From January – December 2007, Freedom Health offered 4 different health plans in the following 10 counties: Broward, Hernando, Hillsborough, Lake, Marion, Miami-Dade, Orange, Pasco, Pinellas, and Sumter. If you are looking from plans for the 2008 enrollment season (November 15, 2007 – December 31, 2008), please view our main Plans & Products page.
Freedom Medicare Plan
This is a basic medical and prescription drug plan with prescription drug coverage through the gap.
Drugs Covered Under Medicare Part B
For all Plans, you pay 20% of the cost for Part B-covered drugs.
Freedom Medicare Plan
You pay the following for prescription drugs:
$ 0 for a one month (30 day) supply of Generic drugs
$ 15 for a one month (30 day) supply of Preferred Brand drugs
$ 30 for a one month (30 day) supply of Non-Preferred Brand drugs
25 % coinsurance for a one month (30 day) supply of Specialty drugs
$ 0 for a three month (90 day) supply of Generic drugs
$ 45 for a three month (90 day) supply of Preferred Brand drugs
$ 90 for a three month (90 day) supply of Non-Preferred Brand drugs
25%coinsurance for a three month (90 day) supply of Specialty drugs
You pay the following for prescription drugs you receive through our mail-order program:
$ 0 for a three month (90 day) supply of Generic drugs
$ 30 for a three month (90 day) supply of Preferred Brand drugs
$ 60 for a three month (90 day) supply of Non-Preferred Brand drugs
Freedom Savings Plan
You pay the following for prescription drugs:
$ 0 for a one month (30 day) supply of Generic drugs
$ 25 for a one month (30 day) supply of Preferred Brand drugs
$ 45 for a one month (30 day) supply of Non-Preferred Brand drugs
33 % coinsurance for a one month (30 day) supply of Specialty drugs
$ 0 for a three month (90 day) supply of Generic drugs
$ 75 for a three month (90 day) supply of Preferred Brand drugs
$ 135 for a three month (90 day) supply of Non-Preferred Brand drugs
33 % coinsurance for a three month (90 day) supply of Specialty drugs
You pay the following for prescription drugs you receive through our mail-order program:
$ 0 for a three month (90 day) supply of Generic drugs
$ 50 for a three month (90 day) supply of Preferred Brand drugs
$ 90 for a three month (90 day) supply of Non-Preferred Brand drugs
Freedom Medi-Medi Plan
Depending upon your income level, you pay a $0 to $53 yearly deductible. Depending on your income level, you pay the lesser of $0 to $215 or 15% coinsurance for generic drugs (including brand drugs treated as generic) and the lesser of $0 to $5.35 or 15% coinsurance for all other drugs.
You may receive drugs for the following:
one month (30 day) supply
three month (90 day) supply
You may receive prescription drugs through our mail-order program
three month (90 day) supply
Freedom HeartCare Plan -
You pay the following for prescription drugs:
$ 0 for a one month (30 day) supply of Generic drugs
$ 25 for a one month (30 day) supply of Preferred Brand drugs
$ 50 for a one month (30 day) supply of Non-Preferred Brand drugs
$ 0 for a three month (90 day) supply of Generic drugs
$ 50 for a three month (90 day) supply of Preferred Brand drugs
$ 100 for a three month (90 day) supply of Non-Preferred Brand drugs
You may receive prescription drugs through our mail-order program:
$ 0 for a three month (90 day) supply of Generic drugs
$ 50 for a three month (90 day) supply of Preferred Brand drugs
$ 100 for a three month (90 day) supply of Non-Preferred Brand drugs
Catastrophic Coverage:
For all Plans, after your total yearly drug costs (paid by you) reach $3,850, you pay the following for your prescription drugs:
Greater of $2.15 or 5% co-insurance for generic drugs
Greater of $5.35 or 5% co-insurance for preferred brand drugs
Greater of $5.35 or 5% co-insurance for non-preferred brand drugs
Greater of $5.35 or 5% co-insurance for specialty drugs
Cost Sharing
The 2007 Freedom Medicare Plan, the Freedom Savings Plan and the Freedom Medi-Medi Plan have no premiums or deductibles. The Heart Care Plan has a monthly premium of $100. The Member is responsible for the co-payments and/or co-insurance described under the benefits. People who have limited incomes, who live in long term care facilities, or who have access to Indian/Tribal/Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact us for details.
