pay deductibles, coinsurance, and copays.
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working.
There are four parts to Medicare:
Part A
Part B
Part C
Part D
Original Medicare Plan (Part A and B):
The Original Medicare Plan is managed by the Federal Government and provides your Medicare Part A and Part B coverage.
Part A helps cover your inpatient care in hospitals, skilled nursing facilities, hospice, and home health care if you meet certain conditions. You are usually charged a fee for each health care service or supply you get, such as copayments, coinsurance and deductibles.
You usually don’t pay a monthly premium for Part A coverage if you or your spouse paid Medicare taxes while working. If you aren’t eligible for premium-free Part A, you may be able to buy it if you meet certain conditions. If you get benefits from Social Security or the Railroad Retirement Board (RRB), you will automatically get Part A starting the first day of the month you turn age 65. If you are under age 65 and disabled, you will automatically get Part A after you get disability benefits from Social Security or RRB for 24 months.

5. Medicare Basics
Part B
Helps cover doctor’s services and outpatient care.
Helps cover some preventive care.
With Part B you pay premium, deductible, coinsurance, and copays.
$96.40 monthly standard Medicare Part B premium generally deducted from Social Security check
$135 Part B annual deductible
20% coinsurance on most services
Part B helps cover medically necessary services like doctor’s services and outpatient care. Part B also helps cover some preventive services. Like Part A, you are usually charged a fee for each health care service or supply you get, such as copayments, coinsurance and deductibles. Additionally, Part B also has a premium charged which most individuals have deducted from their Social Security check.

6. Medicare Basics Part C: Medicare Advantage Plans
Part D: Prescription Drug Plans
Medicare Supplement: Medigap Plans
Part C Medicare Advantage Plans (like an HMO or PPO) are another way to get Medicare benefits. Medicare Advantage Plans are health plan options approved by Medicare and run by private insurance companies, like Univera Healthcare. Medicare Advantage Plans provide all of your Part A (Hospital Insurance) and Part B (Medical Insurance) benefits and cover all of the medically necessary services that the Original Medicare Plan provides. Medicare Advantage Plan options may also include Medicare prescription drug coverage.
Part D Prescription Drug Coverage helps cover prescription drug costs. Medicare drug plans are Part D prescription drug plan options approved by Medicare and run by private insurance companies, such as Univera Healthcare.
Another Medicare coverage option that is available is Medicare Supplement, also known as Medigap Plans.
A Medigap Plan is private health insurance designed to supplement the Original Medicare Plan. This type of policy helps pay some of the health care costs (“gaps”) that the Original Medicare Plan doesn’t cover, like copayments, coinsurance, and deductibles. Some Medigap policies cover extra benefits for an extra cost. Medigap policies only work with the Original Medicare Plan, and they cannot be used to pay your copayments or deductibles for Medicare Advantage Plans.
Generally, when you buy a Medigap policy, you must have Medicare Part A and Part B. In addition to your monthly Part B premium, you will also have to pay a premium for the Medigap policy to our organization.
Medigap insurance companies, like Univera Healthcare, can only sell you a “standardized” Medigap policy. Standardized means that the benefits available under the various Medigap plans are mandated by the government. Each standardized Medigap policy must offer the same basic benefits, no matter which insurance company sells it. Medicare Supplement plans are governed by New York State.
Medigap plans that are currently being sold can’t include prescription drug coverage. This is because Medicare now makes prescription drug coverage available to everyone with Medicare.
Deductibles and premiums associated with Medigap policies are subject to change annually.
I will explain each of our Medicare offerings more fully as we go along.

7. Your Plan Options Medicare Supplement Plans (Medigap)
Secondary payer to Original Medicare
Do not include Part D Drug Coverage
Can purchase Part D separately
Medicare Advantage Plans
Medical Coverage with Part D Drug Coverage (MA-PD)
Medical Coverage without Part D Drug Coverage (MA)
Univera Healthcare offers both Medicare Supplement plans and Medicare Advantage Plans.
Medicare Supplement plans act as a secondary payer to Original Medicare, and they do not include Part D prescription drug coverage. However, you may purchase a stand-alone Part D plan separately.
Medicare Advantage Plans include plans WITH AND WITHOUT Part D drug coverage.

8. What is a Medicare Supplement Plan? (Medigap)
A Medicare Supplement (Medigap) policy is designed to supplement the Original Medicare Plan
Fills gaps in Original Medicare
Medicare Part D drug coverage not included
As I explained earlier, Medigap policies are designed to supplement the Original Medicare Plan.
In addition to the monthly Part B premium, which most individuals have deducted from their Social Security check, you will also pay a premium to our organization for the Medigap policy. Please note that Medigap policies do not include prescription drug coverage.
When you are enrolled in a Medigap plan, your health care providers will bill Medicare first for services provided, then any remaining charges will be billed to Univera Healthcare. You should present both your red, white and blue Medicare ID card and your Univera Healthcare Medicare Supplement Plan ID card when you receive services.

9. Medicare Supplement Plans (Medigap)
Plan A
Basic benefits only
Plan B
Basic benefits
Part A deductible under Original Medicare Plan
Plan C
Parts A & B deductibles under Original Medicare Plan
Foreign travel emergency
Skilled Nursing Facility (SNF) coinsurance
Univera Healthcare offers six Medicare Supplement Plans.
Plan A: Provides coverage for basic benefits only. Basic benefits cover the following three expenses: (1) the Original Medicare Plan Part A coinsurance for inpatient hospital services plus coverage for 365 additional inpatient days in your lifetime after your Original Medicare Plan benefits end, (2) the Original Medicare Plan Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services and (3) the first three pints of blood each year.
Plan B: Plan B also includes basic benefits as we already discussed, plus coverage for your Original Medicare Plan Part A deductible.
Plan C: Covers basic benefits, Part A deductible, Part B deductible, skilled nursing facility coinsurance, and provides foreign travel coverage for emergencies during the first 60 days of each trip outside the U.S.

10. Medicare Supplement Plans (Medigap)
Plan F / High Deductible F+
Basic benefits
Part A & B deductibles under the Original Medicare Plan
Foreign travel emergency
Part B excess charges
Skilled Nursing Facility (SNF) coinsurance
F+ has $2,000 deductible (deductible subject to change annually)
Plan H
Part A deductible under Original Medicare Plan
Plan F and High Deductible F+: Both of these plans cover the same benefits featured in Plan C, however, both Plan F and the High Deductible F+ offer coverage for Part B excess charges, which are charges from your doctor that exceed Medicare-approved amounts, and don’t count toward your out-of-pocket limit. The difference in benefit level between Plan F and F+ is that F+ has a $2,000 deductible to meet before benefits would begin.
Plan H: Covers basic benefits, Part A deductible, skilled nursing facility coinsurance, and provides foreign travel coverage for emergencies during the first 60 days of each trip outside the U.S.
It’s important to note that Medicare Supplement Plan premiums and deductibles are subject to change each year.

11. How Do Medicare Advantage Plans Work?
Provides Part A (Hospital) and Part B (Medical) Benefits
You pay affordable copays/coinsurance
Offers extra benefits such as:
Vision Exam
Hearing Exam
Health and Wellness
Preventive Services
When you receive your health insurance through a Medicare Advantage plan, you get your Medicare Part A and B benefits, along with extra benefits (vision exams, health and wellness programs) all rolled up in one plan! You might also choose a Medicare Advantage Plan that includes Medicare Prescription drug coverage!

12. Eligibility and Service Area
You are eligible to join one of our Medicare Advantage HMO or PPO
plans if:
You have Medicare Part A (Hospital) and are enrolled in Medicare Part B (Medical)
You are a legal resident in the service area of the plan (includes: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming counties, NY)
You do not have End-Stage Renal Disease (ESRD)
So, what are the requirements to join our Medicare Advantage Plans? You can generally join as long as you meet these conditions: You have Medicare Part A and Part B, you live in our service area (the 8 counties of our Western New York region), and you don’t have End-Stage Renal Disease.

