Important Information for 2024 MedMutual Medicare Advantage Plans
When you enroll in a MedMutual Advantage Plan, you should know about a few policies, procedures and documents. Here you can find important resources with information about prescription drug coverage, the appeals process and much more.
Plan Documents and Provider Directory
Annual Notice of Changes
Evidence of Coverage
Provider Directory
Summary of Benefits
Coverage Decisions
Aggregate Number of Prior Authorizations, Appeals, and Grievances
Prior Authorizations and Appeals
Prescription Drug Coverage Determination and Redetermination Request
Request for an Exception
Grievances
Utilization Management Coverage Guidelines
Medicare Part B Prescription Drugs
Medicare Ombudsman
Out-of-network Coverage
Pharmaceutical Assistance Programs
Prescription Drug Information
Drug Management Program
Medicare Part C Transition Policy
Medicare Part D Drug Transition Policy
Medicare Part D Formulary
Medication Adherence
Medication Therapy Management
Out-of-network Pharmacy Coverage and Prescription Drug Claim Form
Pharmacy Directory and Information
Prescription Refills and Mail-order Services
Quality Assurance
Vaccine Coverage
Medicare Prescription Payment Plan
Other Plan Information
Appointment of Representative
Best Available Evidence
Contact Information
Disenrollment Information
Extra Help from Medicare
Getting Care During a Disaster
Interpreter Services
Medical Claim Form
Plan Documents and Provider Directory
Annual Notice of Changes
The Annual Notice of Changes is a summary of changes to your plan’s costs and benefits. For more detailed benefit information, see your Evidence of Coverage.
Ohio Metro Counties
MedMutual Advantage Signature HMO
Cuyahoga, Lake, Medina, Portage, Stark and Summit counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Signature HMO
Ashland, Carroll, Columbiana, Geauga, Holmes, Lorain, Tuscarawas and Wayne counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Signature HMO
Mahoning and Trumbull counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Signature HMO
Brown, Butler, Clermont, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hocking, Licking, Lucas, Madison, Miami, Montgomery, Morrow, Perry, Pickaway, Union, Warren and Wood counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Signature HMO
Clark, Hancock, Marion, Morgan, Muskingum, Seneca and Wyandot counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Signature HMO
MedMutual Advantage Access PPO
Cuyahoga, Lake, Medina, Portage, Stark and Summit counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Access PPO
Ashland, Carroll, Columbiana, Geauga, Holmes, Lorain, Mahoning, Trumbull, Tuscarawas and Wayne counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Access PPO
Brown, Butler, Clermont, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hocking, Licking, Lucas, Madison, Miami, Montgomery, Morrow, Perry, Pickaway, Union, Warren and Wood counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Access PPO
Clark, Hancock, Marion, Morgan, Muskingum, Seneca and Wyandot counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Access PPO
Northeast Ohio Region
MedMutual Advantage Classic HMO, Secure HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Ashland, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas and Wayne counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Classic (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Secure (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Choice (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Plus (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Select (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Preferred (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Premium (PPO)
Select Ohio Counties Region
MedMutual Advantage Classic HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Adams, Allen, Auglaize, Champaign, Clinton, Coshocton, Crawford, Darke, Defiance, Erie, Fayette, Gallia, Guernsey, Hardin, Harrison, Henry, Highland, Huron, Jackson, Knox, Logan, Mercer, Monroe, Noble, Ottawa, Paulding, Pike, Preble, Putnam, Richland, Ross, Sandusky, Scioto, Shelby, Van Wert, Vinton, Washington and Williams counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Classic (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Choice (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Plus (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Select (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Preferred (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Premium (PPO)
Central Ohio, Cincinnati/Dayton and Toledo Region
MedMutual Advantage Classic HMO, Secure HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Brown, Butler, Clark, Clermont, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hancock, Hocking, Licking, Lucas, Madison, Marion, Miami, Montgomery, Morgan, Morrow, Muskingum, Perry, Pickaway, Seneca, Union, Warren, Wood, and Wyandot counties
2023-2024 Annual Notice of Changes for MedMutual Advantage Classic (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Secure (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Choice (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Plus (HMO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Select (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Preferred (PPO)
2023-2024 Annual Notice of Changes for MedMutual Advantage Premium (PPO)
Evidence of Coverage
The Evidence of Coverage booklet tells you how to get your Medicare medical care and prescription drugs covered through our plan. This booklet explains your rights and responsibilities, what is covered, and what you pay as a member of the plan.
Ohio Metro Counties
MedMutual Advantage Signature HMO
Ashland, Brown, Butler, Carroll, Clermont, Columbiana, Cuyahoga, Delaware, Fairfield, Franklin, Fulton, Geauga, Greene, Hamilton, Hocking, Holmes, Lake, Licking, Lorain, Lucas, Madison, Medina, Miami, Montgomery, Morrow, Perry, Pickaway, Portage, Stark, Summit, Tuscarawas, Union, Warren, Wayne and Wood counties
2024 Evidence of Coverage for MedMutual Advantage Signature HMO
Clark, Hancock, Mahoning, Marion, Morgan, Muskingum, Seneca, Trumbull and Wyandot counties
2024 Evidence of Coverage for MedMutual Advantage Signature HMO
MedMutual Advantage Access PPO
Brown, Butler, Clermont, Cuyahoga, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hocking, Lake, Licking, Lucas, Madison, Medina, Miami, Montgomery, Morrow, Perry, Pickaway, Portage, Stark, Summit, Union, Warren and Wood counties
2024 Evidence of Coverage for MedMutual Advantage Access PPO
Ashland, Carroll, Clark, Columbiana, Geauga, Hancock, Holmes, Lorain, Mahoning, Marion, Morgan, Muskingum, Seneca, Trumbull, Tuscarawas, Wayne and Wyandot counties
2024 Evidence of Coverage for MedMutual Advantage Access PPO
Northeast Ohio Region
MedMutual Advantage Classic HMO, Secure HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Ashland, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas and Wayne counties
2024 Evidence of Coverage for MedMutual Advantage Classic (HMO)
2024 Evidence of Coverage for MedMutual Advantage Secure (HMO)
2024 Evidence of Coverage for MedMutual Advantage Choice (HMO)
2024 Evidence of Coverage for MedMutual Advantage Plus (HMO)
2024 Evidence of Coverage for MedMutual Advantage Select (PPO)
2024 Evidence of Coverage for MedMutual Advantage Preferred (PPO)
2024 Evidence of Coverage for MedMutual Advantage Premium (PPO)
Select Ohio Counties Region
MedMutual Advantage Classic HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Adams, Allen, Auglaize, Champaign, Clinton, Coshocton, Crawford, Darke, Defiance, Erie, Fayette, Gallia, Guernsey, Hardin, Harrison, Henry, Highland, Huron, Jackson, Knox, Logan, Mercer, Monroe, Noble, Ottawa, Paulding, Pike, Preble, Putnam, Richland, Ross, Sandusky, Scioto, Shelby, Van Wert, Vinton, Washington and Williams counties
2024 Evidence of Coverage for MedMutual Advantage Classic (HMO)
2024 Evidence of Coverage for MedMutual Advantage Choice (HMO)
2024 Evidence of Coverage for MedMutual Advantage Plus (HMO)
2024 Evidence of Coverage for MedMutual Advantage Select (PPO)
2024 Evidence of Coverage for MedMutual Advantage Preferred (PPO)
2024 Evidence of Coverage for MedMutual Advantage Premium (PPO)
Central Ohio, Cincinnati/Dayton and Toledo Region
MedMutual Advantage Classic HMO, Secure HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Brown, Butler, Clark, Clermont, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hancock, Hocking, Licking, Lucas, Madison, Marion, Miami, Montgomery, Morgan, Morrow, Muskingum, Perry, Pickaway, Seneca, Union, Warren, Wood and Wyandot counties
2024 Evidence of Coverage for MedMutual Advantage Classic (HMO)
2024 Evidence of Coverage for MedMutual Advantage Secure (HMO)
2024 Evidence of Coverage for MedMutual Advantage Choice (HMO)
2024 Evidence of Coverage for MedMutual Advantage Plus (HMO)
2024 Evidence of Coverage for MedMutual Advantage Select (PPO)
2024 Evidence of Coverage for MedMutual Advantage Preferred (PPO)
2024 Evidence of Coverage for MedMutual Advantage Premium (PPO)
Provider Directory
For the most up-to-date provider information, use our online Provider Search Tool. Here you can search by provider or facility name, type and location. You can also print a custom PDF based on your search criteria. Use the Provider Search Tool to find Medicare Advantage medical providers and facilities, dental and vision providers, and pharmacies in your network. If you would like to request a hard copy directory, please call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired).
Summary of Benefits
The Summary of Benefits gives you an overview of what each Medicare Advantage plan covers and what you can expect to pay. It doesn't list every service we cover or every limitation or exclusion. To get a complete list of services we cover, please review your plan's Evidence of Coverage.
