Accessing Benefits During a Disaster or Emergency
What is a Disaster or Emergency?
HealthTeam Advantage will ensure that you will continue to get health plan benefits during an official disaster or emergency. An official disaster or emergency occurs when:
- The President declares a disaster or emergency under either the Stafford Act or the National Emergencies Act;
- The Governor of your state declares a disaster or emergency; or
- The Federal Secretary of Health and Human Services declares a public health emergency.
What Are Your Rights During a Disaster or Emergency?
If you are impacted by an official disaster or emergency, you have the following rights:
- We will lift the “refill-too-soon” edits on your Part D drugs at the point-of-sale.
- You may obtain covered Part D drugs from any out-of-network pharmacies if you cannot reasonably be expected to obtain covered Part D drugs at a network pharmacy and when such access is not routine.
- You may obtain the maximum extended day supply on your Part D drugs, if requested and available at the time of refill.
- We will waive any prior authorization or referral requirements on your medical benefits.
- You may get medical coverage (including any covered supplemental benefits) at any Medicare-certified, non-network facilities. You will be charged the same cost sharing at non-network facilities as you would at network facilities.
- If we make a change to a plan rule that benefits you (such as reducing cost sharing or waiving prior authorization), we will implement the change immediately rather than make you wait 30 days before implementing the change.
How Long Do These Accommodations Last?
These special accommodations and waivers extend 30 past the earliest of any of the following events:
- There has been an official government declaration to an end of the disaster or emergency.
- No end date was declared by an official government agency, but the emergency or disaster declared for the area has ended, including the expiration of the declaration or any renewal of such declaration.
- There is no longer a disruption of access to health care, which is an interruption or interference in the service area such that you do not have the ability to access contracted providers or contracted providers do not have the ability to provide needed services to you, resulting in us not being able to meet the normal prevailing patterns of community health care delivery in your service area.
In the event that our health plan cannot resume normal operations by the end of the public health emergency or state of disaster, we will notify the Centers for Medicare & Medicaid Services (CMS).
