At ADVANTAGE, we have a team of care providers who will work with you, your family and healthcare team to create a plan to help you with your health needs. After enrollment, you will fill out a health survey so we can learn more about your health. You will be assigned to a member of our care team and together with your primary doctor we will create your individualized care plan. Your care plan will also be used as a guide to managing your care.

The ADVANTAGE Special Needs Plan is a Health Maintenance Organization (HMO) designed for individuals who qualify for both Medicare and Medicaid. As a member of an HMO, you must use plan providers except in emergency or urgent care situations, or for out of area renal dialysis. If you obtain routine care from out of network providers, neither Medicare nor ADVANTAGE will be responsible for the costs. If you are currently responsible for Part B premiums (based on your category of Medicaid coverage), you must continue to pay these premiums.

The categories of eligibility under the Indiana Medicaid program are:

• Qualified Medicare Beneficiary (QMB)
• Qualified Medicare Beneficiary with full Medicaid (QMB Plus)
• Specified Low Income Medicare Beneficiary (SLMB)
• Specified Low Income Medicare Beneficiary with full Medicaid (SLMB Plus)
• Qualified Disabled & Working Individual (QDWI)
• Qualifying Individual (QI)
• Full Benefit Dual Eligible (FBDE)

Eligibility Overview

• Individuals must be entitled to Medicare Part A and enrolled in Part B
• Medicare requires that enrollees not have End Stage Renal Disease at the time of enrollment (certain exceptions apply)
• Medicare beneficiaries may enroll at any time of the year
• Must reside in plan service area
• Must continue to pay your Medicare Part B Premium if not paid under Medicaid or by another Third-Party
• This plan is available to anyone who currently has both Medicare and Medicaid

ADVANTAGE Special Needs Plan available through three network choices: Wishard, Community Health Network, and Franciscan St. Francis Health

• Members choosing Community Health Network or Franciscan St. Francis Health must live in one of the following counties: Hamilton, Hancock, Johnson, Marion, Morgan
• Members choosing Wishard must live in Marion County
• You must use plan providers except in emergency or urgent care situations, or for out of area renal dialysis. If you obtain routine care from out of network providers, neither Medicare nor ADVANTAGE Health Solutions will be responsible for the cost
• Members must choose one of these networks

Please click on the following subjects to learn more about Special Needs Program (SNP)

Enrollment Information

You can join ADVANTAGE Health Solutions if: You are entitled to Medicare Part A and enrolled in Medicare Part B. You live in the service area. Individuals with End Stage Renal Disease are generally not eligible to enroll in ADVANTAGE Health Solutions unless they are members of our organization and have been since their dialysis began. You must continue to pay your Medicare Part B premium. Individuals may only enroll in our plans during certain times of the year. Please contact member services for more information. Please visit our enrollment page for additional information. Enrollment Information

Summary of Benefits

The ADVANTAGE Special Needs Plan is a Health Maintenance Organization (HMO) designed for individuals who qualify for both Medicare and Medicaid. As a member of an HMO, you must use plan providers except in emergency or urgent care situations, or for out of area renal dialysis. If you obtain routine care from out of network providers, neither Medicare nor ADVANTAGE will be responsible for the costs. If you are currently responsible for Part B premiums (based on your category of Medicaid coverage), you must continue to pay these premiums.  Summary of Benefits

Evidence of Coverage

The Evidence of Coverage Provides the most detailed description of the benefits offered with each of our plans. It also explains how you would get your Medicare services through ADVANTAGE Health Solutions.  Evidence of Coverage This booklet, together with your enrollment form and any amendments that we may send to you, is our contract with you. It explains your rights, benefits, and responsibilities as a member of ADVANTAGE Health Solutions. It also explains our responsibilities to you. The information in this booklet is in effect for the time period from January 1, 2012, through December 31, 2012. You are still covered by Original Medicare, but you are getting your Medicare services as a member of ADVANTAGE Health Solutions.

Provider Directories

ADVANTAGE Health Solutions serves HMO members who reside in one of the following five counties: Hamilton, Hancock, Johnson, Marion and Morgan. Provider Search Dental Provider Search  Vision Provider Directory

Formulary

Members of ADVANTAGE Health Solutions receive prescription drug benefits in addition to their medical benefits. ADVANTAGE Health Solutions covers both brand name drugs and generic drugs. Generic drugs have the same active ingredient formula as a brand name drug. Generic drugs usually cost less than brand name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand name drugs. All members of ADVANTAGE Health Solutions will receive a formulary. A formulary is a preferred list of drugs selected to meet patient needs at a lower cost. If the formulary changes, you will be notified in writing, before the change. To view an online version of the formulary click on the link below: Prescription Drug Search  Comprehensive Formulary  ADVANTAGE Prior Authorization Criteria  ADVANTAGE Formulary Step Therapy Summary

Pharmacy Directory

The Pharmacy Directory provides a list of network pharmacies. This directory is for the following thirteen (13) counties in Indiana: Allen, Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Morgan, Shelby, and St. Joseph.  Pharmacy Directory ADVANTAGE Health Solutions has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. Currently our Pharmacy Network meets all CMS (Centers for Medicare & Medicaid) access requirements. We also list pharmacies that are in our network but are outside the above thirteen (13) counties in Indiana. We have over 60,000 pharmacies as part of our national pharmacy network. All network pharmacies may not be listed in this directory. To obtain further information about our pharmacies, please contact member services at (800) 523-7533 (TTY: (800) 743-3333) from 8 a.m. to 8 p.m., Monday - Friday. Our mailing address is ADVANTAGE Health Solutions, 9045 River Road Suite 200, Indianapolis, IN 46240. Pharmacies may have been added or removed from the list after this directory was printed. To get current information, please call our Customer Service Department at the number listed above. Our plans have retail, mail-order, I/T/U, and home infusion pharmacies in our network. Mail Order Home delivery prescriptions covered by your ADVANTAGE Health Solutions plan will be filled by Orchard Pharmaceutical Services. You can take advantage of these great benefits that are offered through our mail order service: Your doctor can fax your prescription directly from his/her office to the home delivery pharmacy. You don't have to worry about filing claims. Your prescription may end up costing you less, depending on the medication. Our plan’s mail-order service requires you to order 30-day supply of the drug and no more than a 90-day supply. Your prescriptions can be sent directly to your home or to your work address. You can get friendly, helpful service  Mail Service Order Form

Appeals and Grievances

Appeals and Grievance Information The complaint process is used for certain types of problems only. This includes problems related to quality of care, waiting times, and the customer service you receive. For additional information on this process, please visit our Appeals and Grievance page. Appeals and Grievances