Ohio Metro Counties
MedMutual Advantage Signature HMO
Ashland, Brown, Butler, Carroll, Clermont, Columbiana, Cuyahoga, Delaware, Fairfield, Franklin, Fulton, Geauga, Greene, Hamilton, Hocking, Holmes, Lake, Licking, Lorain, Lucas, Madison, Medina, Miami, Montgomery, Morrow, Perry, Pickaway, Portage, Stark, Summit, Tuscarawas, Union, Warren, Wayne and Wood Counties
2024 Summary of Benefits for MedMutual Advantage Signature HMO
MedMutual Advantage Access PPO
Brown, Butler, Clermont, Cuyahoga, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hocking, Lake, Licking, Lucas, Madison, Medina, Miami, Montgomery, Morrow, Perry, Pickaway, Portage, Stark, Summit, Union, Warren and Wood Counties
2024 Summary of Benefits for MedMutual Advantage Access PPO
Northeast Ohio Region
MedMutual Advantage Classic HMO, Secure HMO, Choice HMO, Plus HMO, Access PPO, Select PPO, Preferred PPO and Premium PPO
Ashland, Carroll, Columbiana, Cuyahoga, Geauga, Holmes, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas and Wayne counties
2024 Summary of Benefits for MedMutual Advantage Classic HMO
2024 Summary of Benefits for MedMutual Advantage Secure HMO
2024 Summary of Benefits for MedMutual Advantage Choice HMO
2024 Summary of Benefits for MedMutual Advantage Plus HMO
2024 Summary of Benefits for MedMutual Advantage Select PPO
2024 Summary of Benefits for MedMutual Advantage Preferred PPO
2024 Summary of Benefits for MedMutual Advantage Premium PPO
Select Ohio Counties Region
MedMutual Advantage Signature HMO
Clark, Hancock, Mahoning, Marion, Morgan, Muskingum, Seneca, Trumbull and Wyandot Counties
2024 Summary of Benefits for MedMutual Advantage Signature HMO
MedMutual Advantage Access PPO
Ashland, Carroll, Clark, Columbiana, Geauga, Hancock, Holmes, Lorain, Mahoning, Marion, Morgan, Muskingum, Seneca, Trumbull, Tuscarawas, Wayne and Wyandot Counties
2024 Summary of Benefits for MedMutual Advantage Access PPO
MedMutual Advantage Classic HMO, Choice HMO, Plus HMO, Select PPO, Preferred PPO and Premium PPO
Adams, Allen, Auglaize, Champaign, Clinton, Coshocton, Crawford, Darke, Defiance, Erie, Fayette, Gallia, Guernsey, Hardin, Harrison, Henry, Highland, Huron, Jackson, Knox, Logan, Mercer, Monroe, Noble, Ottawa, Paulding, Pike, Preble, Putnam, Richland, Ross, Sandusky, Scioto, Shelby, Van Wert, Vinton, Washington and Williams counties
2024 Summary of Benefits for MedMutual Advantage Classic HMO
2024 Summary of Benefits for MedMutual Advantage Choice HMO
2024 Summary of Benefits for MedMutual Advantage Plus HMO
2024 Summary of Benefits for MedMutual Advantage Select PPO
2024 Summary of Benefits for MedMutual Advantage Preferred PPO
2024 Summary of Benefits for MedMutual Advantage Premium PPO
Central Ohio, Cincinnati/Dayton and Toledo Region
MedMutual Advantage Signature HMO, Classic HMO, Secure HMO, Choice HMO, Plus HMO, Access PPO, Select PPO, Preferred PPO and Premium PPO
Brown, Butler, Clark, Clermont, Delaware, Fairfield, Franklin, Fulton, Greene, Hamilton, Hancock, Hocking, Licking, Lucas, Madison, Marion, Miami, Montgomery, Morgan, Morrow, Muskingum, Perry, Pickaway, Seneca, Union, Warren, Wood and Wyandot counties
2024 Summary of Benefits for MedMutual Advantage Classic HMO
2024 Summary of Benefits for MedMutual Advantage Secure HMO
2024 Summary of Benefits for MedMutual Advantage Choice HMO
2024 Summary of Benefits for MedMutual Advantage Plus HMO
2024 Summary of Benefits for MedMutual Advantage Select PPO
2024 Summary of Benefits for MedMutual Advantage Preferred PPO
2024 Summary of Benefits for MedMutual Advantage Premium PPO
Coverage Decisions
Aggregate Number of Prior Authorizations, Appeals, and Grievances
You can request the aggregate number of grievances, appeals and exceptions by calling 1-800-982-3117 (TTY: 711 for hearing impaired).
Prior Authorizations and Appeals
Medical Mutual requires you or your physician to get prior authorization for certain services and drugs. This means you will need to get approval from MedMutual Advantage in some cases before you receive care or fill prescriptions. If you don’t get approval, MedMutual Advantage may not provide coverage. You should discuss whether your medical service or prescription drug requires prior authorization. If prior authorization is required, your physician may complete our prior authorization form.
If you have a concern about whether particular medical service or prescription drugs are covered or the way in which they are covered, or related to payment for medical care or prescription drugs, this section describes how you should approach those situations:
If Medical Mutual requires a Prior Authorization on a medical service or drug, review must be completed to determine if Medical Mutual will pay for it. For example, your plan network doctor makes a request for a coverage decision for certain medical care he/she may provide, or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might determine that a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Utilization Management Coverage Guidelines
When making coverage decisions, Medical Mutual follows applicable Medicare guidelines including statutes, regulations, National Coverage Determinations and Local Coverage Determinations.
In the absence of Medicare Guidelines, Medical Mutual may apply internal coverage criteria approved by our Utilization Management Committee. For more information, please review the policies and guidelines below:
- Medical Policies – Medical Policies provide guidance for determining coverage for specific procedures, therapies, devices, equipment, Part B drugs and services.
- EviCore Guidelines – EviCore provides guidelines for determining coverage for radiology and radiation oncology services.
- MCG Guidelines – MCG provides guidelines for determining coverage for inpatient care as well as specific procedures, devices, equipment and services.
Medicare Part B Prescription Drugs
Medicare Part B prescription drugs may be subject to step therapy requirements, meaning that you may be asked to try a different drug first before we will agree to cover the drug you are asking for. Use the link below to view a list of these drugs.
Making an Appeal
If we deny your prior authorization request for a medical service/item or Part B drug, you, your appointed representative, or your provider can appeal the decision. An appeal is a formal way of asking us to review and change the initial decision we made. You can file an appeal within 60 calendar days of the date you get the original denial letter from us. This is considered a Level 1 appeal. You may be able to get more time to appeal if you can show a good reason for missing the deadline. You or you doctor may also ask for an expedited, or fast, appeal. Your appeal will be reviewed by someone who did not make the prior decision about your case. You may ask for copies of documents, records, clinical guidelines and other information we used to make a decision on your appeal. There is no charge to appeal.
If we say no to all or part of your Level 1 Appeal for medical services/items or Part B drugs your Level 2 Appeal will be automatically forwarded to an independent organization that is not connected to us to review. Either Medical Mutual or the independent organization will notify you about the Level 2 Appeal. In the case of termination of inpatient hospital services, skilled nursing facility, or home health care services you submit your Level 1and Level 2 Appeal requests directly to the independent organization (see information below). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
Types of Appeals
We review two types of appeals: standard appeals and expedited appeals. There is also a special fast-track appeal for discharge from a skilled nursing facility or home health agency or comprehensive outpatient rehabilitation facility services or inpatient hospital services. These types of special appeals are reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contracted by the federal government. You will get information about your rights for fast-track appeals when you get the advance notice of discharge from the facility.
Standard Appeals – Medical Services/Items and Medical Drug
To file a standard appeal of an organizational determination for medical care, send your request in writing.
You may use our appeal form by logging in to My Health Plan. The member appeal form is found under the Resources and Tools/ Member Forms tab. Your request should include:
- Your name and the patient’s name (if different)
- Address
- Member identification number (on your health ID card)
- Claim number
- Date of service
- Reason for appeal
You may also include medical records, doctor’s letters and other documents to support your appeal. You can upload supporting information if you are using our website. The use of our appeal form is not required. You may fax your request in any format and any documentation you would like us to consider toll free to 1-844-606-5394 (TTY: 711 for hearing impaired). You can also mail your request to:
Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, OH 44101-4563
We will notify you of our decision within 30 calendar days for service/item denials and within 60 calendar days for payment denials from the date we receive your request.
For service/item denials, our decision might take longer if you ask for an extension or if we need more information about your case. If we need more time, we will tell you and explain why more time is needed.
Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will notify you of our decision within 72 hours. For a more detailed explanation of service and payment denials, please see the Evidence of Coverage (EOC).
Expedited Appeals – Medical Services/Items and Medical Drugs (Part B)
If you or your doctor believes using the standard appeal timeframe could seriously jeopardize your life, health or ability to regain the ability to do normal everyday tasks, you may be able to request an expedited appeal. Expedited appeals are only available before you get a service/item. We will automatically give you an expedited appeal if a doctor requests one for you.
If you ask for an expedited appeal without support from a doctor, we will decide if your request requires an expedited appeal. To request an expedited appeal, please call us at 1-855-887-2273 (TTY: 711 for hearing impaired) or fax your information to 1-800-221-2640. If your request qualifies for an expedited appeal, we will give you a decision as soon as your health condition requires, but within 72 hours after we receive your appeal request. If your request doesn’t qualify for an expedited appeal, we will give you a decision within 30 calendar days.
Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will give you a decision within 24 hours. If we determine that your request does not need to be expedited, we will give you a decision within 72 hours.
If Your Appeal Is Denied
If Medical Mutual denies any part of your Part C appeal for items or services or Part B drugs you think should be covered, provided, or continued by your health plan, known as an organizational determination, we may inform you of our decision and automatically send your case to MAXIMUS Federal Services to make sure we made the right decision. MAXIMUS is an independent reviewer. MAXIMUS will contact you to let you know how to reach them and to give you information about other rights you may have. You may send MAXIMUS additional information to support your appeal.
MAXIMUS will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.
Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.
You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).
Prescription Drug Coverage Determination and Redetermination Request
Coverage Determination
A coverage determination is a decision we make about your benefits and coverage, or about the amount we will pay for your Part D prescription drugs.
You, your appointed representative or your prescriber have the right to request a coverage determination in the following ways:
- Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
- Complete the Medicare Coverage Determination Request Form and either:
- Fax the form to 1-877-251-5896
- Mail the form to Express Scripts:
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Expedited Coverage Determination
If you or your prescriber believes that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
For more information on asking for coverage decisions about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.