Applicable Conditions and Limitations
There is no monthly coverage limit for your prescription drugs under the Freedom Medicare Plan, the Freedom Savings Plan, the Freedom Medi-Medi Plan or the Heart Care Plan.
In some cases, the Plan requires you to first try one drug to treat to treat your medical condition before they will cover another drug for that condition. Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from Freedom Health for certain prescription drugs.
You may contact our Member Services Department for information on this and other authorization requirements.
Formulary
Freedom Health Medicare Advantage plans use a formulary. A formulary is a list of drugs covered by your plans to meet patient needs at a lower cost. We may periodically add, remove, make changes to coverage limitations or change how much you pay for a drug. If the formulary changes that limit your ability to fill your prescriptions, you will be notified, in writing, 60 days prior to the removal or change in the preferred or tiered cost-sharing status of a Part D drug. We will send you a copy of your formulary. For information on the drugs included in the Freedom Health Medicare Advantage Plans formularies return to the Home Page and click on your Plan’s formulary.
Pharmacy Access
The Freedom Medicare Advantage Plans meet access requirements through contracts with pharmacies that equals or exceeds Centers for Medicare and Medicaid Services (CMS) requirements for pharmacy access in your area. For information on in-network preferred pharmacies, return to the Home Page and click on Hospitals, Physicians & Pharmacy Directory for your geographic area. You will find pharmacy addresses and types of pharmacies (retail, mail-order and home infusion) at this location. Freedom Health currently has 1400 in-network preferred pharmacies as of July 1, 2006.
Out-of-Network Coverage
As a member of the Freedom Medicare Advantage Plans, you have out-of-network pharmacy coverage ONLY for urgent and emergency medical needs.
Coverage Determinations and Exceptions Process
The plan may grant an exception whenever it determines that the non-preferred drug for treatment of the enrollee's condition is medically necessary, consistent with the prescribing physician's oral or written statement which includes:
the preferred drug would not be as effective for the enrollee as the requested drug or
the preferred drug would have adverse effects for the enrollee.
Tiering Exception
The plan will grant a tiering exception when it determines that the preferred drug for treatment of the enrollee’s condition would not be as effective for the enrollee as the requested drug and/or would have adverse effects.
Formulary Exception
The plan will grant a formulary exception when it determines that one of three factors has been demonstrated:
all covered Part D drugs on any tier of the plan’s formulary would not be as effective for the enrollee as the non-formulary drug and/or would have adverse effects;
the number of doses available under a dose restriction for the prescription drugs has been ineffective in the treatment of the enrollee’s disease or medical condition or based on both sound clinical evidence and medical and scientific evidence, the known relevant physical or mental characteristics of the enrollee, and know characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug’s effectiveness or patient compliance; or
the prescription drug alternative(s) listed on the formulary or required to be used in accordance with step therapy requirements has been ineffective in the treatment of the enrollee’s disease or medical condition, or based on both sound clinical evidence and medical and scientific evidence, the known relevant physical or mental characteristics of the enrollee, and known characteristics of the drug regimen, is likely to be ineffective or adversely affect the drug’s effectiveness or patient compliance or has caused or, based on sound clinical evidence and medical and scientific evidence is likely to cause an adverse reaction or other harm to the enrollee.
Exceptions criteria include, but are not limited to:
Consideration of whether the requested non-preferred drug is the therapeutic equivalent of any other drug on the plan's formulary and/or
Consideration of the number of drugs on the plan's formulary that are in the same class and category as the requested prescription drug that is the subject of the exceptions request.
