PTHP - Prime Time Health Plan

Potential for contract termination

PrimeTime Health Plan contracts with The Centers for Medicare and Medicaid Services on an annual basis. Availability of coverage for longer than the current year is not guaranteed.

Beneficiaries and Plan rights and responsibility upon disenrollment

Ending your membership in our Plan may be voluntary (your own choice) or involuntary (not your own choice):

You might leave our Plan because you have decided that you want to leave.

There are also limited situations where we are required to end your membership, for example, if you move permanently out of our geographic service area.

There are only certain times during the year when you may voluntarily end your membership in our Plan. The key time to make changes is the Medicare fall open enrollment period (also know as the "Annual Election Period") which occurs every year from November 15 through December 31. This is the time to review your health care and drug coverage for the following year and make changes to your Medicare health or prescription drug coverage. Any changes you make during this time will be effective January 1. Certain individuals, such as those with Medicaid, those who get extra help, or who move, can make changes at other times.

If you leave our plan it may take some time for your membership to end and your new way of getting Medicare to take effect. While you are waiting for your membership to end, you are still a member and must continue to get your care and prescription drugs as usual through our Plan. If you happen to be hospitalized on the day your membership ends, generally you will be covered by our Plan until you are discharged. Call Member Services for more information and to help us coordinate with your new plan.

Until your prescription drug coverage with our Plan ends, use our network pharmacies to fill your prescriptions. While you are waiting your member to end, you are still a member and must continue to get your prescription drugs as usual through our Plan's network pharmacies. In most cases, your prescriptions are covered only if they are filled at a network pharmacy (including our mail-order-pharmacy service), are listed on our formulary, and you follow other coverage rules.

Quality Assurance Policies and Procedures
...A description of our quality assurance policies and procedures. ...Includes medication therapy management, and drug and or utilization management.

PrimeTime Health Plan's Evidence of Coverage's (EOC) contain information that pertains to Grievances, Coverage Determinations on Prescriptions, and the Appeals Process that has been established. Please refer to the Table of Contents at the front of your EOC for the particular chapter that contains the information you are looking for. If for any reason you need help with understanding this information, please feel free to contact our Member Services.