Coverage Redetermination or Appeal
If your coverage determination for a prescription drug was denied, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
A redetermination or appeal is a formal way of asking us to review and change a coverage decision we have made.
You, your appointed representative or your prescriber have the right to request a coverage redetermination in the following ways:
- Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
- Complete the Medicare Redetermination Request Form and either:
- Fax the form to 1-877-852-4070
- Mail the form to Express Scripts:
Attn: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Expedited Redetermination
If you or your prescriber believes that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.
For more information on asking for a coverage redetermination or appeal a decision about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.
If Your Appeal Is Denied
If Medical Mutual denies any part of your appeal request for a coverage or payment review of a Part D prescription drug, we will inform you of our decision, and explain your further appeal rights, which will instruct you how to exercise those rights. Part D prescription drug appeals must be requested by you for review at C2C Innovative Solutions, Inc. Requests for an independent review of Part D prescription drug appeals must come from you.
C2C will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.
Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.
You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).
Request for an Exception
You can ask Medical Mutual to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to cover a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
Generally, the plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Grievances
Filing a Complaint or Grievance
Generally, the first step in resolving your concern starts with you contacting us. Medical Mutual administers medical benefits for your plan and contracts with Express Scripts to administer the prescription drug benefits for your plan. If your concern is related to your medical benefits, call the Customer Care phone number on your member identification card or email us by logging into My Health Plan at MedMutual.com/Member.
If your concern is related to your prescription drug benefits, call the Rx Member Services phone number on your identification card. We will review your concern and attempt to resolve it appropriately.
When you file a grievance, you are asking us to investigate a complaint which includes but is not limited to issues related to timeliness, appropriateness, access to and/or the setting in which you received or tried to receive a healthcare service.
A complaint about the quality of care you received from a hospital, doctor or other healthcare provider may also be forwarded to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for review.
You can file a grievance either by voice or in writing within 60 days of the event. Please call us at the Customer Care phone at 1-800-982-3117 (TTY: 711 for hearing impaired). You may also fax your grievance to 1-844-606-5394 or put it in writing and mail it to:
Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, Ohio 44101-4563
You also have the option to submit a complaint directly to Medicare with their online Medicare Complaint Form.
Standard Grievance
We will review your complaint and do a full investigation of the grievance as quickly as your case requires. We will notify you of our decision within 30 calendar days after we get your request, unless federal regulations allow for an extended timeframe. If, as permitted under the regulations, we decide it is in your best interest to take an extension, we will notify you promptly and let you know the reason for the extension. This extension will not be more than 14 calendar days.
Expedited Grievance
Under certain circumstances that require a faster response, we will respond to your grievance within 24 hours. See your Evidence of Coverage for more information about the conditions for a faster response to a grievance.
Please see your Evidence of Coverage (EOC) for more information about coverage determinations and appeals.
Medicare Ombudsman
The Medicare Ombudsman helps you with Medicare-related complaints, grievances and other information. Learn more by visiting the Medicare website.
Out-of-network Coverage
Out-of-network Providers - PPO Plans
As a member of a PPO plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.
Other important things to know about using out-of-network providers:
- If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive, except for emergency care.
- You don't need to get a referral or prior authorization when you get care from out-of-network providers, however, you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. It is important to ask for a pre-visit coverage decision.
- If it is later determined that the out-of-network services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care.
- It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment.
- If you are using an out-of-network provider for emergency care, urgently needed services, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.
Please review your Evidence of Coverage for complete information about out-of-network provider coverage.
Out-of-network Providers - HMO Plans
It is important to know which providers are part of our network. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Medical Mutual authorizes use of out-of-network providers.
If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. For this medical care, your provider must obtain approval from the plan before you seek care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider.
Please review your plans Evidence of Coverage for complete information about out-of-network provider coverage.
Out-of-network Pharmacy Coverage and Prescription Drug Claim Form
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.
If you cannot use a network pharmacy, these are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- If the prescriptions are related to the care of a medical emergency or urgently needed care, they will be covered. In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP (True Out-Of-Pocket cost).
- If you are traveling within the United States, but outside the plan's service area, and you become ill or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy (if you follow all other coverage rules identified within your Evidence of Coverage and a network pharmacy is unavailable). In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP.
- If you are unable to get a covered drug in a timely manner within our service area, because there is not a network pharmacy within a reasonable driving distance which provides 24-hour service.
- If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (the drugs include orphan drugs or specialty pharmaceuticals).
- Self-administered medications that you receive in an outpatient setting may be covered under Part D. For consideration, please submit a paper claim.
In these situations, please check first with Customer Care to see if there is a network pharmacy nearby. You can contact Customer Care by calling 1-800-982-3117 (TTY: 711 for hearing impaired). You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
How do you ask for reimbursement from the plan?
If you must use 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. You may request reimbursement for your share of the cost by submitting a paper claim to Medical Mutual. You may, however, be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
This Prescription Drug Claim Form is offered as a tool to assist in getting your claim paid as soon as possible. Please print clearly. Use of this particular form is not required and you may submit equivalent written documentation, but it must provide all of the requested information on this form.
Please review your Evidence of Coverage for complete information about out-of-network pharmacy coverage and how to submit a paper claim for reimbursement, or call Member Services at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).
Pharmaceutical Assistance Programs
Pharmaceutical Assistance Programs (PAPs) are sometimes available to help relieve financial burden by providing free or discounted medications to qualifying patients. These programs are medication specific and may be available to you through various organizations. See if a program is available for your medication.
Prescription Drug Information
Drug Management Program
Medical Mutual is committed to ensuring the safe use of all prescription medications. The Medical Mutual Drug Management Program (DMP) focuses on the safe use of opioids, benzodiazepines and other frequently abused drugs. This program helps coordinate care for Medicare members who get opioid prescriptions from multiple doctors or pharmacies.
Throughout the year, Medical Mutual will review opioid medication usage and identify members who would benefit from our DMP. If we find possible unsafe usage or overuse of prescription opioids, benzodiazepines and other frequently abused drugs we typically contact your prescriber to better coordinate care. Based on these discussions and the outcome of this review, we may add certain limits on your coverage for these types of drugs. For example, members may be required to get these medications from certain doctors or pharmacies. You will be notified in writing if this occurs.
If you think that we’ve made a mistake or would like to appeal this determination, you, your doctor or authorized representative can file an appeal. You should review the information contained in your notification letter for more information about how to request an appeal or click here.
For more information about the DMP or how to submit an appeal, call Customer Care at 1-800-982-3117 (TTY: 711 for hearing impaired).
Medicare Part C Transition Policy
Beginning Jan. 1, 2024, if you are a new member of your MedMutual Advantage Plan and/or to Medicare and are currently undergoing an active course of treatment, you may qualify for a transition period for Medicare Part C covered drugs and services. For some drugs and services, we require additional information from your provider to determine if the drug or service is medically necessary.
We will cover restricted Medicare Part C drugs or services for the first 90 days of your MedMutual Advantage plan to ensure you do not experience any disruptions. We will work with your provider to get all the information needed to determine if we will continue coverage.
For more information regarding our Medicare Part C Transition Process, please call our Customer Care team toll free at 1-800-982-3117 (TTY: 711 for hearing impaired).
Your provider can start a determination (also known as an organization determination) by contacting the following organizations:
- For Part B drugs, have your provider submit a request to MagellanRx.
- For Part C outpatient medical services or items, your provider should submit the request via NaviNet. If your provider does not have access to NaviNet, they should fax in your request.
For Medicare Part D Transition policy, call our Pharmacy Customer Service team at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
Medicare Part D Drug Transition Policy
New members in our health plan may be taking drugs that are not on our formulary (list of drugs) or that are subject to certain restrictions, such as prior authorization, quantity limits or step therapy. Current members may also be affected by changes in our formulary from one year to the next. If your drug is not on the Drug List or is restricted, here are things you can do:
- You may be able to get a temporary supply of the drug (only members in certain situations can get a temporary supply). This will give you and your provider time to change to another drug or to file a request to have the drug covered.
- You can change to another drug.
- You can request an exception and ask the plan to cover the drug or remove restrictions from the drug.
You may be able to get a temporary supply.
Under certain circumstances, the plan can offer a temporary supply of a drug to you when your drug is not on the Drug List or when it is restricted in some way. Doing this gives you time to talk with your provider about the change in coverage and figure out what to do.
To be eligible for a temporary supply, you must meet the two requirements below:
- The change to your drug coverage must be one of the following types of changes:
- The drug you have been taking is no longer on the plan's Drug List.
- or -- the drug you have been taking is now restricted in some way.
- You must be in one of the situations described below:
- For those members who are new or who were in the plan last year:
- We will cover a temporary supply of your drug during the first 90 days of your membership in the plan if you were new and during the first 90 days of the calendar year if you were in the plan last year. This temporary supply will be for a maximum of a 30-day supply. If your prescription is written for fewer days, we will allow multiple fills to provide up to a maximum of a 30-day supply of medication. The prescription must be filled at a network pharmacy. (Please note that the long-term care pharmacy may provide the drug in smaller amounts at a time to prevent waste.)
- For those members who have been in the plan for more than 90 days and reside in a long-term care (LTC) facility and need a supply right away:
- We will cover one 31-day supply of a particular drug, or less if your prescription is written for fewer days. This is in addition to the above temporary supply situation.
- For those members who have been in the plan for more than 90 days and experience a level of care change (from one treatment setting to another):
- We will provide up to a one-month supply of a Non-Formulary Drug and/or a drug that may be restricted in some way, or less if your prescription is written for fewer days.
- Other times when we will cover a temporary 31-day transition supply (or less, if you have a prescription written for fewer days) include:
- When you enter a long-term care facility
- When you leave a long-term care facility
- When you are discharged from a hospital
- When you leave a skilled nursing facility
- When you cancel hospice care
- For those members who are new or who were in the plan last year:
The plan will send you a letter within three business days of your filling a temporary transition supply, notifying you that this was a temporary supply and explaining your options.
Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs used for erectile dysfunction or drugs for weight loss.
For more information regarding our Medicare Part D Transition Process please call our Pharmacy Customer Service team at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
You and/or your provider can ask the plan to make an exception for you and cover the drug in the way you would like it to be covered. If your provider says that you have medical reasons that justify asking us for an exception, your provider can help you request an exception to the rule. For example, you can ask the plan to cover a drug even though it is not on the plan's Drug List. Or you can ask the plan to make an exception and cover the drug without restrictions. If you and your provider want to ask for an exception, Chapter 9, Section 6.4 of the Evidence of Coverage tells what to do. It explains the procedures and deadlines that have been set by Medicare to make sure your request is handled promptly and fairly.
Medicare Part D Formulary
The comprehensive prescription drug formulary is a list of covered drugs selected by MedMutual Advantage in consultation with a team of healthcare providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. MedMutual Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a MedMutual Advantage network pharmacy and other plan rules are followed.
Formulary Documents and Online Pricing Tools
View the Premier Performance formulary PDF that applies to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
You can also use a prescription drug pricing tool for HMO plans and for PPO plans.
Formulary Document and Online Pricing Tool for MedMutual Advantage Signature (HMO) and Access (PPO)
View the High Performance formulary PDF and prescription drug pricing tool that applies to the MedMutual Advantage Signature (HMO) and Access (PPO) plans.
Request a Printed Copy
To request a printed copy of our formulary, fill out our online form. To better understand your formulary, review the Understanding Your Formulary flier.
How to Use the Formulary
There are two ways to find your drug within the downloadable PDF formulary:
- Medical Condition - The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular, Hypertension/Lipids. If you know what your drug is used for, look for the category name in the list that begins on page 1. Then look under the category name for your drug.
- Alphabetical Listing - If you are not sure what category to look under, you should look for your drug in the alphabetical index of all of the drugs included in the link above. Both brand name drugs and generic drugs are listed in the index. Look in the index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list.
MedMutual Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.
Drug Tiers for MedMutual Advantage Classic (HMO), MedMutual Advantage Choice (HMO), MedMutual Advantage Plus (HMO), MedMutual Advantage Secure (HMO), MedMutual Advantage Select (PPO), MedMutual Advantage Preferred (PPO) and MedMutual Advantage Premium (PPO)
| Tier | Includes | Helpful Tips |
|---|---|---|
| Tier 1: Preferred Generic Drugs | This tier includes many commonly prescribed low-cost drugs. | This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the lowest copayments. |
| Tier 2: Generic Drugs | This tier includes additional low-cost drugs. | This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low. |
| Tier 3: Preferred Brand and Generic Drugs | This tier includes preferred brand-name drugs and generic drugs. | Drugs in this tier will generally have lower copayments than non-preferred brand drugs. |
| Tier 4: Non-preferred Drugs | This tier includes non-preferred brand-name and generic drugs. | Many non-preferred drugs have lower cost alternatives in Tiers 1, 2 and 3. Ask your doctor if switching to a lower cost generic or preferred brand may be right for you. |
| Tier 5: Specialty Tier Drugs | This tier includes very high-cost brand-name and generic drugs. Drugs on this tier are limited to a 30-day supply. | To learn more about medications in this tier, you may contact a pharmacist at the numbers listed in your Evidence of Coverage. |
Drug Tiers for MedMutual Advantage Signature (HMO) and Access (PPO)
| Tier | Includes | Helpful Tips |
|---|---|---|
| Tier 1: Preferred Generic Drugs | This tier includes many commonly prescribed low-cost drugs. | This tier includes commonly prescribed generic drugs. Use Tier 1 drugs for the lowest copayments. |
| Tier 2: Generic Drugs | This tier includes additional low-cost drugs. | This tier includes generic drugs. Use Tier 2 drugs to keep your copayments low. |
| Tier 3: Preferred Brand and Generic Drugs | This tier includes preferred brand-name drugs and generic drugs. | Drugs in this tier will generally have lower copayments than non-preferred brand drugs. |
| Tier 4: Non-preferred Drugs | This tier includes non-preferred brand-name and generic drugs. | Many non-preferred drugs have lower cost alternatives in Tiers 1, 2 and 3. Ask your doctor if switching to a lower cost generic or preferred brand may be right for you. |
| Tier 5: Specialty Tier Drugs | This tier includes very high-cost brand-name and generic drugs.Drugs on this tier are limited to a 30-day supply. | To learn more about medications in this tier, you may contact a pharmacist at the numbers listed in your Evidence of Coverage. |
| Tier 6: Select Care Drugs | This tier includes low-cost generic maintenance drugs. | This tier includes certain generic low-cost maintenance drugs, Use Tier 6 drugs for the lowest copayments. It is important to take these medications as your doctor prescribed. |
The amount you pay for a covered drug will depend on:
- Your coverage stage. MedMutual Advantage has different stages of coverage. In each stage the amount you pay for a drug may change.
- The drug tier for your drug. Each covered drug is in one of five drug tiers. Each tier may have a different copayment or coinsurance amount. The Drug Tiers chart above explains what types of drugs are included in each tier and shows how costs may change with each tier.
Your Evidence of Coverage (EOC) has more information about the plan’s coverage stages and lists the copayment and coinsurance amounts for each tier.
For information on how to fill your prescriptions, please review your Evidence of Coverage or the Prescription Refills and Mail-order Services section below.
Changes to the Formulary
Generally, if you are taking a drug that was covered on our formulary at the beginning of the year, we will not discontinue or reduce coverage of the drug during the coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released. Other types of formulary changes, such as removing a drug from our formulary, will not affect members who are currently taking the drug. Those drugs will remain available at the same cost-share for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety.
Members will be notified at least 30 days in advance if we remove drugs from our formulary, add prior authorization, quantity limits or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier. All affected members will be notified of these changes at least 30 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a month supply of the drug. If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug’s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.
Drug Utilization Management
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These utilization management requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of physicians and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members.
Examples of these utilization tools are listed below.
Prior Authorization
We require you to get prior authorization for certain drugs. You will have to meet specific clinical criteria for use of these drugs. Learn more about prior authorization guidelines for different prescription drugs using the resources below.
View the prior authorization guidelines that apply to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the prior authorization guidelinesthat apply to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)
Quantity Limits
For certain drugs, we limit the amount of the drug that we will cover per prescription or for a defined period of time. For a list of quantity limits, please refer to our complete listings.
View the quantity limits list that applies to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the quantity limits list that applies to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)
Step Therapy
In some cases, we require you to first try one drug to treat your medical condition before we will cover another drug for that condition. Learn more about the criteria for step therapy.
View the step therapy criteria guidelines that apply to:
- MedMutual Advantage Classic (HMO)
- MedMutual Advantage Choice (HMO)
- MedMutual Advantage Plus (HMO)
- MedMutual Advantage Secure (HMO)
- MedMutual Select (PPO)
- MedMutual Preferred (PPO)
- MedMutual Premium (PPO)
View the step therapy criteria guidelines that apply to:
- MedMutual Advantage Signature (HMO)
- MedMutual Advantage Access (PPO)
Generic Substitution
When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.
Notification of Additional Changes
If there are additional changes made to the formulary that affect you and are not mentioned above, you will be notified in writing of these changes within a reasonable period of time from when the changes are made.
To get updated information about the drugs covered by MedMutual Advantage, please contact Medical Mutual Member Services at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, seven days a week.
Pharmacy Directory and Information
The pharmacy network may change at any time. You will receive notice when necessary. You can review our current Pharmacy Directory to see if your pharmacy is in our network.
In most cases, your prescriptions are covered under MedMutual Advantage only if they are filled at a network pharmacy or through our mail order pharmacy service. Once you go to one pharmacy, you are not required to continue going to the same pharmacy to fill your prescription but can switch to any other of our network pharmacies. We will fill prescriptions at non-network pharmacies under certain circumstances as described in your Evidence of Coverage.
Pharmacies may be added or removed from the list. For the most current list, please review our online Pharmacy locator or contact Member Services at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, seven days a week.
You can go to all of the pharmacies listed in our Pharmacy Directory, but your costs for some drugs may be less at pharmacies in this list that offer preferred cost-sharing. We have marked these pharmacies with “P” in the Pharmacy Directory to distinguish them from other pharmacies in our network that offer standard cost-sharing.
You can get prescription drugs shipped to your home through our network mail order delivery service. For more information, please contact us or see the Prescription Refills and Mail-order Services section below.
We also list pharmacies that are in our network but are outside Ohio, the area in which you live. You may also fill your prescriptions at these pharmacies. For more information, please see the Network Pharmacies Outside Ohio section in our Pharmacy Directory or call us at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).
To view your pharmacy out-of-pocket spending including Part D and the other drugs covered by your plan, log in to your account. You can view this information beginning January 1 of each plan year.
If you have questions about any of the above, including instructions on how to submit claims for prescriptions that you had to fill at a non-network pharmacy, please see your Evidence of Coverage or contact us.
Prescription Refills and Mail-order Services
For certain kinds of drugs, you can use the plan's preferred mail-order pharmacy, Express Scripts. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan's mail-order service are marked as "mail-order" drugs in our Drug List.
Your plan's mail-order benefit allows you to order up to a 90-day supply.
To get order forms and information about filling your prescriptions by mail, please call Customer Service (phone numbers are on the front of your card).
Usually, a mail-order pharmacy order will get to you in no more than 14 days. Delays can occur for various reasons such as weather conditions, mail carrier issues, or action is required by you or your prescriber. If you have not received your order within 14 days, it's best to contact your Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired) to determine the reason for the delay. Additionally, we do not want you to have an interruption in therapy, so be sure to also discuss any options you have in obtaining a short-term supply at your local pharmacy while you wait for your mail order supply.
