2012 Liberty Dual Power Plan (HMO SNP)

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Liberty Health Advantage HMO offers two Medicare Advantage Plans, one for beneficiaries with Medicare and one for beneficiaries with Medicare and Medicaid. Both plans include Part D prescription drug coverage. If you are already a member of the Liberty Health Advantage Dual Power plan, you must maintain your Medicaid status. To enroll in the Liberty Dual Power Plan, you must have active Medicare Part A and Part B and also active New York State Medicaid. If you are a Dual Eligible, your Medicare Part B Premium will be payed by the state on your behalf. Part C Medicare Advantage (Medicare Part C) Information Summary of Benefits H3337_LHA_MARK_1200 CMS Approved 09/19/2011 Resumen de Prestaciones H3337_LHA_MARK_1200SP CMS Approved 09/19/2011 Evidence of Coverage H3337_LHA_MARK_1204E CMS Approved 09/19/2011 Evidencia de Cobertura H3337_LHA_MARK_1204E_SP CMS Approved 09/19/2011 Premiums LIS Premiums Premium and Cost Sharing Search Options 2012 Plan Rating Information Best Available Evidence Notices 2012 Rights & Responsibilities Help with Low Income Subsidy (LIS) Privacy Statement Potential Termination of Contract Out of Network Provision Ending your Membership Grievance and Appeals - Medical Presentación de quejas de y solicitudes ds las prestaciones - Medico Medicare Plan Rating Calificaciones del Plan Medicare Medicare Ombudsman Medicare Complaint Form Part D Prescription Drug (Medicare Part D) Information *Liberty Health Advantage (LHA)* Provides the following useful tools in aiding our members to locate participating pharmacies and a formulary look up. Liberty Health Advantage has contracts with over 2,592 pharmacies that meet or exceed CMS requirements for pharmacy access in your area. Forms Prescription Drug Reimbursement Form Instructions for requesting a redetermination Medicare Part D Coverage Determination and Redetermination Vaccine Reimbursement Form How to Appoint a Representative Appointment of Representative Medicare Prescription Drug Determination Request Form (Members) Medicare Prescription Drug Determination Request Form (Providers) Mail Order Brochure Folleto Electrónico Orden Grievance and Appeals-Prescription Drugs Summary of Part D plan grievance, coverage determination and appeals process. Resumen del procedimiento para la presentación de quejas y solicitudes Prestaciones para medicamentos de Parte D To obtain an aggregate number of Appeals, Grievance & Exceptions filed with LHA, please contact Member Services. Policies Transition Letter General Transition Policy Medication Therapy Management Program (MTMP) Step Therapy FAQ's Problem Solving plan for Step Therapy Drug Utilization Management Quanity Limits Step Therapy Protocol Prior Authorization Pharmacy Directory Liberty Health Advantage Pharmacy Search Formulary Changes Formulary Changes Formulary Searches Liberty Health Advantage Formulary Pharmacy Copayments Pharmacy Copayments