13. Medicare Advantage Plan Enrollment Periods
There are only certain times during the year when you may change or voluntarily end your membership in a Medicare Advantage or stand-alone Prescription Drug Plan.
Annual Enrollment Period (AEP)
Runs from November 15 – December 31, each year
Can change Medicare Advantage or stand-alone Prescription Drug Plans
Can add or drop prescription drug coverage
Can return to Original Medicare
Enrollment changes take effect on January 1
Open Enrollment Period (OEP)
Runs from January 1 – March 31, each year
Can change Medicare Advantage Plans
Cannot add or drop prescription drug coverage
One opportunity to change to a similar plan (no-drug plan to no-drug plan - OR - drug plan to drug plan)
Enrollment or disenrollment becomes effective the month after the application is received
There are certain times when you can join a Medicare Advantage or Prescription Drug Plan and certain times when you cannot. I want to review these with you so you understand what period we are in now and what options you have.
The Annual Enrollment Period is from November 15 to December 31 each year. During that time you can leave your existing plan, join a new plan, add or drop drug coverage or stay with the Medicare Advantage or stand-alone Prescription Drug Plan you have and make no changes!
The Open Enrollment Period is from January 1 to March 31 each year. During that time you can switch Medicare Advantage plans once, but only from a like plan to a like plan. For example, if you are enrolled in a Medicare Advantage Plan with drug coverage you may elect to switch to another Medicare Advantage Plan with drug coverage OR if you are enrolled in a Medicare Advantage Plan with no drug coverage you may elect to switch to another Medicare Advantage Plan with no drug coverage.

14. Medicare Advantage Plan Enrollment Periods
Initial Enrollment Period (IEP)
3 months before you turn age 65 to 3 months after the month you turn age 65
If you get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability
Can join a Medicare Advantage or stand-alone Prescription Drug Plan.
Enrollment changes take effect on the first day of your birth month.
Special Enrollment Period (SEP)
Change of residence into or out of the service area
Loss of employer coverage
Qualify for Low Income Subsidy
To obtain information regarding Medicare Advantage Plan Enrollment Periods you can call our Customer Service Department at TTY/TDD , Monday – Friday, 8:00 a.m. – 8:00 p.m., From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
For those who will soon be eligible for Medicare, there is something called the Initial Enrollment Period.
The duration of this period is from 3 months before you turn age 65 to 3 months after the month you turn age 65.
For those who get Medicare due to a disability, you can join during the 3 months before to 3 months after your 25th month of disability.
You may also be entitled to a Special Enrollment Period if you change your residence (if you move out of your current insurance carrier’s service area and into a new insurance carrier’s area) or if you are covered by an employer group, and you drop or lose that coverage. You would also have a Special Enrollment Period if you newly qualify for Low Income Subsidy.
To obtain information regarding Medicare Advantage Plan Enrollment Periods you can call our Customer Service Department at TTY/TDD Monday through Friday, 8:00 a.m. to 8:00 p.m. From November 15 to March 1, representatives are also available weekends from 8:00 a.m. to 8:00 p.m.

15. HMO vs. PPO HMO PPO Health Maintenance Organization
Preferred Provider Organization
Primary Care Physician (PCP) is required
Primary Care Physician (PCP) not required
Referral required to see a specialist
No referral required to see a specialist
Must use In-Network providers
(You must use plan providers except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis))
Can use In-Network & Out-of-Network providers*
(Out-of-pocket costs may be higher when you use an Out-of-Network provider, except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis)
*Univera Healthcare provides reimbursement for all covered benefits regardless of whether they are received in-network, as long as they are medically necessary.
We have contracted with doctors, other healthcare professionals, hospitals and other healthcare facilities that are licensed by the state, and eligible to receive payment from Medicare to coordinate or provide covered services to our plan members. The providers we have contracted with are referred to as our in-network providers. Providers that do not have a contract with our organization are referred to as out-of-network providers.
Who knows what HMO stands for? Right! Health Maintenance Organization. With an HMO, you must select one of our in-network providers as your Primary Care Physician. Your Primary Care Physician is responsible for coordinating your medical care, and he or she will provide you with a referral if you need to see a specialist.
Please note that Univera Healthcare does allow an “open-ended” referral, which is good indefinitely, so you would not need to get a new referral each year. It is entirely up to your PCP whether or not an open ended referral is right for you.
You must use our network providers to get your medical services except in the case of emergency care, urgently needed care, or out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Univera Healthcare will be responsible for the costs. Generally, with an HMO, you pay copayments, coinsurance and deductibles for most services.
Now who can tell me what PPO stands for? Right again: Preferred Provider Organization. With a PPO, you do not need to select a Primary Care Physician, and referrals are not needed. With a PPO, you have access to both In- and out-of-network providers and you may see any doctor, anywhere, at any time.
However, your out-of-pocket costs may be higher when you use an out-of-network provider, except in cases such as emergency care, urgently needed care, or out-of-area renal dialysis.

