4. DeanCare Gold Cost Q&A

Q&A: DeanCare Gold (Cost)

DeanCare Gold has formed a network of doctors, specialists and hospitals. You can use any doctor who is part of our network. You may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current provider directory by contacting our customer service number or you can search our provider directory online.

You can always choose to go to a doctor outside our network. We may not pay for the services you receive outside of our network, but Medicare will pay for its share of charges it approves. You are responsible for Medicare Part B deductible and co-insurance.

DeanCare Gold does cover Part B prescriptions drugs. DeanCare Gold does NOT cover Medicare Part D prescription drugs.

All Medicare Cost plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue for another year. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas.

Also, Medicare may decide to end a contract with a plan. Even if your Medicare Cost Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 60 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

As a member of DeanCare Gold, you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if your want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision.

You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service.

If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the types of drugs listed below. Contact DeanCare Gold for more details.

  • Some Antigens: if they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
  • Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
  • Erythropoietin (Epoetin Alfa or Epogen(r)): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.
  • Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.
  • Injectable Drugs: Most injectable drugs administered incident to a physician's service.
  • Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
  • Some Oral Cancer Drugs: If the same drug is available in injectable form.
  • Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.
  • Inhalation and Infusion Drugs administered through DME.

The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select "Health and Drug Plans" then "Compare Drug and Health Plans" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan.