To enroll in the AlphaCare Renew Plan, you must have Medicare Parts A & B, and continue to pay your Part B premium, and you must live in the service area, Bronx, Kings, New York and Queens counties.
|Benefits at a Glance
(AlphaCare Renew HMO - for Medicare Beneficiaries)
|Monthly Plan Premium||$0 premium||$0 premium|
|Office Visit: Primary Care||$5 copay||$5 copay|
|Office Visit: Specialist||$25 copay||$20 copay|
|Inpatient Hospital Stay||$150/day copay (days 1-7), $0/day copay (days 8-90)||$150/day copay (days 1-7), $0/day copay (days 8-90)|
|Skilled Nursing Facility||$25/day copay (days 1-20), $125/day copay (days 21-100)||$25/day copay (days 1-20), $125/day copay (days 21-100)|
|Prescription Coverage (For a 30 day supply)||Preferred Generic ($2)/ Non-Preferred Generic ($8) / Preferred Brand ($40)/ Non-Preferred Brand ($90)/ Specialty Drugs (33%) to initial coverage limit of $2,850||Preferred Generic ($2)/ Non-Preferred Generic ($8) / Preferred Brand ($40)/ Non-Preferred Brand ($90)/ Specialty Drugs (33%) to initial coverage limit of $2,850|
|Out of Pocket Maximum||$3,400/year||$3,400/year|
(Using an OTC prepaid card)
|You get up to $360/year||You get up to $180/year|
|Vision||$25 copay for up to one routine eye exam per year, $0 copay for eyewear up to a max of $100 each year||$20 copay for up to one routine eye exam per year, $0 copay for eyewear up to a max of $150 every 2 years|
|Hearing||$25 copay - up to 1 supplemental routine hearing exam/year
$1,500 - Plan coverage limit for supplemental hearing aids and/3 years and $25 copay - fitting/3 years
|$20 copay - up to 1 supplemental routine hearing exam/year
$1,500 - Plan coverage limit for supplemental hearing aids and/3 years and $0 copay - fitting/3 years
|Dental||$0 copay, one cleaning, exam, fluoride treatment and dental x-ray per calendar year.||$0 copay, one cleaning, exam, fluoride treatment and dental x-ray per calendar year.|
|Preventive Services||$0 copay||$0 copay|
|Home Health||$0 copay||$0 copay|
|Physical Therapy||$25 copay||$20 copay|
|Speech Therapy||$25 copay||$20 copay|
|Lab||$0 copay||$0 copay|
|X-Ray||$0 copay||$0 copay|
|Diagnostic Radiology||$100 copay||$100 copay|
|Therapeutic Radiology||20% coinsurance||20% coinsurance|
|Urgent Care||$25 copay||$5 or $0 (if admitted to hospital within 24 hours from time of ER visit)|
|Outpatient Surgery||$150 copay||$150 copay|
|The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.|
You can review the benefits of the Renew Plan in detail by selecting one of the links below.
Other Important Information:
Prescription Drug Information
You, your representative, or your prescriber can use:
- This form to request a coverage determination, including an exception, from us; and
- This form to request a redetermination (appeal) from us.
Generally, while you are a member of AlphaCare you must use network providers to get your medical care and services. The only exceptions are:
- Urgently needed care when a network provider is unavailable;
- Out-of-area dialysis services; and
- When AlphaCare has authorized the use of an out-of-network provider.
If you do not have your copy of the Provider/Pharmacy Directory, you can request a copy or download it from this website.
Quality Assurance Policies
For certain items/services, we have special requirements for coverage or limits on our coverage. These requirements and limits help ensure that our members use their benefits in an effective way and help us control costs so we can pass on our savings to members. Examples of utilization management tools we use are described below:
- Prior Authorization: This means that you will need to get approval from us before you receive a service. If you don’t get approval, we may not provide coverage.
- 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.
- Step Therapy: In some cases, we require you to first try one drug to treat your medical condition before we will provide coverage for another drug for that condition.
More information is available at the following links and you can find out if additional requirements apply by looking in the Summary of Benefits or our formulary. If they do apply, you are able to ask us to make an exception to our coverage rules
- Drug Utilization Management / Medication Therapy Management Program (MTMP)
- Quantity Limits
- Step Therapy Requirements
- Step Therapy Requirement Changes (8/1/2014)
- Step Therapy Protocol
- Prior Authorization
We also conduct drug utilization reviews to make sure that you are receiving safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribe their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. If we identify a medication problem during our drug utilization review, we will work with your doctor to correct the problem.
Grievance and Appeals (Part C and Part D)
If you would like to file an appeal or grievance for your medical benefit coverage, click on the following link:
To obtain an aggregate number of Appeals, Grievance & Exceptions filed with AlphaCare, please contact Member Services at 1-(855)-652-5742. TTY/TDD: 711
To check the status of your Appeal or Grievances, call Member Services at 1-(855)-652-5742. TTY/TDD 711
You are also able to submit feedback about us directly to Medicare by clicking on the following link:
AlphaCare has a contract with the Centers for Medicare & Medicaid Services (“CMS”), the government agency that runs Medicare. This contract may be renewed each year; however, we or CMS can decide to end the contract at any time. We will attempt to give you with 90 days advance written notice if this situation occurs. Your advance notice may be as little as 30 days, or even fewer days, if CMS must end our contract in the middle of the year. If our Medicare contract with CMS were to end:
- Your benefits will continue until your membership ends; and
- You will qualify for a special enrollment period so you can enroll in another plan.
Voluntary disenrollment may occur by:
- Enrolling in another plan (during a valid enrollment period);
- Giving or faxing us a signed written disenrollment notice; or
- Calling 1-800-Medicare.
The following are examples of involuntary disenrollment reasons:
- You move outside our service area for more than 6 months;
- You lose you entitlement to Part A or Part B; and
- You are a SNP Member and lose your special needs status.
AlphaCare provides the following useful tools in aiding our members to locate participating pharmacies and to search for prescription drugs in our formulary.