16. Medicare Advantage Plan Options
HMO Plans
SeniorChoice® Value (HMO)
SeniorChoice® Value Plus (HMO)
SeniorChoice® Secure (HMO)
SeniorChoice® Select (HMO)
PPO Plan
Univera Medicare PPOSM Plan 102 (PPO)
We have a variety of plans that provide a range both in price and individual benefits. It is important to remember that when selecting a plan, you should consider both the benefits AND price to determine which is the BEST for YOU.
For full information on our SeniorChoice and/or our Univera Medicare PPO benefits, call our Customer Service Department at , TTY/TDD Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
Our contract with CMS is renewed annually and the availability of coverage beyond the current contract year is not guaranteed. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, Please contact Univera Healthcare for details.

17. SeniorChoice® Value (HMO) $161
Benefit
SeniorChoice® Value (HMO)
Inpatient Hospital Care
(unlimited days each benefit
period)
$500 copay for each Medicare-covered stay at a network hospital;
Maximum 3 copays per year;
4th and subsequent hospitalizations are covered in full
Primary Care Physician
$20 copay per visit
Specialist
$40 copay per visit
Outpatient Hospital Services 2
$0 - $125 copay per visit
Radiology
20% coinsurance
Outpatient Prescription Drugs3
(Part D)
Part D with $150 annual deductible; Before total annual drug costs reach $2,830, for each 30 day supply you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
25% coinsurance for Tier 4 specialty drugs
(Read slide verbatim and answer questions pertaining to this slide.)
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you then pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.

18. SeniorChoice® Value Plus (HMO) $461
Benefit
SeniorChoice® Value Plus (HMO)
Inpatient Hospital Care
(unlimited days each benefit
period)
$350 copay for each Medicare-covered stay at a network hospital; Maximum 3 copays per year;
4th and subsequent hospitalizations are covered in full
Primary Care Physician
$20 copay per visit
Specialist
$35 copay per visit
Outpatient Hospital Services 2
$0 - $100 copay per visit
Radiology
10% coinsurance
Outpatient Prescription Drugs3
(Part D)
Part D with $150 annual deductible; Before total annual drug costs reach $2,830, for each 30 day supply you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
25% coinsurance for Tier 4 specialty drugs
(Read slide verbatim and answer questions pertaining to this slide.)
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you then pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.

19. SeniorChoice® Secure (HMO) $861
Benefit
SeniorChoice® Secure (HMO)
Inpatient Hospital Care
(unlimited days each benefit
period)
$250 copay for each Medicare-covered stay at a network hospital; Maximum 3 copays per year;
4th and subsequent hospitalizations are covered in full
Primary Care Physician
$15 copay per visit
Specialist
$30 copay per visit
Outpatient Hospital Services 2
$0 - $50 copay per visit
Radiology
$30 copay
Outpatient Prescription Drugs3
(Part D)
Part D with $0 annual deductible;
Before total annual drug costs reach $2,830, for each 30 day supply you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
33% coinsurance for Tier 4 specialty drugs
(Read slide verbatim and answer questions pertaining to this slide.)
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you then pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.

20. SeniorChoice® Select (HMO) $551
Benefit
SeniorChoice® Select (HMO)
Inpatient Hospital Care
(unlimited days each benefit
period)
$100 copay for each Medicare-covered stay at a network hospital; Maximum 3 copays per year;
4th and subsequent hospitalizations are covered in full
Primary Care Physician
$10 copay per visit
Specialist
$25 copay per visit
Outpatient Hospital Services 2
$0 - $35 copay per visit
Radiology
$25 copay
We also offer one Medicare Advantage plan with no prescription drug coverage included. This works well if you qualify for EPIC or the VA for your Part D equivalent drug coverage.
(Read slide verbatim and answer questions pertaining to this slide.)
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party.
2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. See Summary of Benefits for more details.