New Prescriptions the Pharmacy Receives Directly from Your Doctor's Office
The pharmacy will automatically fill and deliver new prescriptions it receives from health care providers, without checking with you first, if either:
- You used mail order services with this plan in the past, or
- You sign up for automatic delivery of all new prescriptions received directly from health care providers. You may request automatic delivery of all new prescriptions now or at any time by providing consent on your first new home delivery prescription sent in by your doctor or health provider.
If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.
If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact us by calling Part D Customer Service 1-844-404-7947.
If you have never used our mail order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.
To opt out of automatic deliveries of new prescriptions received directly from your health care provider's office, please contact us by calling Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).
Refills on Mail-order Prescriptions
For refills of your drugs, you have the option to sign up for an automatic refill program. Under this program we will start to process your next refill automatically when our records show you should be close to running out of your drug. The pharmacy will contact you prior to shipping each refill to make sure you are in need of more medication, and you can cancel scheduled refills if you have enough of your medication or if your medication has changed. If you choose not to use our auto refill program, please contact your pharmacy 14 days before you think the drugs you have on hand will run out to make sure your next order is shipped to you in time.
To opt out of our program that automatically prepares mail order refills, please contact us by calling the number on the back of your member ID card so the pharmacy can reach you to confirm your order before shipping, please make sure to let the pharmacy know the best ways to contact you. You may provide our mail-order vendor with your preferred contact information by calling Part D Customer Service toll free at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).
Quality Assurance
MedMutual Advantage's Quality Assurance and Utilization Management Program was created to help ensure appropriate use of prescription drugs covered under Medicare Part D, and most importantly, keep our members safe. The program is designed to reduce drug interactions and adverse drug events, optimize medication utilization, and provide clinically appropriate incentives to help keep drug costs down as much as possible to save our members money. This program is offered at no additional cost to members and providers.
Our Quality Assurance Program uses a range of tools to ensure high quality prescription drug coverage for all of our members. These tools include, but are not limited to: prior authorizations, quantity limitations, step therapy requirements, drug utilization reviews and clinical edits.
Drug Utilization Review
We use utilization review (DUR) systems to screen every prescription billed by your pharamcy, both retrospectively and at the point of sale. These edits help your dispensing pharmacist catch any potential drug interactions and address any issues before you receive the medication to keep you safe.
The clinical issues addressed by DUR include, but are not limited to:
- Duplication of therapy
- Misuse
- Abuse
- Overutilization or underutilization
- Drug interactions that are clinically significant
- Incorrect or inappropriate drug therapy
- Contraindications that are patient specific;
Medication Adherence
Taking medications as directed by your doctor or healthcare provider is often referred to as medication adherence. Filling your prescriptions and taking medications as directed by your doctor or healthcare provider are important parts of managing your health. To prevent serious complications, you should take your medications exactly as prescribed — even if you don’t feel any symptoms. Many common generic medications for treating high blood pressure, high cholesterol and diabetes have low or $0 copay for up to a 90-day supply at preferred network pharmacies, including Express Scripts home delivery. Show your MedMutual Advantage card at the pharmacy and ask that they use it for all medications covered by your plan.
Medication Therapy Management
The Medication Therapy Management (MTM) Program is a service for members with multiple health conditions and who take multiple medicines. The MTM program helps you and your doctor make sure that your medicines are working to improve your health.
Eligible members will be automatically enrolled into the program and the service is provided at no additional cost to the member. Please see below for eligibility details. Participation is voluntary, but strongly encouraged. Members may choose not to participate in the program and opt out of the program on a yearly basis.
The MTM program is offered through our partnership with Clarest Health. The MTM program is not considered a part of the plan’s benefit.
Who Is Eligible for the MTM Program
You may qualify for the MTM Program if:
- You have 3 or more chronic health problems. These may include:
- Asthma
- Chronic Heart Failure (CHF)
- Chronic Obstructive Pulmonary Disease (COPD)
- Diabetes
- High blood lipid (fat) levels
- High blood pressure
- Osteoporosis
- You take 7 or more daily medicines covered by Medicare Part D.
- You spend $5,330 or more per year on Part D covered medications
How the MTM Program Helps You
If you qualify for the MTM Program, you will be contacted and have the chance to speak with a highly-trained pharmacist or other qualified clinician. During that call, the pharmacist or other qualified clinician will complete a comprehensive medication review of your medicines and talk with you about:
- Any questions or concerns about your prescription or over-the-counter medicines, such as drug safety and cost
- Better understanding your medicines and how to take them
- How to get the most benefit from your medicines
Preparing for Your Medication Review
To get the most out of your free medication review, we encourage you to gather all your medications, including over the counter drugs, vitamins and supplements and have them handy prior to the review. If needed, have a family member or caregiver on hand to help you ask questions and understand answers about the drugs that you are taking.
What You Will Receive
If you qualify for the MTM Program, you will receive:
- Welcome letter by mail and/ or phone call that tells you know how to get started.
- Full medication review
- You will have the chance to review your medicines and any issues you may have with a highly-trained pharmacist or other qualified clinician.
- This review will take about 20-30 minutes. This call can be scheduled at a convenient time for you.
- Summary letter will be mailed that contains the following:
- A medication action plan which contains a list of actions that can be completed by you to help improve your health. Included in the plan is space for you to take notes or write down any follow-up questions that you can address with your doctor at your next visit.
- A personal medication list is a record of all of the medicines, prescription and non-prescription, that you take and the reasons why you take them.
- Click here to see an example of a full medication review letter which includes the Personal Medication List.
- Ongoing targeted medication reviews
- At least once every 3 months, your medicines will be reviewed, and you or your doctor may receive a letter or a phone call about any identified problems.
How to Learn More about the MTM Program
For information about the MTM Program or to see if you qualify, please contact the Medication Management Center at 1-877-205-8550 (TTY: 711 for hearing impaired).
If you are already enrolled in the MTM Program and you would like to complete your medication review, you can call Clarest Health at 1-877-205-8550 (TTY: 711 for hearing impaired), Monday through Friday, 9 a.m. to 6 p.m. EST.
To view a PDF file, you will need Adobe Acrobat Reader™. If you do not already have this reader on your computer, you can download a free copy from Adobe®.
Vaccine Coverage
Preventive vaccines can be covered under Medicare Part D Prescription Drug Coverage or under the Part B Medical Coverage. It’s important to know what vaccines are covered, your potential out-of-pocket costs, and where to get it.
Part B Covered Vaccines
- Covered Medicare Part B services include the following and are covered (in-network) with no coinsurance, copayment, or deductible:
- Pneumonia vaccine
- Flu shots (once each flu season in the fall and winter, with additional flu shots if medically necessary)
- Hepatitis B vaccine (if you are at high or intermediate risk of getting Hepatitis B)
- COVID-19 vaccine
- Other vaccines if you are at risk and they meet Medicare Part B coverage rules
Where should I get my Part B vaccines?
You can obtain these vaccines through your network physician. You can also get your flu and COVID-19 shots at one of our network pharmacies.
Part D Covered Vaccines
Important Message About What You Pay for Vaccines
Our plan covers most Part D vaccines at no cost to you, even if you haven't paid your deductible. Call Member Services for more information.
Medicare Part D covers vaccines not covered by Part B (medical) as long as the vaccine is reasonable and necessary to prevent illness. A few examples of Part D covered vaccines include Shingrix (Shingles) vaccine, Tetanus vaccine, and MMR (measles, mumps, rubella) vaccine. You can find these vaccines in the plan's List of Covered Drugs (Formulary).
Where should I get my preventive Part D vaccines?
The amount you have to pay for vaccinations covered by Part D will depend on your particular Part D drug plan, where you get the vaccine and who gives you the vaccine.
- Recommended method: Your local pharmacy provides and administers the vaccine. Getting your Part D covered vaccine at participating network retail pharmacies like Discount Drug Mart, Marc’s, Kroger, Walgreens and Walmart may save you the most money. You are responsible for your deductible (if applicable), the copay or coinsurance for the vaccine and administration. Your MedMutual Advantage plan will pay for the remaining costs. Find a pharmacy near you by using our Pharmacy Locator tool.
- Your primary care provider’s (PCP) office has the vaccine and administers it. If you receive your vaccine at your PCP office, you are responsible for the entire upfront cost of the vaccine and administration of the vaccine. Some PCP offices will also charge office visit fees. You may ask Medical Mutual to reimburse you for the vaccine and administration. The amount you will be reimbursed will depend on the benefit stage you are in and the amount your provider billed. You will only be reimbursed up to the allowed amount. Any amount over the allowed amount that does not get reimbursed will apply to your Part D true out-of-pocket costs for the year.
- You buy the vaccine from the pharmacy and take it to your PCP to administer it. If you go this route, you will be responsible for your deductible (if applicable) and the copay or coinsurance for the vaccine at the pharmacy. Additionally, once you take the vaccine to your PCP, you will have to pay the entire cost for the vaccine administration, as well as the office visit. You may ask Medical Mutual to reimburse you for a portion of what you paid. The amount you will be reimbursed for the administration fee will depend on the benefit stage you are in and the amount your provider billed. You will only be reimbursed up to the allowed amount. Any amount over that does not get reimbursed will apply to your Part D true out-of-pocket costs for the year. You will not be reimbursed for any costs associated with the office visit.
How do I ask Medical Mutual to pay me back or to pay a bill I have received?
To ask Medical Mutual to reimburse you for a Part D covered vaccine administered by your PCP, send us a claim form along with your bill and documentation of any payment you have made. For more information about this process, see Chapter 7 of your Evidence of Coverage.
Medicare Prescription Payment Plan
The Medicare Prescription Payment Plan is a new payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket Medicare Part D drug costs by spreading them across the calendar year (January-December). Starting in 2025, anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option and participation is voluntary.
Coverage Decisions
Aggregate Number of Prior Authorizations, Appeals, and Grievances
You can request the aggregate number of grievances, appeals and exceptions by calling 1-800-982-3117 (TTY: 711 for hearing impaired).
Prior Authorizations and Appeals
Medical Mutual requires you or your physician to get prior authorization for certain services and drugs. This means you will need to get approval from MedMutual Advantage in some cases before you receive care or fill prescriptions. If you don’t get approval, MedMutual Advantage may not provide coverage. You should discuss whether your medical service or prescription drug requires prior authorization. If prior authorization is required, your physician may complete our prior authorization form.
If you have a concern about whether particular medical service or prescription drugs are covered or the way in which they are covered, or related to payment for medical care or prescription drugs, this section describes how you should approach those situations:
If Medical Mutual requires a Prior Authorization on a medical service or drug, review must be completed to determine if Medical Mutual will pay for it. For example, your plan network doctor makes a request for a coverage decision for certain medical care he/she may provide, or if your network doctor refers you to a medical specialist. You or your doctor can also contact us and ask for a coverage decision if your doctor is unsure whether we will cover a particular medical service or refuses to provide medical care you think that you need. In other words, if you want to know if we will cover a medical service before you receive it, you can ask us to make a coverage decision for you. We are making a coverage decision for you whenever we decide what is covered for you and how much we pay. In some cases we might determine that a service or drug is not covered or is no longer covered by Medicare for you. If you disagree with this coverage decision, you can make an appeal.
Utilization Management Coverage Guidelines
When making coverage decisions, Medical Mutual follows applicable Medicare guidelines including statutes, regulations, National Coverage Determinations and Local Coverage Determinations.
In the absence of Medicare Guidelines, Medical Mutual may apply internal coverage criteria approved by our Utilization Management Committee. For more information, please review the policies and guidelines below:
- Medical Policies – Medical Policies provide guidance for determining coverage for specific procedures, therapies, devices, equipment, Part B drugs and services.
- EviCore Guidelines – EviCore provides guidelines for determining coverage for radiology and radiation oncology services.
- MCG Guidelines – MCG provides guidelines for determining coverage for inpatient care as well as specific procedures, devices, equipment and services.
Medicare Part B Prescription Drugs
Medicare Part B prescription drugs may be subject to step therapy requirements, meaning that you may be asked to try a different drug first before we will agree to cover the drug you are asking for. Use the link below to view a list of these drugs.
Making an Appeal
If we deny your prior authorization request for a medical service/item or Part B drug, you, your appointed representative, or your provider can appeal the decision. An appeal is a formal way of asking us to review and change the initial decision we made. You can file an appeal within 60 calendar days of the date you get the original denial letter from us. This is considered a Level 1 appeal. You may be able to get more time to appeal if you can show a good reason for missing the deadline. You or you doctor may also ask for an expedited, or fast, appeal. Your appeal will be reviewed by someone who did not make the prior decision about your case. You may ask for copies of documents, records, clinical guidelines and other information we used to make a decision on your appeal. There is no charge to appeal.
If we say no to all or part of your Level 1 Appeal for medical services/items or Part B drugs your Level 2 Appeal will be automatically forwarded to an independent organization that is not connected to us to review. Either Medical Mutual or the independent organization will notify you about the Level 2 Appeal. In the case of termination of inpatient hospital services, skilled nursing facility, or home health care services you submit your Level 1and Level 2 Appeal requests directly to the independent organization (see information below). If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
Types of Appeals
We review two types of appeals: standard appeals and expedited appeals. There is also a special fast-track appeal for discharge from a skilled nursing facility or home health agency or comprehensive outpatient rehabilitation facility services or inpatient hospital services. These types of special appeals are reviewed by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) contracted by the federal government. You will get information about your rights for fast-track appeals when you get the advance notice of discharge from the facility.
Standard Appeals – Medical Services/Items and Medical Drug
To file a standard appeal of an organizational determination for medical care, send your request in writing.
You may use our appeal form by logging in to My Health Plan. The member appeal form is found under the Resources and Tools/ Member Forms tab. Your request should include:
- Your name and the patient’s name (if different)
- Address
- Member identification number (on your health ID card)
- Claim number
- Date of service
- Reason for appeal
You may also include medical records, doctor’s letters and other documents to support your appeal. You can upload supporting information if you are using our website. The use of our appeal form is not required. You may fax your request in any format and any documentation you would like us to consider toll free to 1-844-606-5394 (TTY: 711 for hearing impaired). You can also mail your request to:
Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, OH 44101-4563
We will notify you of our decision within 30 calendar days for service/item denials and within 60 calendar days for payment denials from the date we receive your request.
For service/item denials, our decision might take longer if you ask for an extension or if we need more information about your case. If we need more time, we will tell you and explain why more time is needed.
Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will notify you of our decision within 72 hours. For a more detailed explanation of service and payment denials, please see the Evidence of Coverage (EOC).
Expedited Appeals – Medical Services/Items and Medical Drugs (Part B)
If you or your doctor believes using the standard appeal timeframe could seriously jeopardize your life, health or ability to regain the ability to do normal everyday tasks, you may be able to request an expedited appeal. Expedited appeals are only available before you get a service/item. We will automatically give you an expedited appeal if a doctor requests one for you.
If you ask for an expedited appeal without support from a doctor, we will decide if your request requires an expedited appeal. To request an expedited appeal, please call us at 1-855-887-2273 (TTY: 711 for hearing impaired) or fax your information to 1-800-221-2640. If your request qualifies for an expedited appeal, we will give you a decision as soon as your health condition requires, but within 72 hours after we receive your appeal request. If your request doesn’t qualify for an expedited appeal, we will give you a decision within 30 calendar days.
Please note: For decisions related to Part B medical drugs (drugs you receive while in a hospital outpatient facility or at a doctor's office), we will give you a decision within 24 hours. If we determine that your request does not need to be expedited, we will give you a decision within 72 hours.
If Your Appeal Is Denied
If Medical Mutual denies any part of your Part C appeal for items or services or Part B drugs you think should be covered, provided, or continued by your health plan, known as an organizational determination, we may inform you of our decision and automatically send your case to MAXIMUS Federal Services to make sure we made the right decision. MAXIMUS is an independent reviewer. MAXIMUS will contact you to let you know how to reach them and to give you information about other rights you may have. You may send MAXIMUS additional information to support your appeal.
MAXIMUS will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.
Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.
You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).
Prescription Drug Coverage Determination and Redetermination Request
Coverage Determination
A coverage determination is a decision we make about your benefits and coverage, or about the amount we will pay for your Part D prescription drugs.
You, your appointed representative or your prescriber have the right to request a coverage determination in the following ways:
- Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
- Complete the Medicare Coverage Determination Request Form and either:
- Fax the form to 1-877-251-5896
- Mail the form to Express Scripts:
Attn: Medicare Reviews
P.O. Box 66571
St. Louis, MO 63166-6571
Expedited Coverage Determination
If you or your prescriber believes that waiting 72 hours for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received.
For more information on asking for coverage decisions about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.
Coverage Redetermination or Appeal
If your coverage determination for a prescription drug was denied, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination.
A redetermination or appeal is a formal way of asking us to review and change a coverage decision we have made.
You, your appointed representative or your prescriber have the right to request a coverage redetermination in the following ways:
- Call 1-800-935-6103 (TTY: 1-800-716-3231 for hearing impaired), 24 hours a day, 7 days a week.
- Complete the Medicare Redetermination Request Form and either:
- Fax the form to 1-877-852-4070
- Mail the form to Express Scripts:
Attn: Medicare Appeals
P.O. Box 66588
St. Louis, MO 63166-6588
Expedited Redetermination
If you or your prescriber believes that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.
For more information on asking for a coverage redetermination or appeal a decision about your Part D prescription drugs, please see Chapter 9 of your Evidence of Coverage.
If Your Appeal Is Denied
If Medical Mutual denies any part of your appeal request for a coverage or payment review of a Part D prescription drug, we will inform you of our decision, and explain your further appeal rights, which will instruct you how to exercise those rights. Part D prescription drug appeals must be requested by you for review at C2C Innovative Solutions, Inc. Requests for an independent review of Part D prescription drug appeals must come from you.
C2C will notify you in writing when they have made a decision on your case, including the reasons for that decision. If they deny any part of your appeal, they will send you information about any remaining appeal rights you have.
Information on your right to file appeals is also included in your Evidence of Coverage. If you have questions you can also call us toll free at 1-800-982-3117 (TTY: 711 for hearing impaired) for help. We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (excluding Thanksgiving and Christmas Day). From April 1 to September 30, we are open Monday through Friday from 8 a.m. to 8 p.m.
You may also contact the Medicare Rights Center at 1-800-333-4114 (TTY: 711 for hearing impaired) for help. The Medicare Rights Center is a non-profit organization providing counseling and advocacy services to support access to affordable healthcare. Or you may contact Medicare directly at 1-800-MEDICARE, 24 hours a day, seven days a week. (TTY: 1-877-486-2048 for hearing impaired).
Request for an Exception
You can ask Medical Mutual to make an exception to our coverage rules. There are several types of exceptions that you can ask us to make:
- You can ask us to cover your drug even if it is not on our formulary.
- You can ask us to waive coverage restrictions or limits on your drug. For example, for certain drugs, the plan limits the amount of the drug that we will cover. If your drug has a quantity limit, you can ask us to waive the limit and cover more.
- You can ask us to cover a non-preferred drug at the lower cost-sharing terms applicable to drugs in a preferred tier.
Generally, the plan will only approve your request for an exception if the alternative drugs included on the plan’s formulary would not be as effective in treating your condition and/or would cause you to have adverse medical effects.
