HealthSun Health Plans Benefits & Eligibility

HealthSun Health Plans is a Medicare Advantage Health Maintenance Organization (HMO). This website details some features of our plan. It does not list every service that we cover, every limitation, or every exclusion. To get a complete list of our benefits, please call HealthSun Health Plans and ask for the "Summary of Benefits".

WHEN CAN YOU ENROLL IN A MEDICARE HEALTH PLAN

November 15 – December 31, 2009 (Annual Election Period, AEP):
Medicare beneficiaries can enroll in a 2010 Medicare health benefits plan, such as a Medicare Advantage HMO plan, Original Medicare, or a stand-alone prescription drug plan (PDP).

January 1 – March 31, 2010 (Open Enrollment Period, OEP):
You are allowed to make one of the following changes to your health plan coverage:

1. If you are enrolled in a stand-alone PDP plan, you can only change to another Medicare Advantage plan with prescription drug coverage.
2. If you have a Medicare Advantage plan with prescription drug coverage (MAPD), the new plan you choose must also include prescription drug coverage. You may also disenroll from an MAPD plan back to Original Medicare. To do so, however, you must also enroll in a stand-alone PDP Plan via a Special Election Period.
3. If your Medicare Advantage plan doesn’t include prescription drug coverage, you can only switch to another plan that doesn’t include drug coverage or enroll in Original Medicare.
4. If you are enrolled in Original Medicare, you can only choose to enroll in a Medicare Advantage plan without prescription drug coverage.
5. If you are enrolled in Original Medicare and a prescription drug plan, the new plan you choose must be a Medicare Advantage plan with prescription drug coverage.

As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare Advantage Health plan, like HealthSun Health Plans, a Medicare Advantage approved HMO. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.

Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year.

You may join or leave a plan only at certain times. Please call HealthSun Health Plans at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call 1-877-486-2048.

The service area for this plan includes: Miami-Dade and Broward Counties in Florida. You must live in one of these places to join the plan. If you are in prison, you cannot join this plan.

HealthSun Health Plans, a Medicare Advantage approved HMO offers plans the following plans:

• SunPlus Advantage Plan Miami Dade County Plan 001
• SunPlus Advantage Plan Broward County Plan 002
• Healthy Advantage Plan Miami Dade County Plan 005
• MediMax Plan for Miami Dade County and Broward County Plan 006

HealthSun Health Plans Medicare Advantage approved HMO benefit plans cover all the benefits of Original Medicare and much more, including:

• Medically necessary doctor visits
• Hospitalization coverage
• Worldwide coverage for Emergency

Please remember that you must use HealthSun Health Plans' network providers.

SunPlus Advantage is a Benefit Plan offered by HealthSun Health Plan a Medicare Advantage approved HMO plan that allows you to choose your own primary care physician. Together, you and your primary care physician (PCP) coordinate all of your care. You even have the option to change your Primary Care Physician at any time. Your Primary Care Physician will refer you to specialists or hospitals when you need specialized care.

If you enroll in this plan HealthSun Health Plans will pay your Medicare Part B monthly premium of $96.40 per month. This means that while you are enrolled in this plan, the U.S. Social Security Administration will increase the amount of your monthly Social Security check by $96.40. You will not have to complete any paperwork to receive this benefit, only the enrollment application. You might not see the increase in your Social Security check for several months after the effective date of the plan. However, once the Social Security Administration completes the application processing, your next check will include the increases for all of the delayed months. If you disenroll from this plan, some delays may occur. Your monthly Social Security Check might include the additional $96.40 for several months after your disenrollment. Once the processing is completed, the U.S. Social Security Administration will deduct the full amount for the retroactive monthly Part B payments from your next Social Security check.

New in 2010 is the MediMax Plan. We believe our MediMax Plan will be beneficial to Medicare Beneficiaries that are Low Income Subsidy. The new MediMax Plan has a $310 yearly deductible but if the beneficiary qualifies he or she would receive assistance towards the payment of the deductible. In addition, the plan provides reductions to the co-pays and provides for more OTC benefits than our other Plans while offering the defined standard Part D benefit.

The MediMax Benefit Plan offered by HealthSun Health Plan allows you to choose your own primary care physician. Together, you and your primary care physician (PCP) coordinate all of your care. You even have the option to change your Primary Care Physician at any time. Your Primary Care Physician will refer you to specialists or hospitals when you need specialized care.

HealthSun Health Plans has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list. Our number is listed at the end of this introduction.

If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither HealthSun Health Plans, Inc. nor the Original Medicare Plan will pay for these services.

HealthSun Health Plans has formed a network of pharmacies. You can use any pharmacy in our network. The pharmacies in our network can change at any time. Call us for a current Pharmacy Network List — our hours and numbers are listed at the end of this page.

If you go to a pharmacy that's not in our network, you might have to pay more for your prescriptions. You also might have to follow special rules before getting your prescription in order for the prescription to be covered under our plan. For more information, call the telephone number at the end of this page.

HealthSun Health Plans does cover both Medicare Part B prescription drugs and Part D prescription drugs.

HealthSun Health Plans uses a formulary. A formulary is a preferred list of drugs selected to meet patient needs. The plan may periodically make changes to the formulary. If the formulary changes, affected enrollees will be notified in writing before the change is made. Contact HealthSun Health Plans for details.

A Medication Therapy Management (MTM) Program is a benefit that your plan may offer. You may be identified to participate in a program designed for your specific health and pharmacy needs. It is recommended that you take full advantage of this covered benefit if you are selected. Contact HealthSun Health Plans for more details.

The following outpatient prescription drugs may be covered under Medicare Part B. This may include, but is not limited to, the following types of drugs. Contact HealthSun Health Plans 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 alpha or Epogen©): 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 provided through DME.

Please call HealthSun Health Plans, Inc. for more information about this plan. Member Service Hours: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00am – 8:00pm Eastern. You may leave us a voice mail message after hours, Saturdays, Sundays and Holidays, and we will return your call the next business day.

Current and Prospective members should call 305-234-9292. TTY users should call 1-877-206-0500. Current and Prospective members should call 305-234-9292 for questions related to the Medicare Part D Prescription Drug program. TTY users should call 1-877-206-0500.

For more information about Medicare, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov on the web.

If you have special needs, this document may be available in other formats.