Find answers to the most commonly asked Medicare questions

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Understanding my coverage and benefits

What is a network?

A network is a group of doctors, hospitals, pharmacies, and other medical service providers associated with your unique health plan.


What is a plan medical group (PMG)?

A plan medical group (PMG) is a designated group of physicians and hospitals associated with your network. You have access to hospitals, specialty care and urgent care centers affiliated with your PMG. It is important to keep in mind that referrals or authorizations do not transfer between PMGs, and you only have access to one PMG at a time.

With the Sharp Direct Advantage Network, you’ll find a family of providers close to where you live and spend time. Our network includes Sharp Rees-Stealy Medical Group (SRS), Sharp Community Medical Group (SCMG) and our regional partner, Greater Tri Cities Medical Group. To find out which doctors are affiliated with your PMG, refer to the Sharp Direct Advantage Network provider directory at sharpmedicareadvantage.com/findadoctor or call Customer Care at 1-855-562-8853 (TTY 711).


Accessing care

How do I get started with Silver&Fit?

Getting started with Silver&Fit is easy. We’ve made it simple with just three steps:
 
1. Visit SilverandFit.com online to find a participating Silver&Fit fitness center near you.
All you need to do is choose the type of fitness center you’d like to join, and type in your 
ZIP code or city. Then click Search to find the right gym for you.

2. Contact Silver&Fit to let them know which participating fitness center you’d like to join.
You can call the Silver&Fit toll-free Customer Services hotline at 1-877-427-4788 (TTY/TDD 1-877-710-2746). Your effective date, or the date you can start using your fitness center’s facilities for free, will be the day after you call to enroll.

3. Silver&Fit will send you a fitness card to bring when you show up to the fitness center of your choice.

If you’re not able to travel to a facility or prefer exercising at home, your benefits include a free at-home fitness option. Silver&Fit offers a Home Fitness Program, where you can choose up to two Home Fitness Kits per benefit year. Each kit has a fitness theme, and will include materials such as DVDs, booklets and a quick start guide. You can enroll online or by phone, using the customer services hotline above. To learn more about Silver&Fit, please visit their website at SilverandFit.com.


The gym I’m trying to enroll in can’t verify my eligibility. What do I do?

If your local Silver&Fit facility can’t find you in their system, please call Silver&Fit toll-free Customer Services hotline at 1-877-427-4788 (TTY/TDD 1-877-710-2746). They are available to assist you Monday – Friday 5 a.m. to 6 p.m., Pacific Time. If they are unable to find you in their system, please call Sharp Health Plan Customer Care at 1-855-562-8853 (TTY 711) to report this issue. Please be sure to have your Sharp Health Plan member ID number available.


Will I get a card for my Vision Service Plan (VSP)?

No. When you access vision care, your VSP provider can verify your coverage using your Sharp Health Plan member ID number (starts with the letter S).


My eye doctor is unable to verify my eligibility. What do I do?

If your Vision Service Plan (VSP) provider can’t find you in their system, please contact VSP Member Services at 1-800-877-7195, or send an email to imember@vsp.com to verify that you are in their system. They are available to assist you Monday – Friday, 5 a.m. to 8 p.m., Saturdays 7 a.m. to 8 p.m., and Sundays 7 a.m. to 7 p.m. Pacific Time. If they are unable to find you in their system, please call Sharp Health Plan Customer Care at 1-855-562-8853 (TTY 711) to report this issue. Please be sure to have your Sharp Health Plan member ID number available.


My dentist can’t verify my eligibility. What do I do?

If your dental provider can’t find you in their system, please call Delta Dental’s Customer Service Department at 1-800-390-3368 (TTY/TDD 711). They are available to assist you Monday – Friday, 5 a.m. to 5 p.m., Pacific Time. If they are unable to find you in their system, please call Sharp Health Plan Customer Care at 1-855-562-8853 (TTY 711) to report this issue. Please be sure to have your Sharp Health Plan member ID number available.


Is the Assist America® phone number on my Sharp Direct Advantage member ID card?

No. Assist America’s contact information is not shown on your member ID Card. To contact Assist America in the U.S., please call 1-800-872-1414. To contact Assist America outside of the U.S., please call 1-609-986-1234. They are available to assist you 24 hours a day, seven days a week. Please be sure to have your Sharp Health Plan member ID number available.