Grievances
Filing a Complaint or Grievance
Generally, the first step in resolving your concern starts with you contacting us. Medical Mutual administers medical benefits for your plan and contracts with Express Scripts to administer the prescription drug benefits for your plan. If your concern is related to your medical benefits, call the Customer Care phone number on your member identification card or email us by logging into My Health Plan at MedMutual.com/Member.
If your concern is related to your prescription drug benefits, call the Rx Member Services phone number on your identification card. We will review your concern and attempt to resolve it appropriately.
When you file a grievance, you are asking us to investigate a complaint which includes but is not limited to issues related to timeliness, appropriateness, access to and/or the setting in which you received or tried to receive a healthcare service.
A complaint about the quality of care you received from a hospital, doctor or other healthcare provider may also be forwarded to the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for review.
You can file a grievance either by voice or in writing within 60 days of the event. Please call us at the Customer Care phone at 1-800-982-3117 (TTY: 711 for hearing impaired). You may also fax your grievance to 1-844-606-5394 or put it in writing and mail it to:
Medical Mutual Member Appeals and Grievances Department
P.O. Box 94563
Cleveland, Ohio 44101-4563
You also have the option to submit a complaint directly to Medicare with their online Medicare Complaint Form.
Standard Grievance
We will review your complaint and do a full investigation of the grievance as quickly as your case requires. We will notify you of our decision within 30 calendar days after we get your request, unless federal regulations allow for an extended timeframe. If, as permitted under the regulations, we decide it is in your best interest to take an extension, we will notify you promptly and let you know the reason for the extension. This extension will not be more than 14 calendar days.
Expedited Grievance
Under certain circumstances that require a faster response, we will respond to your grievance within 24 hours. See your Evidence of Coverage for more information about the conditions for a faster response to a grievance.
Please see your Evidence of Coverage (EOC) for more information about coverage determinations and appeals.
Medicare Ombudsman
The Medicare Ombudsman helps you with Medicare-related complaints, grievances and other information. Learn more by visiting the Medicare website.
Out-of-network Coverage
Out-of-network Providers - PPO Plans
As a member of a PPO plan, you can choose to receive care from out-of-network providers. Our plan will cover services from either network or out-of-network providers, as long as the services are covered benefits and are medically necessary. However, if you use an out-of-network provider, your share of the costs for your covered services may be higher.
Other important things to know about using out-of-network providers:
- If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive, except for emergency care.
- You don't need to get a referral or prior authorization when you get care from out-of-network providers, however, you may want to ask for a pre-visit coverage decision to confirm that the services you are getting are covered and are medically necessary. It is important to ask for a pre-visit coverage decision.
- If it is later determined that the out-of-network services are not covered or were not medically necessary, we may deny coverage and you will be responsible for the entire cost. If we say we will not cover your services, you have the right to appeal our decision not to cover your care.
- It is best to ask an out-of-network provider to bill the plan first. But, if you have already paid for the covered services, we will reimburse you for our share of the cost for covered services. Or if an out-of-network provider sends you a bill that you think we should pay, you can send it to us for payment.
- If you are using an out-of-network provider for emergency care, urgently needed services, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount.
Please review your Evidence of Coverage for complete information about out-of-network provider coverage.
Out-of-network Providers - HMO Plans
It is important to know which providers are part of our network. In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan's network) will not be covered. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Medical Mutual authorizes use of out-of-network providers.
If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. For this medical care, your provider must obtain approval from the plan before you seek care from an out-of-network provider. In this situation, you will pay the same as you would pay if you got the care from a network provider.
Please review your plans Evidence of Coverage for complete information about out-of-network provider coverage.
Out-of-network Pharmacy Coverage and Prescription Drug Claim Form
Generally, we cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. To help you, we have network pharmacies outside of our service area where you can get your prescriptions filled as a member of our plan.
If you cannot use a network pharmacy, these are the circumstances when we would cover prescriptions filled at an out-of-network pharmacy:
- If the prescriptions are related to the care of a medical emergency or urgently needed care, they will be covered. In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP (True Out-Of-Pocket cost).
- If you are traveling within the United States, but outside the plan's service area, and you become ill or run out of your prescription drugs, we will cover prescriptions that are filled at an out-of-network pharmacy (if you follow all other coverage rules identified within your Evidence of Coverage and a network pharmacy is unavailable). In this situation, you will have to pay the full cost (rather than paying just the copayment or coinsurance) when you fill your prescription. You can ask us to reimburse you by submitting a paper claim to us for up to usual, customary, and reasonable (UCR). Any amount you pay over the UCR will be applied to your TrOOP.
- If you are unable to get a covered drug in a timely manner within our service area, because there is not a network pharmacy within a reasonable driving distance which provides 24-hour service.
- If you are trying to fill a covered prescription drug that is not regularly stocked at an eligible network retail or mail-order pharmacy (the drugs include orphan drugs or specialty pharmaceuticals).
- Self-administered medications that you receive in an outpatient setting may be covered under Part D. For consideration, please submit a paper claim.
In these situations, please check first with Customer Care to see if there is a network pharmacy nearby. You can contact Customer Care by calling 1-800-982-3117 (TTY: 711 for hearing impaired). You may be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
How do you ask for reimbursement from the plan?
If you must use 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. You may request reimbursement for your share of the cost by submitting a paper claim to Medical Mutual. You may, however, be required to pay the difference between what you pay for the drug at the out-of-network pharmacy and the cost that we would cover at an in-network pharmacy.
This Prescription Drug Claim Form is offered as a tool to assist in getting your claim paid as soon as possible. Please print clearly. Use of this particular form is not required and you may submit equivalent written documentation, but it must provide all of the requested information on this form.
Please review your Evidence of Coverage for complete information about out-of-network pharmacy coverage and how to submit a paper claim for reimbursement, or call Member Services at 1-844-404-7947 (TTY: 1-800-716-3231 for hearing impaired).
Pharmaceutical Assistance Programs
Pharmaceutical Assistance Programs (PAPs) are sometimes available to help relieve financial burden by providing free or discounted medications to qualifying patients. These programs are medication specific and may be available to you through various organizations. See if a program is available for your medication.
Appointment of Representative
You can appoint a relative, friend, advocate, caregiver or anyone else to act on your behalf for healthcare-related affairs. If you choose to have someone act for you, then you and that person must sign and submit an Appointment of Representative (AOR) Form, or an equivalent notice, to Medical Mutual.
Please note: An AOR Form is valid for 365 days from the date both parties signed the document. Once a valid AOR form is submitted, the form will be on file with us until it expires. You may ask us to reuse an AOR on file with each new appeal or grievance request.
If you choose to submit an equivalent notice, please include:
- The name, address, and telephone number of the member and the individual being appointed
- The members Identification (ID) Number
- A statement that the enrollee is authorizing the representative to act on his or her behalf for the claim(s) at issue, and a statement allowing the plan to give identifying information to the representative
- A statement by the individual being appointed that he or she accepts the appointment
- Signed and dated by the enrollee making the appointment
- Signed and dated by the individual being appointed as representative
- The appointed representative’s professional status or relationship to the party
- An explanation of the purpose and scope of the representation
Best Available Evidence
If you believe you are eligible for Extra Help with your health plan premium, costs for your prescription drugs, or if you believe you have limited income and need help paying for your premium and/or drug costs, you or your appointed representative may contact Medical Mutual, your local Social Security Administration Office, your local Medicaid Office, or contact 1-800-MEDICARE at any time.
If you believe you are paying too much for your prescription drugs at the pharmacy, Medical Mutual and its pharmacies want to make sure you pay the lowest, most appropriate cost for your prescription drugs. If you have one of the documents below, please submit it at the pharmacy when obtaining your drugs or submit directly to Medical Mutual.
- A copy of your Medicaid card that includes your name and an eligibility date during a month after June of the previous calendar year
- A copy of a State document that confirms your active Medicaid status during a month after June of the previous calendar year
- A print out from the State electronic enrollment file showing your Medicaid status during a month after June of the previous calendar year
- A screen print from the State’s Medicaid systems showing your Medicaid status during a month after June of the previous calendar year
- Other documentation provided by the State showing your Medicaid status during a month after June of the previous calendar year
- A Social Security Administration (SSA) Supplemental Security Income (SSI) Notice of Award with an effective date
- An Important Information letter from SSA confirming that you are “...automatically eligible for extra help...”
- A copy of the SSA or State Medicaid Agency award letter
Any one of the following forms of evidence to establish that you are institutionalized or enrolled in a home and community-based services (HCBS) waiver program:
- A remittance from the facility showing Medicaid payment for a full calendar month for you during a month after June of the previous calendar year
- A copy of a State document that confirms Medicaid payment on your behalf to the facility for a full calendar month after June of the previous calendar year
- A screen print from the State’s Medicaid systems showing your institutional status based on at least a full calendar month stay for Medicaid
- A copy of a State-issued Notice of Action, Notice of Determination, or Notice of Enrollment that includes your name and HCBS eligibility date during a month after June of the previous calendar year
- A copy of a State-approved HCBS Service Plan that includes your name and effective date beginning during a month after June of the previous calendar year
- A copy of a State-issued prior authorization approval letter for HCBS that includes your name and effective date beginning during a month after June of the previous calendar year
- Other documentation provided by the State showing HCBS eligibility status during a month after June of the previous calendar year
When you submit one of these documents to Medical Mutual (or one of its pharmacies), we then use it to update your records. If you have one of these documents, please send it to Medical Mutual at the following address or fax number.
Medical Mutual
Medicare Enrollment Department
Attn: Best Available Evidence
P.O. Box 94563
Cleveland, OH 44101
Or fax to: 1-800-542-2583
If you have any questions about Extra Help for persons with limited income, please call Customer Care at 1-800-982-3117 (TTY: 711 for hearing impaired):
October 1 to March 31
7 days a week, 8 a.m. - 8 p.m.