21. Univera Medicare PPOSM 102 (PPO) $361
Benefit
In Network
Out of Network
Inpatient Hospital Care
(unlimited days each
benefit period)
$500 copay for each Medicare-covered stay
at a network hospital; Maximum 3 copays per year
4th and subsequent hospitalizations are
covered in full
30% coinsurance per visit
Primary Care Physician
$20 copay per visit
$25 copay per visit
Specialist
$40 copay per visit
$45 copay per visit
Outpatient Hospital
Services 2
$0 - $125 copay per visit
Radiology
20% coinsurance
30% coinsurance
Outpatient Prescription
Drugs3
(Part D)
Part D with $150 annual deductible;
Before total annual drug costs reach $2,830, for each 30 day supply you pay:
$5 for Tier 1 generic drugs
$30 for Tier 2 preferred brand drugs
$75 for Tier 3 non-preferred brand drugs
25% coinsurance for Tier 4 specialty drugs
Emergency Benefit Only
(Read slide verbatim and answer questions pertaining to this slide.)
1 You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another 3rd party. 2 Your cost share will be higher when the service performed is of a surgical nature or observation and the lower cost share is applicable when the service is non-surgical. 3 See Summary of Benefits for more details. When your total Part D drug costs reach $2,830, you then pay 100% of the cost of your drugs. Once you or others on your behalf spend $4,550 in out-of-pocket costs, you then pay $2.50 for generics, and $6.30 for brand drugs or 5% of the price (whichever is greater). Copays based on getting 30-day supply; call us about reduced copays for mail order or a 90-day supply.

22. Medicare Prescription Drug Plan (Part D)
2 ways to get Medicare Prescription Drug Coverage:
Join a stand-alone Medicare Prescription Drug Plan (PDP)
Join a Medicare Advantage Prescription Drug Plan (MA-PD)
Now let’s move on and talk about a very important subject: prescription drug coverage. There are two ways to get Medicare prescription drug coverage; you can join a Medicare Prescription Drug Plan, known as a PDP, which adds drug coverage to your Original Medicare plan, OR you can enroll in a Medicare Advantage Prescription Drug Plan, known as an MA-PD.
When you join an MA-PD plan, you get all of your Medicare coverage (Part A and B) including prescription drug coverage (Part D), through one plan. Please note that you may choose either a PDP or an MA-PD plan, not both. For example, if you are enrolled in a SeniorChoice or Univera Medicare PPO plan that includes Medicare prescription drug coverage (an MA-PD), and you enroll in a PDP, you will be automatically disenrolled from the MA-PD (HMO or PPO plan).

23. Medicare Prescription Drug Plan (Part D)
Formulary
List of drugs that are covered under your Part D drug plan
To obtain a copy of our formulary go to our Web site at
Network
About 60,000 pharmacies nationwide
Retail, mail order, long term care, home infusion, Indian/Tribal/Urban pharmacies included
For additional information regarding our pharmacy network, quantity limits, and mail order prescription drug service call:
TTY/TDD Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1 representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
You may write us at: Univera Healthcare, PO Box 546, Buffalo, NY 14201
We have a list of covered Part D drugs which is called a formulary. This must always meet Medicare’s requirements. To obtain a copy of our formulary, you can go to our Web site at Or, I would be happy to be sure you receive a copy.
With our plans, you won’t have to worry about where you can fill your prescriptions, since about 60,000 pharmacies participate in our nationwide network. A network pharmacy is a pharmacy that has a contract with us to provide your covered prescription drugs. Generally, you must use network pharmacies to get your prescription drugs covered, except under non-routine circumstances when a network pharmacy cannot reasonably be accessed.
You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances when you cannot reasonably use network pharmacies.

