Medicare Advantage Special Needs Plan

Our Medicare Advantage Special Needs Plan includes coverage for prescription drugs, along with important benefits for Vision, Hearing, Dental and our Patient Navigator Service.

The monthly premium for this plan is $30.00.  However, most beneficiaries who are eligible for the Special Needs Plan are also eligible for the Low Income Subsidy (LIS) program. Those eligible for LIS will have this monthly premium paid for by Social Security, resulting in a net $0 monthly premium along with reduced copays for prescription drugs.  See additional information about the LIS program below on this page.

On this page you will find the following information for our Special Needs Plan

• Plan Benefit Information
• Patient Navigator Service
• Provider Directories
• Dental Directory
• Pharmacy Directory
• Formulary Drug List
• Easy Enrollment Instructions and Forms
• Low Income Subsidy Program-extra help to pay for prescription drug costs
• Policies and Procedures for Member Privacy, Rights, Appeals and Grievances

The Community HealthFirst Medicare Advantage Special Needs Plan includes the Part D with pharmacy benefit and is offered by Community Health Plan, which contracts with the Federal Government as a Medicare HMO.

Our Medicare Advantage Special Needs Plan (H5826 005) is available to eligible beneficiaries living in the following counties: Adams, Benton, Chelan, Cowlitz, Douglas, Ferry, Franklin, Grant, Grays Harbor, Island, King, Kitsap, Lewis, Lincoln, Mason, Okanogan, Pend Oreille, Pierce, Skagit, Snohomish, Spokane, Stevens, Thurston, Walla Walla, Whatcom & Yakima.

Benefit Highlights – an easy to understand overview of Plan Benefits and how they compare to original Medicare.

Summary of Benefits provides important details about the plan benefits, premiums, cost sharing and requirements for receiving care.

Evidence of Coverage is sent to members after they enroll and provides details about your Medicare Advantage Plan coverage. This booklet is an important legal document. It will be helpful to you after you have enrolled in the plan. 

The Evidence of Coverage document provides you with the following information:

• The Plan’s service area
• The Plan’s benefits, including annual deductible amount of initial coverage limit, and cost sharing
• How to access Part D benefits, including how to fill a prescription through retail pharmacy and mail order service
• How to access drugs at out-of-network pharmacies and submit a claim
• Major exclusions and limitations
• Network pharmacy information
• Exception process
• Quality assurance policies and procedures, including drug utilization management and medication therapy management programs
• Formulary tier structure and drug information
• Grievance, coverage determinations, exceptions process, and appeals rights and procedures
• Disenrollment rights, responsibilities, and procedures

The Patient Navigator Program is a service that is provided FREE to all Community HealthFirst Members.  The Patient Navigator, is your advocate and will guide you in exploring and understanding your new health benefits under the Community HealthFirst.  Patient Navigator services include:

• Answering your questions about your Community HealthFirst, Medicare, or Medicaid benefits.
• Helping you schedule appointments with your Primary Care Provider(PCP).
• Helping you schedule appointments with specialty care providers when needed.
• Helping you find and schedule appointments with dentists who accept Medicaid reimbursement
• Assisting you with non-emergency transportation arrangements
• Assistance in using translation services when appropriate
• Assistance in maintaining Social Security Administration and Medicaid Dual Eligibility paperwork
• Connecting you with community and social service resources in your area.

For more information on the Patient Navigator program, please contact us Monday - Friday, 8 a.m. to 5 p.m. at 1-866-717-2479 (TTY/TDD hearing impaired call 1-866-816-2479).

Community HealthFirst and your Primary Care Provider (PCP) work as partners to be sure you get the right care, at the right time, at the right place.  Your PCP takes care of most of your health needs and writes you a referral when you need to see a specialist.  Ultimately, you and your PCP decide the best course of action for your health care. 

In the provider directories you will find the following information:

• Obtaining health care services
• Choosing a Primary Care Provider (PCP)
• Changing your PCP
• Specialist referrals
• Prior Authorizations
• Coverage for Urgent Care and Emergencies
• Billing from out of network providers
• Who to call if you have questions

To search for a specific Provider, simply click on the proper link below to open the Directory PDF, find the Directory listing for the county you live in, then check the network providers listed for your county.

Directory of Primary Care Providers and Hospitals
Addendums to this directory

Directory of Specialists
Addendums to this directory

If you sign up for our Medicare Advantage Special Needs Plan, you will receive coverage for dental services.

Community HealthFirst’s dental network contains over 450 dentists in Washington.

There are two ways to receive dental services:

1. In-Network Providers:

Visit a dentist listed in our provider directory. These “In-Network” dentists have agreed to treat Community HealthFirst members at a contracted rate. Generally, your benefit coverage will cover more services if they are provided by an in-network dentist.

To search for a specific dental provider, simply click named “Directory of Network Dentists” in order to open the directory in PDF format. Once the directory is open, look for the county you live in, then check the list of network providers in your county.