Accessing plan materials and correspondence

Is there a way to decrease the amount of mail I receive from Sharp Health Plan? Can I elect for email notifications instead?

Unfortunately, no. Sharp Health Plan is required by the Centers for Medicare & Medicaid Services (CMS) to communicate most plan information to members by mail. For this same reason, we are unable to offer an email notification option for member correspondence at this time.


Filling prescriptions

How do I sign up for mail-order prescriptions?

To sign up for mail-order prescriptions, please visit sharpmedicareadvantage.com/mailorder. You can also call Postal Prescription Services at 1-800-552-6694. They are available to assist Monday – Friday, 6 am to 6 pm, and Saturdays 9 am to 2 pm, Pacific Time. Please note that Tier 5 medications are not available through mail order.

*Important note: We will be transitioning to a new mail order partner in January 2020. To learn more, visit Pharmacy FAQ.


Over-the-counter benefit 2020

Where can I find my Sharp Health Plan member ID number?

It can be found on the front of your health plan member ID card.


How can I find out what my benefit allowance is?

Benefit allowances vary depending on your plan. Check your Evidence of Coverage (EOC) to see what plan you’re enrolled in. You can access your EOC online through your Sharp Connect account at sharphealthplan.com/login.


Where can I find an OTC benefit catalog?

You can download the OTC benefit catalog for your plan. You can also have a catalog mailed to you by calling OTC Health Solutions at 1-888-628-2770 (TTY: 711). They are available to assist you Monday through Friday, 6 am to 5 pm Pacific Time.


How do I place my order?

You can either place your order online or over the phone. To order online, visit cvs.com/otchs/sharp and log in with your Sharp Health Plan member ID number and ZIP code.


I take aspirin every day. Can I use my allowance to buy it?

Yes, aspirin is just one of the hundreds of everyday health care products available in the catalog.


Is there a shipping and handling charge?

No. There is no charge to you for shipping and/or handling.


How long does it take to get my order once I’ve placed it?

You should receive your order within 7 to 10 business days of placing your order.


Can I track my orders?

Yes. Visit cvs.com/otchs/sharp, go to My Account and click on Order History. Or you can call 1-888-628-2770 (TTY: 711) to check the status of your order.


Can I use my allowance at my local pharmacy?

No, the benefit allowance can only be used for products from the Sharp Health Plan OTC catalog and can’t be used at a pharmacy or retail store.


What if the cost of my order is less than my allowance?

Let’s say your benefit allowance per quarter is $80 and you spend only $20 on your first order. That means you have another $60 left to use as long as you place the second order before the next quarter begins. Remember, unused benefits do not roll over from one quarter to the next.


What if the cost of my order is more than my allowance?

You won’t be able to place an order for an item that is above your allowance amount.


Can I check my account balance?

Yes. Visit the Sharp Health Plan OTC website and click on My Account to see your balance. Or you can call 1-888-628-2770 (TTY: 711) to find out what your account balance is.

 


What if I have money left in my account at the end of the quarter? Can I add it to the allowance for the next quarter?

No, the benefit allowance does not roll over into the next quarter. At the beginning of each quarter, your allowance will be reset to your quarterly spending limit.


Can I return my order?

Yes. If you receive a damaged item, please call OTC Health Solutions within 30 days after receiving your order. An identical replacement item will be shipped to you free of charge. No other returns or exchanges are allowed.


Registering for the portal

What is Sharp Connect?

Sharp Connect is our free online member portal that connects you with important plan information 24-hours a day. It’s mobile friendly, and allows you to view your benefits, update plan information, change your primary care physician, request a new member ID card, print a temporary card, check the covered drug list and much more.


I have a Sharp Connect account, why do I have to re-register?

We’re excited to announce a  portal upgrade that will offer even better functionality for our members online. As a result, we’re asking existing portal users to re-register on the portal for a brand new experience. You can do that by visiting the Sharp Medicare Advantage login page beginning January 1, 2018.


Selecting or changing my primary care physician

How do I choose a primary care physician (PCP)?