Exceptions criteria include, but are not limited to:
Consideration of whether the requested non-preferred drug is the therapeutic equivalent of any other drug on the plan's formulary and/or
Consideration of the number of drugs on the plan's formulary that are in the same class and category as the requested prescription drug that is the subject of the exceptions request.
Medication Therapy Management (also referred to as medical quality management)
Medication Therapy Management is a distinct service that optimizes therapeutic outcomes for individual patients. Medication Therapy Management Services are independent of, but can occur in conjunction with, the provision of a medication product.
Medication Therapy Management encompasses a broad range of professional activities and responsibilities within the licensed pharmacist’s, or other qualified health care provider's, scope of practice. These services include but are not limited to the following, according to the individual needs of the patient:
Performing or obtaining necessary assessments of the patient’s health status;
Formulating a medication treatment plan;
Selecting, initiating, modifying, or administering medication therapy;
Monitoring and evaluating the patient’s response to therapy, including safety and effectiveness;
Performing a comprehensive medication review to identify, resolve, and prevent medication-related problems, including adverse drug events;
Documenting the care delivered and communicating essential information to the patient’s other primary care providers;
Providing verbal education and training designed to enhance patient understanding and appropriate use of his/her medications;
Providing information, support services and resources designed to enhance patient adherence with his/her therapeutic regimens; and
Coordinating and integrating medication therapy management services within the broader health care-management services being provided to the patient.
Eligibility and Enrollment
Not all members are eligible or require MTM programs. The identification of prospective MTMP members will be accomplished with two methodologies:
monthly drug data queries for high cost Part D formulary drugs and
quarterly drug data queries to identify multiple Part D formulary utilization that may have the potential of reaching the $4,000 annual threshold. MTM programs may have limited eligibility criteria. The qualifying conditions are listed in the attached Table 1. These programs are not a Plan benefit but are available to members who are identified by network physicians and/or through prescription drugs as potential candidates for participation.
MTM Qualifying Chronic Diseases for 2007
Anticoagulation
Asthma
Behavioral Health
Benign Prostatic Hyperplasia (BPH)
Cerebro-vascular Disease
Chronic Pain
Chronic Obstructive Pulmonary Disease (COPD)
Dyslipidemia
GI/Reflux/Ulcer Conditions
Heart Failure
Hepatitis C
Diabetes
Hypertension
Multiple Sclerosis
Osteoarthritis
Osteoporosis
Rheumatoid Arthritis
Enrollment into the MTMP will be an Opt-in program with a two tiered process, once the member has been identified as meeting all 3 criteria described below. In the first tier of the enrollment process the member will be called and the program will be discussed. At this time the member will be asked if they want to opt-in to the MTMP. The second tier (depending on the decision to participate), a letter will be sent explaining the benefits of the program and expectation is they answered “yes” to participation. Those members who opt not to participate in the MTMP will also receive a letter explaining the benefits of the program and asking one more time about their interest in participating in the MTMP.
After a member has agreed to participate in the MTMP, a letter will be sent to the prescribing physician’s identifying their patient as a participant in the MTMP. This will explain the program and the expectations. The goals of the program specific to their patient will also be outlined. Suggested therapy changes will be sent to the prescribing physician’s along with the identified benefits of such changes. The prescribing physician’s will be given a timeline for response based on the patient’s medical condition.
The member will also be contacted via phone and by letter if unreachable. Those changes recommended to the physician will be discussed with the member along with the benefits of making such changes. The member will be encouraged to discuss these with their physician at their next doctor’s appointment.
Follow up calls/letters will occur monthly to both member and prescribing physician’s until a response is obtained either agreeing to the changes or not agreeing to the suggested changes. During this initial intervention phase if a member has also been identified as being a candidate for one of the Freedom Health disease management programs, the enrollment into this program will be coordinated with the MTMP.
Follow up to a response will occur every six months, while reviewing the member’s drug profile a minimum of every quarter for new medications added to regimen. The member’s pharmacy will be contacted on an as needed basis to augment communication and changes made by the physician.
Please contact the Member Services Department at Freedom Health, Inc. for additional information on the program.
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