24. Medicare Prescription Drug Plan (Part D)
4 Coverage Phases
Catastrophic Coverage begins when you or others on your behalf have spent $4,5501.
You pay $2.50 for generics and $6.30 for brand name drugs, or 5% of the price (whichever is greater)
Catastrophic Coverage
Univera Healthcare
pays the balance
No coverage when total drug spend exceeds $2,8301 until your true out of pocket spending reaches $4,5501.
Coverage Gap
All costs are out-of-pocket
Initial Coverage starts after you have met your deductible, if applicable, and continues until your total drug costs reach $2,8301.
You Pay
Your copays/coinsurance
Initial Coverage Period
Univera Healthcare pays the balance
Using chart as a visual guide:
Part D plans have different levels of coverage within each plan. With some Part D options, you may have an initial deductible amount that you would be responsible to pay before coverage begins. Some plans have no deductibles, and you receive prescription coverage benefits right away. Whichever Part D plan you choose, you should be aware that the initial coverage limit has increased for 2010.
It will increase to $2,830. What this means is should the total cost of your Part D drugs reach $2,830, you would reach the initial coverage limit and you would enter into the coverage gap. In this event, you would pay 100% of the cost for your prescription drugs, less the discount that you receive by being a Univera Healthcare member.
If your total out-of-pocket costs for Part D prescription drugs should reach $4,550, you would then be in the catastrophic coverage phase of your benefit. At the catastrophic level, you pay $2.50 for generics and $6.30 for brand name drugs, or 5% coinsurance, whichever is greater. This is an annual benefit and starts over each year.
You must pay your deductible, if applicable, before you start getting your prescription drug coverage.
Deductible is out-of-pocket
$0 or $1502
Out Of Pocket
Medicare Drug Benefit
1 Coverage limits for all phases of the Part D benefit change annually.
2 Benefits, formulary, pharmacy network, premium, copayment/coinsurance may change on January 1, Contact Univera Healthcare for details.

25. Medicare Prescription Drug Plan (Part D) Some prescription drugs may have additional requirements or limits.
Prior Authorization
In some cases, we require you to obtain prior approval from us before you fill your prescription.
Step Therapy
In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition.
Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover per prescription.
There are some covered drugs that may have additional requirements or limits on coverage. These requirements and limits may include:
Prior Authorization: We may require you and/or your physician to have approval from us before you fill your prescription. If you don’t get approval, we may not cover the drug.
Step Therapy: In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.
Quantity Limits: For certain drugs, we limit the amount of the drug that is covered. If for medical purposes, you require a higher amount, your physician should provide us with proof of medical necessity stating the medical reasons.

26. Medicare Prescription Drug Plan (Part D)
You may be able to get Extra Help to pay for your prescription drug premiums and costs.
To see if you qualify for getting Extra Help, call:
1-800-MEDICARE ( ), TTY/TDD users should call , 24 hours a day/ 7 days a week
The Social Security Office at between 7:00 a.m. – 7:00 p.m., Monday through Friday, TTY/TDD users should call ; or
Your State Medicaid office
You may be able to receive Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for getting Extra Help, you can call:
1-800-MEDICARE 24 hours a day, 7 days a week. TTY/TDD
The Social Security Administration at between 7:00 a.m. and 7:00 p.m. Monday through Friday. TTY/TDD , or;
Your state Medicaid office. This can be done by contacting your county’s Department of Social Services.

27. Medicare Prescription Drug Plan (Part D)
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for:
seventy-five percent of drug costs including monthly prescription drug premiums,
annual deductibles, and
coinsurance.
Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty.
Many people are eligible for these savings and don’t even know it.
For more information about this Extra Help, contact your local Social Security Office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY users should call
People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for seventy-five percent of drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call MEDICARE ( ), 24 hours per day, 7 days per week. TTY users should call

28. Other Government Insurance
EPIC - Elderly Pharmaceutical Insurance Coverage
New York State residents that are 65 or older, and have an annual income of $35,000 or less if single, or $50,000 or less if married
New York State Department of Health:
Department of Veterans Affairs
Provides coverage to veterans
Call the VA in your area if you believe that you may be eligible
I want to be sure you are aware of two other possible sources of assistance, specifically for prescription drugs.
The Elderly Pharmaceutical Insurance Coverage plan, or EPIC, is a New York State program that helps senior citizens pay for their prescription drugs. It is only for residents who are 65 or older, and have an annual income of $35,000 or less if single, or $50,000 or less if married. EPIC may also require you to join a Part D plan along with EPIC. You should contact EPIC to check into whether or not you would be required to do this. Your Univera Healthcare Medicare Prescription Drug Plan and EPIC can work together. For more information, call
The Department of Veterans Affairs provides medical and prescription coverage to qualified veterans. Most people keep their VA coverage as long as they qualify. You may have VA insurance along with other health insurance. VA insurance generally is quite beneficial in providing prescription drug benefits. Call the VA in your area if you believe that you may be eligible.