Your personal doctor, or primary care physician (PCP), is your partner in health. Whether it’s your first visit or an annual preventive care check-up, they will coordinate all of your care. They also provide referrals to other plan providers within your plan medical group. When you select a PCP, you are selecting your plan medical group. We encourage you to select a PCP who best suits your needs. If you are unable to select a PCP at the time you enroll in Sharp Health Plan, we will select one for you based on your mailing address, so that you can access care immediately.


Can I change my primary care physician (PCP)?

We know choosing the right PCP is a personal decision, which is why we make it easy for you to change your selection at any time. You can find a list of doctors online at sharpmedicareadvantage.com/findadoctor. If you wish to make a change, you can log in to Sharp Connect to use the online change PCP form, or call Customer Care at 1-855-562-8853 (TTY 711) and we will help you select a new PCP. The change will be effective on the first day of the following month. Upon making your selection, we will mail you a new member ID card.


Applying for coverage

When can I apply for Medicare coverage? How do I go about applying for it? 

If you are turning 65 and plan to begin Medicare, you can apply for coverage up to three months before and three months after your 65th birthday through Social Security. Unless you are still working and have comparable coverage through your employer, you could incur late enrollment penalties if you don’t sign up during your Initial Enrollment Period. 

You can sign up for Medicare by:

  • Visiting Social Security services online
  • Going to your local Social Security office
  • Calling Social Security at 1-800-772-1213 (toll free) or 1-800-325-0778 (toll-free TTY for the hearing/speech impaired), Monday through Friday, 7 a.m. to 7 p.m. ET


Am I able to apply for Medicare if I do not plan on retiring at 65?

If you or your spouse plan to continue working past the age of 65 and you want to keep your employer-based health coverage, you do not need to enroll in Medicare until you retire. If you prefer to enroll in a Medicare plan even through you or your spouse is still working you may do so. You can then choose to keep your employer health plan, or if you choose to disenroll, ask your employer about their rules for disenrolling.


Should I apply for Medicare if I am already receiving Social Security benefits?

You do not need to apply for Medicare if you are already receiving Social Security benefits, as you will be automatically enrolled in the Medicare program through those benefits. You should receive your Medicare card and coverage documents from your Social Security office approximately 90 days before your 65th birthday. Once you have your red, white and blue Medicare card, you can choose to enroll in a Medicare Advantage plan like Sharp Direct Advantage, or other types of additional Medicare coverage.


How do I get Medicare Part D drug coverage?

You can receive Medicare Part D coverage by enrolling in a qualifying plan, such as a Medicare Advantage with Part D coverage (MAPD) or Sharp Direct Advantage. If you do not enroll in a plan with Part D drug coverage when you are first eligible, you may receive late enrollment penalties from Medicare.


Understanding Medicare coverage and costs

What is Original Medicare? How do I use my Original Medicare benefits?

Original Medicare refers to Part A (Hospital Insurance) and Part B (Medical Insurance). When you visit a medical provider that accepts Medicare patients, these visits are covered with a cost share from Medicare. Although Original Medicare may cover a percentage of your care, there is no cap on your out-of-pocket costs and most drugs are not covered. Most people with Medicare enroll in additional coverage, such as a Medicare Advantage plan (like Sharp Direct Advantage), Medicare Supplement (Medigap) plan or stand-alone Medicare prescription drug plan.


Is there a cost for Medicare? 

Most people pay no premium for Part A but do pay a monthly premium for Part B, which may vary by your income level and when you enrolled. Depending on income, some people also pay a monthly premium for Part D. These premiums are payable to Medicare and are typically deducted from your Social Security check if you receive one.


How do Medicare Advantage plans work? 

Private insurance companies like Sharp Health Plan offer Medicare Advantage plans, or Part C plans. These plans always offer at least the same benefits as Original Medicare and usually more. Depending on the plan, premiums can be as little as $0 per month. These plans combine Part A, Part B and usually Part D into one comprehensive plan, and may add benefits not found in Original Medicare, like hearing and vision. When you enroll in a Medicare Advantage plan, you must only use in-network providers (except in emergency situations).


What is the difference between Medicaid and Medicare? Can I qualify for both? 