April 1 to September 30
Mon.-Fri. 8 a.m. to 8 p.m.
To learn what you can do if you believe you are eligible for Low Income Subsidy, but do not have a required piece of evidence, please call Customer Care or visit the CMS Best Available Evidence page.
Contact Information
If you have questions or concerns about our health plans, we encourage you to contact us.
Prospective Members
Please call our licensed insurance sales agents at 1-800-543-3241 (TTY: 711 for hearing impaired).
October 1 through March 31
Monday through Friday: 7 a.m. to 9 p.m.
Saturday and Sunday: 10 a.m. to 7 p.m.
April 1 through September 30
Monday through Friday: 9 a.m. to 9 p.m.
Saturday: 10 a.m. to 7 p.m.
Current Members
Please call our Customer Care Center at 1-800-982-3117 (TTY: 711 for hearing impaired).
October 1 through March 31
7 days a week, 8 a.m. - 8 p.m.
April 1 through September 30
Monday - Friday 8 a.m. - 8 p.m.
Please mail written correspondence to:
Medical Mutual Medicare
P.O. Box 94563
Cleveland, OH 44101
Or fax: 1-216-687-7885
For more information about Medicare, contact Medicare directly at 1-800-MEDICARE (TTY: 1-877-486-2048 for hearing impaired), 24 hours a day, seven days a week. You can also visit Medicare.gov.
Disenrollment Information
You may end your membership in our plan only during certain times of the year, known as enrollment periods. All members have the opportunity to leave the plan during the Annual Enrollment Period (October 15 to December 7) and during the annual Open Enrollment Period (January 1 to March 31). In certain situations, you may also be eligible to leave the plan at other times of the year (also known as a Special Enrollment Period).
Usually, to end your membership in our plan, you simply enroll in another Medicare plan during one of the enrollment periods. However, if you want to switch from our plan to Original Medicare without a Medicare prescription drug plan, you must ask to be disenrolled from our plan. If you would like to be disenrolled, you can make a request in writing to us.
Medical Mutual
Attn: Medicare Advantage Enrollment Department
P.O. Box 94563
Cleveland, OH 44101-4563
Note: If you disenroll from Medicare prescription drug coverage and go without creditable prescription drug coverage, you may need to pay a late enrollment penalty if you join a Medicare drug plan later. ("Creditable" coverage means the coverage is expected to pay, on average, at least as much as Medicare's standard prescription drug coverage.)
In most cases disenrollment from a plan is your choice (voluntary) but, in some circumstances you may not have a choice (involuntary). There are situations which require you to leave a plan such as:
- You lose your Part A benefits and/or are no longer enrolled in Part B
- You fail to pay your plan premium
Disenrollment from a Medicare Advantage plan is subject to CMS rules. For more information about disenrolling from our plan or your rights and responsibilities, please review your plan's Evidence of Coverage.
If you have questions about disenrollment just call Customer Care at 1-800-982-3117 (TTY: 711 for hearing impaired), 8 a.m. to 8 p.m. EST, 7 days a week. You can also call 1-800-Medicare to disenroll.
Extra Help from Medicare
People with low incomes or limited assets may qualify for “extra help” to pay for their prescription drug costs. This extra help is sometimes called a Low Income Subsidy or LIS. If you qualify, Medicare could pay up to 75 percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. In addition, people who qualify will not have a coverage gap or late enrollment penalty.
Many people are eligible and don’t even know it. To see if you qualify, call:
Medicare
1-800-MEDICARE (1-800-633-4227)
TTY: 1-877-486-2048 for hearing impaired
24 hours a day/7 days a week
The Social Security Office
1-800-772-1213
TTY: 1-800-325-0778 for hearing impaired
7 a.m. and 7 p.m., Monday through Friday
Or contact your state Medicaid office.
2023 LIS Premium Chart
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. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.
Medical Mutual's premium includes coverage for both medical services and prescription drug coverage.
This table shows you what your monthly plan premium will be if you get extra help. The monthly plan premiums listed include coverage for both medical services and prescription drug benefits. You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medicaid or another third party. (This does not include any Medicare Part B premium you may have to pay.)
| Monthly Premium | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Level of Extra Help | Region | Classic HMO | Signature HMO | Secure HMO | Choice HMO | Plus HMO | Select PPO | Preferred PPO | Premium PPO | Access PPO |
| 25% | Northeast Ohio | $0.00 | $0.00 | $16.50 | $31.30 | $91.50 | $35.30 | $71.30 | $125.30 | $0.00 |
| Select Ohio Counties | $0.00 | N/A | N/A | $91.30 | $128.50 | $91.30 | $141.30 | $191.30 | N/A | |
| Central Ohio, Cincinnati/Dayton and Toledo | $0.00 | $0.00 | $22.50 | $31.30 | $91.50 | $41.30 | $71.30 | $127.30 | $0.00 | |
| 50% | Northeast Ohio | $0.00 | $0.00 | $11.00 | $22.60 | $86.00 | $26.60 | $62.60 | $116.60 | $0.00 |
| Select Ohio Counties | $0.00 | N/A | N/A | $82.60 | $123.00 | $82.60 | $132.60 | $182.60 | N/A | |
| Central Ohio, Cincinnati/Dayton and Toledo | $0.00 | $0.00 | $15.00 | $22.60 | $86.00 | $32.60 | $62.60 | $118.60 | $0.00 | |
| 75% | Northeast Ohio | $0.00 | $0.00 | $5.50 | $14.00 | $80.60 | $18.00 | $54.00 | $108.00 | $0.00 |
| Select Ohio Counties | $0.00 | N/A | N/A | $74.00 | $117.60 | $74.00 | $124.00 | $174.00 | N/A | |
| Central Ohio, Cincinnati/Dayton and Toledo | $0.00 | $0.00 | $7.50 | $14.00 | $80.60 | $24.00 | $54.00 | $110.00 | $0.00 | |
| 100% | Northeast Ohio | $0.00 | $0.00 | $0.00 | $5.30 | $75.10 | $9.30 | $45.30 | $99.30 | $0.00 |
| Select Ohio Counties | $0.00 | N/A | N/A | $65.30 | $112.10 | $65.30 | $115.30 | $165.30 | N/A | |
| Central Ohio, Cincinnati/Dayton and Toledo | $0.00 | $0.00 | $0.00 | $5.30 | $75.10 | $15.30 | $45.30 | $101.30 | $0.00 | |
Please note: This does not include any Medicare Part B premium you may have to pay.
If you have any questions, please call 1-800-982-3117 (TTY: 711 for hearing impaired). We are open 8 a.m. to 8 p.m. seven days a week from October 1 to March 31 (except Thanksgiving and Christmas), and 8 a.m. to 8 p.m. Monday through Friday from April 1 through September 30 (except holidays). Our automated telephone system is also available 24 hours a day, seven days a week for self-service options.
Getting Care During a Disaster
As a MedMutual Advantage Medicare member, we want you to understand your options during a disaster. Use the following information as guidelines for seeking care during a disaster. If you have specific questions or need more information, or assistance in getting care, please contact us.
Seeing Doctors or Other Providers
During a declared disaster or emergency, you may be able to get care from out-of-network providers at in-network rates. Call Medical Mutual to see if any MedMutual Advantage coverage policies may have temporarily changed. In the event that your plan is impacted, your plan will return to normal 30 days from the date of the initial declaration.
You may not have to meet the prior authorization rules for out-of network services.
How to Get Your Prescription Drugs
Medical Mutual and Express Scripts (ESI) have a process that helps lift “refill-too-soon” rules for people impacted by state of disasters or emergencies in a specified geographical area.
- If you can’t go to your usual network pharmacy to replace your prescription drugs, check with Medical Mutual or Express Scripts to find another network pharmacy nearby.
- You can move most prescriptions from one network pharmacy to another, and back to your regular pharmacy when the emergency or disaster ends.
- You may request and obtain the maximum extended day supply, if it is available at the time of refill.
Replacing Lost or Damaged Durable Medical Equipment or Supplies
If your durable medical equipment (like a wheelchair or walker) or supplies (like diabetic supplies) are damaged or lost due to an emergency or disaster:
- MedMutual Advantage Plans may cover the cost to repair or replace your equipment or supplies
- Generally, MedMutual Advantage Plans will also cover the cost of rentals for items (such as wheelchairs) during the time your equipment is being repaired
Replacing a Lost Plan Membership Card
If you have a lost or damaged ID card, you can print a temporary ID card, or order a replacement card by visiting MedMutual.com/Member.
Paying your Premium
If you pay a premium directly to us each month, you may still be responsible for paying your premium on time. To make sure you’re still making timely payments, you may want to consider having your premium withheld each month from your Social Security check or sign up for automatic premium deductions. If you are disenrolled for not paying your monthly premiums and you didn’t pay on time because of the emergency or disaster, you may be able to ask for a reconsideration of the decision and get your coverage back. Contact us for more information.
Please use this information as a guide, in the event of an actual disaster, contact us to verify benefits.
Interpreter Services
We have free interpreter services to answer any questions you may have about our health plans. Our Customer Care Center and Sales Center will provide interpreter services upon request. There is no cost for this service. Learn more about our multi-language interpreter services.
Medical Claim Form
Sometimes when you get medical care, you may need to pay the full cost right away. Other times, you may find that you have paid more than you expected under the coverage rules of the plan. In either case, you can ask our plan to pay you back. To submit a request asking us to pay for our share of the cost for medical care you have received, complete the medical claim form and send to us at Medical Mutual, P.O. Box 6018, Cleveland, OH 44101-1018.
For more information on situations in which you may need to ask us for reimbursement or to pay a bill you have received from a provider, see Chapter 7 of your Evidence of Coverage.