29. Coverage While Traveling
SeniorChoice (HMO):
Emergency: Nationwide and Worldwide
Urgent Care: Nationwide
Routine Care: Covered under the Travel Benefit on SeniorChoice® Secure (HMO) and Select (HMO) plans.
Univera Medicare PPO:
Emergency: Nationwide and Worldwide
We know that when you travel, you want your health insurance to travel with you! With both SeniorChoice and Univera Medicare PPO plans, you are covered nationwide and worldwide for emergency care. That means should you experience chest pain, or have a serious injury anywhere in the world, you are covered!
With our plans you are also covered nationwide for urgent care such as an ear infection or an ankle sprain. So, if you are visiting relatives out of state and you need urgent care, no need to worry, because we cover you! You would pay whatever copay was applicable, just like you were back in the Western New York area!
We also provide some coverage for routine care out of area on our SeniorChoice Secure and SeniorChoice Select plans. You would pay 30% of the costs and Univera Healthcare would pay 70% of the costs up to a maximum annual benefit of $1,500.
What all of this means to you is that you will have peace of mind that you are covered even when you travel!

30. Health and Wellness Active Anytime® Flexible Fitness Benefit
Up to $650 per calendar year*
Qualified fitness facility membership fees
Qualified weight management program membership fees
Included in SeniorChoice (HMO) and Univera Medicare PPO plans
* This benefit does not cover any ancillary services or items that are not part of a membership fee.
One of the most exciting features of our Medicare Advantage Plans is our Active Anytime Flexible Fitness Benefit. I say this because Active Anytime gives each member up to $650 per calendar year to use toward qualified fitness facility membership fees and weight management program membership fees!
All this is provided by the Active Anytime benefit at no extra cost! I encourage you to take advantage of this great feature.
It’s been proven that being active helps us all stay more healthy and improve our quality of life!

31. Valuable Extras 24-hour Personal Health Coaching Line
Provides education and programs on nutrition, weight management and much more.
Disease & Case Management
Clinical staff work with you to make informed choices on your health care and prescriptions.
You are only a phone call away from a medical professional 24 hours a day, with our Personal Health Coaching Line. Feel free to call with any medical questions or concerns.
We also provide clinical staff to work with you to make informed choices on your health care and prescriptions. This is all part of our disease and case management program.
All of our teams work together toward helping you obtain your best health!

32. Enhanced Web Tools …and more! www.univerahealthcare.com/medicare
Our Enhanced Web site
Allows members and prospective members to:
Estimate annual costs
Compare our plans
Learn more about cost-cutting options
Enroll online*
*Medicare beneficiaries may enroll in Univera Healthcare Medicare Advantage Plans through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at For more information, contact Univera Healthcare at , TTY/TDD , Monday – Friday, 8:00 a.m. – 8:00 p.m. From November 15 – March 1, 8:00 a.m. – 8:00 p.m., 7 days a week.
…and more!
Our team has devoted a lot of time to developing a new, enhanced version of our Web site. Some of the features include:
Estimate Annual Costs
Compare plans
Learn more about cost cutting options;
Enroll Online through the Centers for Medicare and Medicaid Service’s Online Enrollment Center. Or, through our own online enrollment system.
Our Web Site is easy to remember:
Take some time to go online and see what’s there.