Medicaid (known as Medi-Cal in California) is a state health care program available to people who qualify based on low income status. Medicare is a federal health care program available to people who are 65 and older, as well as people under 65 with specific qualifying disabilities, or people with end-stage renal disease (ESRD). If you think you may qualify for Medi-Cal, you should speak with a representative of your local Social Security office. 


Getting enrolled

What are the requirements to enroll in the Sharp Direct Advantage Medicare plan? 

To enroll in Sharp Direct Advantage, you must meet the following requirements:

  1. Have Medicare Part A and be eligible for Medicare Part B
  2. Reside in San Diego County 
  3. Enroll during a valid enrollment period.
  4. Not have end-stage renal disease (ESRD), except under specific circumstances 


How do I enroll in a Sharp Medicare health plan?

You can choose how you would like to enroll


How can I check my enrollment status?

Contact Customer Care at 1-855-562-8853 (TTY/TDD 711) to check your enrollment status. For your convenience, our office hours are 8 a.m. to 8 p.m. 7 days per week from October 1 to March 31: 7 days per week 8 a.m. to 8 p.m. From April 1 to September 30: Monday through Friday, 8 a.m. to 8 p.m. and on weekends and holidays, your call will be handled by our voicemail system. A Customer Care Representative will return your phone call the next business day. 


Paying my bill

I elected to have my premiums deducted from my Social Security/checking account, but I am still getting a bill. Do I need to pay this?

No. If you have automatic payments set up, you do not need to pay the bill. Social Security deductions take place at the end of the month, after Sharp Health Plan creates billing statements. Your statement should show the previous month's payments. This confirms that your automatic payments are processing, and that you do not need to pay the bill.


Online payments

What information will I see on the payment portal and what can I do there?

Medicare members will see:

  • Current plan
  • Online transaction history
You will have options to make either one-time or scheduled automatic payments. 


Is making an online payment secure?

The Sharp Health Plan payment portal is a safe and secure way to pay your premium online. We use Payment Card Industry (PCI) compliant software with a secure payment gateway - technology used to transfer data. 


Will I get confirmation after making my online payment?

After making your online payment, you will receive an on-screen confirmation. You will also receive an emailed confirmation of your payment, including the receipt number and payment amount.


Why can't I view my balance due? 

The ability to view your balance due is currently unavailable, but we hope to offer this feature in the near future. 

Your correct monthly premium can be found on your monthly premium billing statement or 2020 coupon book from Sharp Health Plan. You can also view your billing correspondence on Sharp Connect. Please use this information to update your automatic payments.


I tried to set up a payment method using my American Express or Discover card, but it would not process. Why?

Sharp Health Plan accepts Visa® and Mastercard® credit or debit cards only.


How can I set up automatic payments?

Here are the steps to set up automatic payments:

  1. Create an account on the payment portal by entering the required information.
  2. Go to the “Automatic payments” page and click “Add automatic payment.”
  3. Select your payment method, plan and enter your payment amount.
  4. Choose a start and end date for the payments:
    • Start date: The day your payment will be processed each month.
    • End date: The last day your payments will automatically be made. We do not accept automatic payments after the 28th of each month.

Remember to update your automatic payment schedule(s) each year, before December 31. This will ensure accurate and timely premium payments.

Please note that if your payment method fails during a scheduled payment, payments will stop after three (3) failed attempts. To set up automatic payments again, you will have to delete your existing schedule, and create a new one with your updated payment method.

NOTE: You are responsible for canceling your automatic payments if your health coverage is terminated for any reason prior to the end date. Your payment amount is not automatically updated when you make changes to your health plan benefits.


How do I cancel an automatic payment?

To cancel automatic payments:

  • Log in to your payment portal account
  • Go to the “Automatic payments” page.
  • Under "Automatic payments," click on the trash icon located to the right of the scheduled automatic payment.

NOTE: You are responsible for canceling your automatic payments when your health coverage is terminated for any reason or when you no longer wish to make automatic payments.


Do I need to create an account to make a one-time payment?

Yes, all customers will need to create an account in order to make a one-time payment. Creating an account will also allow you to see your online transaction history and set up automatic payments.


I use automatic payments. When I make plan changes are my automatic payments automatically updated?

To ensure your automatic payments reflect your correct monthly premium, we recommend that you update your automatic payments regularly. Our online payment portal does not automatically update your payment information when you make a change to your health plan benefits.

Your correct monthly premium can be found on your monthly premium billing statements from Sharp Health Plan. You can also view your billing correspondence by registering or logging in to Sharp Connect. Please use this information to update your automatic payments.


How can I see my transaction history?

After logging in to your payment portal account, go to the “Transaction history” page. Your transaction history will display payments starting from Jan. 1, 2019. For more information, please call Customer Care at 1-855-562-8853.


How do I change my payment portal email address?

Please call Customer Care at 1-855-562-8853 to change the email address for your payment portal account.


How do I update or change a credit card?

If your credit card information changes, log into the payment portal and select “Profile.” Under the “Payment methods” section, simply delete the old credit card and add the new credit card information. If you update the credit card information used for your automatic payments, you will need to delete the current automatic payment that is set up and create a new automatic payment schedule.


I canceled my plan benefits. Why am I still getting charged?

Our online payment portal does not automatically update your payment information when you end your coverage. Automatic payments will continue until you cancel them. Please log in to the payment portal to cancel any automatic payments.


Introducing CVS Caremark® — our 2020 pharmacy benefit manager

What is changing?

We are partnering with a new pharmacy benefit manager (PBM) and mail order supplier in 2020 to help us improve your pharmacy experience. This new partnership will bring some enhancements for you beginning January 1, 2020:

  • A new, dedicated Medicare prescription helpline staffed by pharmacy experts who are available to assist you 24/7.
  • An improved digital pharmacy experience that allows you to access medication, prescription and pharmacy network tools and information through our website and Sharp Connect member portal.
  • Enhanced digital tools, like a free CVS Caremark® mobile app that lets you see your personalized pharmacy benefit information, refill or request new mail service prescriptions, track order status, view prescription history and much more.

We’ll also be making some updates to our pharmacy network and formulary. For more information, please read the frequently asked questions that follow below.


What changes will be made to the formulary?

Our formulary (or drug list) will be changing for 2020. There will be more positive formulary changes than negative. We will cover non-formulary drugs only when their use has been determined to be medically necessary after a review of a member’s specific needs. There will also be some tier, specialty drug and utilization management changes, including new step therapy, prior authorization and quantity limit requirements. In October, you will be able to see the 2020 formulary.


Why is the formulary changing?

Formularies change as new drugs are approved, and more information about new uses for drugs becomes available. These formulary changes help us to ensure that our formulary is up-to-date and includes the latest safety data and FDA-approved prescribing information.


When will the new formulary be effective?

The new formulary will be effective Jan. 1, 2020.


Is my pharmacy network changing?

Our pharmacy network (where prescriptions can be filled) will remain 99% the same in 2020. You can continue using all Sharp® pharmacies, in-network community pharmacies, and retail pharmacy chains such as Albertsons®, Costco®, Ralphs®, Rite Aid®, Vons®, Walgreens® and Walmart® in addition to CVS Pharmacy® stores. To find a pharmacy near you, visit sharphealthplan.com/pharmacy.


Will I get a new member ID card?

Yes. New member ID cards will be mailed in December. These cards will include new BIN and PCN information, which is used by pharmacies when you fill a prescription. Cards will also include a new, dedicated pharmacy telephone number for 24/7 support. Beginning Jan. 1, 2020, you should use your new ID card whenever getting care or filling prescriptions. See samples of the new ID cards.


Do I need to let my pharmacist know that I have a new ID card?

Yes. Your new ID card will include new BIN and PCN information, which is used by pharmacies when you fill a prescription. To ensure the best customer experience, it’s important to let your pharmacist know that you have a new ID card with new pharmacy information.


Plan notifications about formulary changes in 2020

How will I know if the formulary changes impact me?

We will notify members of any potential formulary changes by mail in November and December. These notices will only be sent to members who are taking medication that will be affected by changes to the formulary. If you get a letter from us, you will be directed to work with your doctor if you have questions. Your doctor will be notified of these changes too so that they are prepared to assist you with questions.


Managing prescriptions in 2020

Can I get a transition refill of my current prescription?

