Frequently Asked Questions (FAQs)

Below are common questions about your coverage with Soundpath Health and Medicare. Don't see your question here? Call Customer Service at 1-866-789-7747 (TTY/TDD 1-866-264-4141). Soundpath Health's hours of operation are 8 am to 8 pm, Monday through Friday, and 8 am to 8 pm, Saturday and Sunday from October 15 to February 14.

Q. How does the coverage gap work?

A. The coverage gap is when Medicare temporarily stops paying for your prescriptions. If you are in the coverage gap, you will pay the majority of the cost of your medications. Once you are out of the gap and have transitioned to catastrophic coverage, you will pay a $2.60 copay for generic drugs and a $6.50 copay for brand-name drugs.

Q. What is the difference between preferred generic drugs and non-preferred generic drugs?

A. Preferred generic drugs are medications that are less expensive that non-preferred generic drugs but are useful to treat the same problem. Preferred generic drugs cost less that $50 per prescription and non-preferred generic drugs cost more than $50.

Q. What is an Explanation of Benefit (EOB)?

A. The explanation of benefit (EOB) provides details regarding how Soundpath Health of MedImpact (our contracted Pharmacy Benefit Manager) processed your medical insurance claims or your pharmacy claims. The EOB tells you what portion of the claim was paid and what portion of the payment is your responsibility. Although the EOB may look like a bill, it is not a bill. It is strictly for your records.

Q. Why did my premiums increase from 2011 to 2012?

A. A portion of this is a result of changes to the Medicare payment schedule and a portion is related to helping maintain long-term affordable coverage when medical costs are constantly rising. We offer a variety of plans with different cost sharing. Higher premiums often equal lower out-of-pocket costs. This is to allow individuals to choose the best plan for their individual medical needs.

Q. What is the difference between a copay, coinsurance and a deductible?

A. Copay is the amount you may be required to pay as your share of the cost for a medical service or supply, like a doctor’s visit, hospital outpatient visit or a prescription drug. A copay is usually a set amount, rather than a percentage. For example, you might pay $10 for a primary care office visit. Coinsurance is the amount you may be required to pay as your share of the cost for services or prescription drugs. Coinsurance is usually a percentage. A deductible is the amount you must pay for health care or prescriptions before our plan begins to pay.

Q. According to the Evidence of Coverage, there is no copay for lab services. Is that true for all labs?

A. Soundpath Health covers Medicare-approved lab work at 100 percent. There are some labs that are not covered by Medicare such as the General Health Panel. This is a series of tests that, as a whole, Medicare will not cover. If your physician orders tests that Medicare does not consider medically necessary, you will be responsible for 100 percent of that bill.

Q. What services are covered by Soundpath Health Medicare Advantage Plans that original Medicare does not cover?

  • Part A & B Deductibles
  • Routine hearing examinations
  • Routine eye examinations, Eyeglasses or Contact Lenses
  • Worldwide emergency coverage
  • Fitness Programs

Q. What if I am planning to work past the age of 65?

A. You do not have to be retired to enroll in Medicare.

Q. How do I keep my coverage if I travel out of state or out of the country?

A. Original Medicare coverage outside the United States is limited to emergency and urgent care medical services provided in Canada when you travel on the most direct route through Canada between Alaska and another state. Medicare also covers emergency hospital, ambulance, and inpatient physician services if a foreign hospital is closer or easier to get to than any hospital in the United States (the “United States” includes the 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa). In some cases, Medicare may pay for services that you get while on board a ship within the territorial waters adjoining the land areas of the United States. Medicare Advantage Plans often provide worldwide coverage for emergencies.

Q. Are the Soundpath Health Medicare Advantage Plans the same as Medicare supplement plans?

A. No. Soundpath Health Medicare Advantage Plans are not supplemental policies. Our plans provide coverage for Medicare Parts A and B, and much more. Unlike a Medicare Advantage plan, which replaces your Original Medicare benefits, a Medicare Supplement plan is purchased in addition to your Original Medicare benefits. Medicare Supplement policies are standardized into twelve plans, labeled “A” through “L,” each with its own set of benefits. These plans help cover the “gaps” in coverage that are left unpaid after Original Medicare pays its portion of your health care expenses. For this reason, these plans are often referred to as Medigap plans.

Q. What if I have a medical emergency?

A. With the Soundpath Health Medicare Advantage Plan, you're always covered for emergencies wherever you are. If you become ill or injured, or you have an emergency medical condition, don't hesitate to seek emergency health services. Call 911 or go to the nearest hospital emergency room or urgent care center.

Q. What happens after I become a Soundpath Health Medicare Advantage Plan member?

A. When you enroll in a Soundpath Health Medicare Advantage Plan, you will receive a confirmation letter from us, followed by your ID card and a welcome packet that includes an Evidence of Coverage (EOC) booklet. Your Evidence of Coverage booklet explains your policy with us and is required by the federal government. It explains:

  • Your plan benefits as a Soundpath Health Medicare Advantage Plan member
  •  Your rights and responsibilities as a member of Soundpath Health

The Evidence of Coverage is an important document. Please review it and keep it with your insurance records.

Q. Can Soundpath Health discontinue my health care coverage?

A. Once you're enrolled in a Soundpath Health Medicare Advantage Plan, you cannot be disqualified for any medical condition and cannot be canceled for any medical condition you may develop. There are very few reasons why Soundpath Health would discontinue your coverage. These include:

  • If you move permanently outside the Soundpath Health Medicare Advantage Plan service area or are temporarily absent for more than six (6) months
  • Federal regulations also allow us to involuntarily disenroll you if you: (1) Fail to pay any required plan premium or (2) Commit Medicare fraud

A complete description of your disenrollment rights can be found in your Soundpath Health Medicare Advantage Plan Evidence of Coverage.

Q. If my PCP or other provider is not in the Soundpath Health network, can he or she be added?

A. If your PCP or other provider is not currently in our network, please contact Customer Service. You may provide their name, address and phone number, and we will explore whether there is an opportunity to have them join our network.

Q. If my pharmacy is not in the Soundpath Health network, can it be added?

A. If your pharmacy is not currently in our network, please contact Customer Service. You may provide the name, address and phone number of the pharmacy, and we will explore whether there is an opportunity to have them join our network.

Q. If a prescription drug I am taking is not in your formulary, can I request to have it covered?

A. Yes, if your plan includes Part D prescription drug coverage, but a certain medication is not covered on our formulary, you can contact us and ask for a “Formulary Exception.” In order to help us make a decision more quickly, you should submit supporting medical information from your doctor when you request an exception.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

Q. If my physician wants me to take a prescription drug that is classified as non-preferred in your formulary, do I have to pay the non-preferred co-payment or co-insurance?

A. Not necessarily. If your plan includes Part D prescription drug coverage, you can contact us and ask for a “Tiering Exception” to have a Part D non-preferred drug covered at the preferred co-payment or co-insurance level. Ask your doctor to send us a supporting statement.

If we approve your exception request, our approval is valid for the remainder of the plan year, so long as your doctor continues to prescribe the drug for you and it continues to be safe and effective for treating your condition. If we deny your exception request, you can appeal our decision.

Page Last Updated: November 28, 2011