33. How to Enroll Complete application form One application per person
You must continue to pay your Medicare Part B premium
You may need to cancel your other insurance carrier
Effective date of coverage is determined by enrollment period and when application is signed and received
We’d be happy to welcome you into our Univera Healthcare family of members! In order to enroll in either SeniorChoice or Univera Medicare PPO, you will need to complete, sign and date an individual enrollment request form. Husbands and wives each need to complete a separate enrollment request form.
Let’s go over the enrollment request form now. Even if you are not turning in your enrollment request form today, please follow along with me so that you will be ready when you decide to enroll later.
(Go over each line of application, clarify and explain: enrollment date, how to pay premium, when premium bill will arrive, you must continue to pay Part B premium, notify other insurance carrier, how to disenroll, etc.)
Until you receive your Univera Healthcare member ID card, you can receive services on or after your effective date by showing the provider your SeniorChoice or Univera Medicare PPO acceptance letter which shows your effective date and member number.
Remember, when receiving services, always present your Univera Healthcare member ID card, and NOT your red, white and blue Original Medicare plan card.
If you are enrolling in an HMO plan and you are currently seeing specialists, please check with your Primary Care Physician to obtain new referrals under your new Univera Healthcare member ID number.

34. Why Univera Healthcare?
More than 3,000 Participating Providers
In business for over 30 years
Offering plans that fit your needs and budget
Commitment to our local community
If you were going to hire a builder to build your new house, you would be sure they had built houses before and that the houses were still solid and standing, right? Well, when you consider trusting a health insurance company to provide your health insurance, you want to be certain the company has been around awhile, right?
Well, I’m pleased to let you know that Univera Healthcare contracts with the Federal Government to offer our Medicare plans and has a long history of offering our healthcare plans in the Western New York area. We serve the 8 counties of Western New York and have a vast network of doctors. We also participate with nearly all the hospitals in the area. That means you may use the doctors and hospitals of your choice, in the Western New York area.

35. How To Contact Us Call us: Write us:
Medicare Sales Representative:
TTY/TDD
Monday – Friday 8:00 a.m. – 8:00 p.m. From November 15 – March 1, representatives are also available weekends from 8:00 a.m. – 8:00 p.m.
For full information on our Medicare benefits call a Medicare Customer Service Representative:
TTY/TDD
Write us:
Univera Healthcare
P.O. Box 546
Buffalo, NY 14201
Visit us on the web at:
If you need to contact us, we are only a phone call away! Should you have questions prior to becoming a member, please call me at (Rep’s phone #) or our dedicated Medicare Sales line at , TTY/TDD , Monday through Friday, 8:00 a.m. to 8:00 p.m. From November 15 to March 1, representatives are also available 8:00 a.m. to 8:00 p.m.
For full information on Univera Healthcare benefits, call our Customer Service Department at , TTY/TDD , Monday – Friday, 8:00 a.m. – 8:00 p.m. From November 15 to March 1, representatives are also available on weekends from 8:00 a.m. to 8:00 p.m.
And, once you become a member, please call our dedicated Medicare Customer Service Department. They are available to assist you! We frequently receive comments about how helpful our representatives have been!
Don’t forget that our office is local, at 205 Park Club Lane in Williamsville, so feel free to stop in to say hello or receive assistance if you are in the area. We’d be glad to see you!
You can also visit our Web site at

36. Important Numbers Centers for Medicare & Medicaid Services (CMS)
TTY/TDD
24 hours a day, 7 days a week
To apply for Low Income Subsidy
Social Security Administration:
TTY/TDD
Monday – Friday 7:00 am – 7:00 pm
We pride ourselves in not only providing you with information about our health plans, but also in informing you about Medicare resources and general Medicare information which may assist you when working through your Medicare health insurance needs.
Here are the numbers for CMS (Centers for Medicare and Medicaid Services) as well as the Social Security Administration.
(Read telephone numbers off slide)

37. Questions ?
Well, we’ve covered a lot of ground in the last hour, haven’t we? Before I close, I want to be sure you don’t leave with any questions unanswered. So, what questions do you have for me? I’d be happy to spend a few minutes and address those. Don’t be shy because someone else may have the exact same question on their mind!
(Conduct Q & A time)

38. Thank You! H3351, H _0 (10/2009)
On behalf of myself and Univera Healthcare, I would like to thank you for taking the time to come to our workshop today. I trust our time together has been informative and helpful.
If you are joining our Univera Healthcare family of members today, welcome!
If you are not Medicare eligible yet, or if you just need to mull it over a bit, please know that I am here to assist you in whatever way I can.
And, if there is someone you know who has questions about Medicare, or needs health insurance to go along with their Medicare, please send them my way. I would also be glad to assist them.
Thanks again and drive safely! (or have a happy holiday, or be careful in the snow, or whatever applies!)