Yes. You can get a one-time, 30 day supply refill (also called a transition fill) of your current prescription during the first 90 days of 2020. The only exception is if your prescription is expired or does not have any refills left. For the best customer experience, please use a pharmacy that is in your network. To find a pharmacy near you, visit sharphealthplan.com/pharmacy.


Can I continue filling my prescriptions at a pharmacy that is no longer a part of my network?

Yes, but for the best customer experience, we encourage you to use a pharmacy in your network. To find a pharmacy near you, visit sharphealthplan.com/pharmacy. Please note that if you choose to use a pharmacy that is out of your network, you will only be reimbursed the network rate for your medications.


What should I do if I’m going on vacation?

If you have a vacation planned, it’s a good idea to refill your prescriptions before you leave. If you are traveling before Jan.1, 2020, please contact Customer Care at 1-855-562-8853 to request an exception to fill your prescription early. Beginning Jan. 1, 2020, you can call our dedicated prescription helpline at 1-855-222-3183 to request an exception.


Mail order in 2020

Do I need to update my mail order account?

Yes. We’ll be moving from Postal Prescription Services® Mail Order to CVS Caremark Mail Service Pharmacy. Your prescriptions will be transferred from Postal Prescription Services to CVS Caremark unless your prescription has expired, there are no refills left on their prescription, or if you are taking a controlled substance. These three instances will require you to get a new prescription. If you want to continue receiving mail order prescriptions, then you will have to create an account with CVS Caremark, and add your payment information. You can do that by calling the dedicated prescription helpline on the back of your new member ID card on or after Jan. 1, 2020, or by clicking here.


Pharmacy prior authorization in 2020

What if I have a prior authorization for my current medication?

All existing pharmacy prior authorizations will remain in effect until the date noted on your original approval letter from Sharp Health Plan. If you no longer have your approval letter, please contact Customer Care at 1-855-562-8853 before the end of the year so that we can assist you.


Member reimbursement in 2020

Will the member reimbursement process change for prescription drugs?

Yes. You will continue to be able to download the request form from our website. Please note that the form will have a new look and feel. Beginning Jan. 1, 2020, you will need to send your member reimbursement forms to CVS Caremark Medicare Part D Claims Processing at P.O. Box 52066, Phoenix AZ 85072-2066. This contact information will be printed on the request form.


Specialty pharmacy in 2020

Do I need to do anything if I use a specialty pharmacy?

Please make sure to share your new member ID card with your pharmacist, and let them know that you have new BIN and PCN information on the back of your member ID card.


Who to contact about my 2020 medications

Who should I contact with questions about my medications?

If you have questions about your medications for 2020, please work with your doctor. For all other questions contact Customer Care at 1-855-562-8853. Our hours of operation are 8 am to 8 pm Pacific Time, Monday through Friday. (From October through March, you can call us seven days a week.) Calling after hours will direct you to our voicemail system and a Customer Care representative will return your call the next business day.

Beginning Jan. 1, 2020, we’re excited to offer a new, dedicated prescription helpline that will be available for members to call with pharmacy-related questions. The helpline will be available 24/7 at 1-855-222-3183.


What is the new pharmacy telephone number?

Our new dedicated prescription helpline will be available beginning Jan. 1, 2020. The number will be printed on the back of your new member ID card, and will be available on the contact us page of our website.

Plan Type 24/7 Prescription Helpline
Medicare 1-855-222-3183


Explanation of benefits in 2020

Can I elect to receive paperless pharmacy EOBs?

Yes. Beginning Jan. 1, 2020, you can elect to receive paperless pharmacy EOBs. To do this, you will have to create an account at caremark.com. Once you’ve signed up, you’ll be able to change your pharmacy EOB preferences to paperless. After you’ve made this selection, a monthly email will be sent to notify you when your pharmacy EOB is available to view online. You will then need to log into your CVS Caremark account to view your pharmacy EOBs.


 

If you have additional questions, please contact us at Sharp Direct Advantage. We’re here to help.



 

Sharp Direct Advantage is offered by Sharp Health Plan. Sharp Health Plan is an HMO with a Medicare contract. Enrollment with Sharp Health Plan depends on contract renewal. Read the full disclaimer.

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