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Explore our plan

Our plan benefits for 2025

If you are interested in enrolling before 2025, you can find our 2024 benefit documentation here.

You pay $0 for all these benefits:

Benefits

Monthly premium

Annual deductible

Doctor visits

  • In office or in your home
  • Annual wellness visit and/or routine physical
  • Primary care or specialist (in-network or out-of-network)

Prescription drugs

  • Up to a 100-day supply
  • All Part D drugs and vaccines
  • Prior authorization may be required for certain drugs

Supplemental drugs

  • Drugs not normally covered by Medicare included in the formulary (drug list) $1.60
  • Diabetic supplies
  • Lab tests and X-rays
  • Outpatient surgery and services
  • Inpatient hospitalization
  • Urgent care (nationwide coverage) and virtual visits for non-emergency care
  • Emergency room (nationwide coverage)
  • Ambulance (nationwide coverage)

$0

Additional benefits and extras for CareOregon Advantage members

CareOregon Advantage CareCard

  • $1,378 per year ($344.50 per quarter) for healthy foods, health items and utilities
  • Reward funds for qualifying healthy activities

Routine eye exam (every 12 months)

  • Routine eye exam (every 12 months)
  • Eyeglasses or contact lenses (every 12 months); all basic, progressive and high-index lens categories covered.
  • Personal emergency response system (PERS)
    • 24 hours a day, 7 days a week emergency response and monitoring
  • Silver&Fit® gym membership and home fitness kits
  • Papa Pals in-home support services (up to 60 hours a year)
  • Teladoc Health urgent care
    • Talk to doctors by phone or video 24 hours a day, 7 days a week

$0

Benefits for people with Medicare and Medicaid

Additional dental care

  • Exams and X-rays (includes oral cancer screening)
  • Cleanings, fluoride, fillings and extractions
  • Full dentures every 10 years and partials every 5 years if recommended by your dentist (Authorization required)
  • Denture adjustments, replacing missing or broken false teeth
  • Deep cleaning for gum disease
  • Emergency dental services

Hearing benefits

  • Exam (every 12 months)
  • Hearing aids (authorization required, up to 2 aids every 5 years)
  • Hearing aid batteries (60 per calendar year)
  • Acupuncture and chiropractic care
    • authorization required
  • Meal delivery after inpatient stays
    • three meals per day for 4 weeks
  • Transportation
    • unlimited rides to health care appointments
  • Incontinence supplies 
    • adult diapers, disposable briefs/pads, bed pads, gloves
  • Interpreter services for office visits

$0

Drug coverage

Prior Authorization

CareOregon Advantage Plus requires you or your prescriber to get prior authorization for certain drugs. This means that you will need to get approval from CareOregon Advantage before you fill your prescriptions. If you don’t get approval, we may not cover the drug. 

2024 CareOregon Advantage Prior Authorization Criteria (PDF)

Step Therapy

In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, we may not cover Drug B unless you try Drug A first. If Drug A does not work for you, we will then cover Drug B.  

You can find out if your drug has any additional requirements or limits by checking our Drug List/Formulary.   
You can ask us to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition. See the Drug List/Formulary for information about how to request an exception. 

2024 CareOregon Advantage Step Therapy Criteria (PDF)

COA Part B Step Therapy Criteria (PDF)

FAQ

CareOregon Advantage Plus has no premium for medical coverage for Part A and B services. You must continue to pay your Medicare Part B premium unless it's paid for through your Medicaid coverage. Most medical services have no copayment as long as you have Medicaid coverage through CareOregon.

For Part D services, CareOregon Advantage Plus has a premium of $0 per month for prescription drugs (any premium is covered through Low-Income Subsidy).