 Directory of Network Dentists
 Addendums to the Dental Directory

2. Out-of-Network Providers:

If it is not convenient for you to visit an in-network dentist, you may visit any dentist. “Out-of-Network” dentists may bill Community HealthFirst a higher rate for a service than an In-Network dentist would. Therefore, your benefit coverage will cover fewer services.

A dental provider’s listing does not guarantee that the provider is still in the plan network. To make sure a provider or facility is still in the network, you can contact the provider’s office or our Customer Service at the number listed on this page. Current members should call 1-800-942-0247. Prospective members should call 1-800-944-1247. TTY/TDD hearing impaired users should call 1-866-816-247

Community HealthFirst has contracts with pharmacies that meet or exceed CMS requirements for pharmacy access in your area.  The network Pharmacy information provided on the following links is updated quarterly.  As of the most current period, the Community HealthFirst Pharmacy network contains over 1,200 contracted pharmacies in Washington and 58,000 contracted pharmacies nationwide.

In the Pharmacy Directory you will find the following information:

• Finding a network Pharmacy in your area
• Filling your prescription at a network Pharmacy
• Filling your prescription outside the Pharmacy network
• How to find a network Pharmacy in my area
• How to  fill a prescription by mail order
• How to submit a paper claim

To search for a specific Pharmacy, simply click on the proper link below to open the Directory PDF, find the Directory listing for the type of Pharmacy you are seeking (Retail, Long Term Care, etc), then look for county you live in, then check the network pharmacies listed for your county.

Pharmacy Directory
Addendums to the Pharmacy Directory

A formulary is a list of covered drugs selected by Community HealthFirst in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Community HealthFirst will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Community HealthFirst network pharmacy, and other plan rules are followed.

To search for a specific drug, simply click on the Formulary link below, click on the Search Function in the tool bar at top represented by the binocular icon, type the name of the drug you wish to search for in the box that appears on the top right hand side of the page and click Search.

Comprehensive Formulary of prescription drugs covered by Community HealthFirst.

The Community HealthFirst Formulary is updated monthly.  Click here to view the Notice of Formulary Changes which contains the most recent changes to the Community HealthFirst Formulary, including removing a drug, adding prior authorization, quantity limits, step therapy or any other restrictions.

Requesting exceptions to the Formulary Drug List and coverage policies / procedures. 
If your drug is not listed in the formulary, you should first contact Customer Service and ask if your drug is covered. If you learn that Community HealthFirst does not cover your drug, you may request an exception be made for coverage of that drug.  You may also ask us to waive coverage restrictions or limits on a drug.

Generally, Community HealthFirst will only approve your request for an exception if the alternative drugs included on the plan’s formulary, or additional utilization restrictions would not be as effective in treating your condition and/or would cause you to have adverse medical effects.  Policies, procedures and forms for requesting formulary exceptions and coverage determinations.

We realize that situation may arise where you may need to access drugs that are not on the formulary or cases in which you need a refill sooner than expected.  We call this a Plan Transition Process and have taken into account these special circumstances. 
Plan Transition Process.

Questions about Prescription Drug coverage?
If you have any questions about our Formulary Drug List, tiering, copay levels or policies, please call Customer Service, 8 a.m. to 8 p.m., 7 days a week. Current Members should call 1-800-942-0247, Prospective Members should call 1-800-944-1247 and all TTY/TDD hearing impaired users should call 1-866-816-2479.  Or you can send questions to Community HealthFirst, PO Box  960,  Seattle, WA  98111-0960

Enrolling in a Community HealthFirst Plan is easy as 1, 2, 3
Click here for our handy Enrollment Check List, Instructions and Forms

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly 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.

The table shows you what your monthly plan premium will be if you get extra help.

Your level of extra help	Monthly Premium for Community HealthFirst MA w/Pharmacy (Urban)*	Monthly Premium for Community HealthFirst MA w/Pharmacy (Rural)*	Monthly Premium for Community HealthFirst MA Special Needs Plan*
100%	$0	$0	$0
75%	$7.50	$7.50	$7.50
50%	$15.00	$15.00	$15.00
25%	$22.50	$22.50	$22.50

*This does not unclude any Medicare Part B premium you may have to pay.

Community HealthFirst premium includes coverage for both medical services and prescription drug coverage.

If you aren't getting extra help, you can see if you qualify by calling:

• 1-800-Medicare or TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
• Your state Medicaid Office, or
• The Social Security Administration at 1-800-772-1213.  TTY/TDD users should call 1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions, please call our Customer Service Department, 7 days a week, from 8:00 a.m. to 8:00 p.m. Pacific Time, at 1-800-942-0247.  TTY/TDD users should call 1-866-816-2479.

We take your rights and concerns very seriously.  We want to ensure you receive the right care, at the right time, in the right place and that it is delivered with the respect and service you deserved.  When you do not agree with our benefit determinations or have issues with the treatment you receive, we want to know about it.   We consider them opportunities to improve care and service to our members.

Policies and Procedures for Member Privacy, Rights, Appeals and Grievances.