If you qualify for Extra Help with your Medicare prescription drug plan costs, your premium will be lower. When you join CareOregon Advantage, Medicare will tell us how much Extra Help you are getting. Then, we will let you know the amount you will pay. If you aren't getting any Extra Help, you can see if you qualify by calling:

  • 800-MEDICARE (800-633-4227)
    TTY users should call 877-486-2048
  • Health Systems Division  (8 a.m. to 5 p.m.)
    Phone: 503-945-5772
    Phone: 800-527-5772
    TTY: 800-375-2863
  • The Social Security Administration at 800-772-1213 (7 a.m. to 7 p.m. Monday through Friday). TTY users should call 800-325-0778

An online application for Extra Help is also available.

As a member of CareOregon Advantage, most medical services and office visits do not have copays. If you receive a bill, do not pay it. Please call Customer Service, who can work with you and your provider to resolve the balance. 

CareOregon Advantage has a network of providers that our members can choose from. See our Provider Directory or online provider search tool to find a specific provider, or to see if your current provider is in our network. 

If you do not choose a network provider as your primary care provider (PCP) when you sign up, we will assign one to you. You can change your PCP by calling Customer Service at 503-416-4279, toll-free at 888-712-3258 or TTY 711. Our hours are 8 a.m. to 8 p.m. seven days a week, October 1 to March 31, and 8 a.m. to 8 p.m. Monday through Friday, April 1 to September 30. 

Point-of-Service (POS) benefit 

Generally, you must use providers who are in our network to receive benefits. However, CareOregon Advantage Plus has a Point-of-Service (POS) option that allows you to get care from out of network PCPs and specialists under certain conditions. There are annual limits to this benefit. For more information, see “POS benefit” Chapter 4, section 2.1 of the Evidence of Coverage. 

You can find the Evidence of Coverage on the My plan documents web page. 

Special enrollment periods are times when you may be eligible to enroll in Medicare even though it’s outside of Medicare open enrollment. Open enrollment, also called the annual enrollment period (AEP), runs from October 15 to December 7 every year. 

Certain circumstances, though, make you eligible to enroll in Medicare Part A, B or both at other times. For example: 

  • If you’re covered by a current employer’s group health plan (not as a retiree plan or COBRA), your special enrollment period covers the entire time you’re working or your spouse is working. (Or, if you’re disabled, when a family member is working.)
  • An eight-month special enrollment period is triggered by whichever of these two events happens first: your employment ends or your employer-provided group health coverage ends. Coverage will begin the following month.
  • If you are eligible for both Medicare and Medicaid (in Oregon, the Oregon Health Plan is Medicaid), you may enroll in Medicare at any time. Your enrollment period never closes.

Yes, the Medicare rules offer Medicare Advantage plan enrollees a limited chance to back out of their choice. This three-month opportunity is called the Medicare Advantage Open Enrollment Period. From January 1 to March 31, you may drop or disenroll from your Medicare Advantage plan and switch to Original Medicare Parts A and B. If you disenroll, the change takes effect the first day of the month after your plan gets your disenrollment notice. 

To switch to Original Medicare, contact your current plan, or call 800-MEDICARE (800-633-4227). 

If you disenroll from Medicare Advantage, you’re allowed to enroll in a Part D prescription drug plan. This is important because Original Medicare doesn’t include prescription drug coverage. Your new Part D drug benefits will start on the first day of the month after the plan gets your enrollment form. 

The allowed actions during the disenrollment period are very narrow. You may not switch from one Medicare Advantage plan to another Medicare Advantage plan, you may not switch from one Part D plan to another, and you may not switch from Original Medicare to a Medicare Advantage plan. 

The CareOregon Advantage CareCard is an added benefit to our Plus plan that gives you up to $1,378 per year ($344.50 per quarter) to spend on health items, healthy foods and household utilities. This is money that would otherwise come out of your own pocket. There are also opportunities to earn more money by getting your checkups and/or treating specific qualifying conditions*.  

There is no cost to get this card and it can be used to shop at stores like Albertsons, Walgreens, Walmart, Fred Meyer, Farmbox Rx and more, or to pay your utility bills.  

*Please note: some screenings or activities are only available to members who meet program conditions or when recommended by a provider. 

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Page last updated: October 1, 2024
Pending CMS approval H5859_COAWEB_M_2025

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