Disclaimers and Policies

Martin’s Point Generations Advantage is a health plan with a Medicare contract offering HMO, HMO-POS, HMO SNP, and Local and Regional PPO products. Enrollment in a Martin’s Point Generations Advantage plan depends on contract renewal.

Martin’s Point Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

Premiums vary by plan and county. You must continue to pay your Medicare Part B premium. 

This information is not a complete description of benefits.  Contact the plan for more information.

Limitations, copayments, and restrictions may apply. Benefits, formulary, provider and pharmacy network, premium, copayments, and coinsurance may change on January 1 of each year.

The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

Martin’s Point Generation Advantage’s pharmacy network includes limited lower-cost, preferred pharmacies in suburban areas in Maine and New Hampshire. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call 1-866-544-7504 (TTY:711) or consult the online pharmacy directory.

Other pharmacies/physicians/providers are available in network.

This is not a complete list of all formulary alternatives covered by the Part D sponsor for the drug you have selected.

This is not a complete list of drugs covered by our plan. For a complete listing, please call 1-866-544-7504 (TTY:711) or, for your coverage, see click your plan page formulary below.

Prime Plan Formulary (List of Covered Drugs)

Flex Plan Formulary (List of Covered Drugs)

Select Plan Formulary (List of Covered Drugs)

Value Plus Plan Formulary (List of Covered Drugs)

Focus DC Plan Formulary (List of Covered Drugs)

Plan selection information from Medicare Advantage/Part D Contract and Enrollment Data reports available at www.cms.gov.

Medicare beneficiaries may also enroll in Martin's Point Generations Advantage through the CMS Medicare Online Enrollment Center at http://www.medicare.gov.

Every year, Medicare evaluates plans based on a 5-star rating system.  5-Star Special Enrollment Period runs from 1/1/20–11/30/20. You may switch to a 5-Star plan once during this period.

Generations Advantage 2020 Overall Ratings: 5 out of 5 Stars for LPPO Contract H1365; 4.5 out of 5 Stars for HMO Contract H5591. RPPO Contract R0802 was too new to receive a 2020 Star Rating. Visit http://www.medicare.gov for more information.

The Generations Advantage Focus DC (HMO-SNP) plan is available (in Cumberland County only) to anyone with Medicare who has been diagnosed with diabetes.

Out-of-network/non-contracted providers are under no obligation to treat Generations Advantage plan members, except in emergency situations. Please call our Member Service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

A salesperson will be present at seminars with information and applications. For accommodation of persons with special needs at meetings, call 1-888-640-4423 (TTY: 711).

Member Services 866-544-7504 (TTY:711) is available 8 am-8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year.

Each year the federal agency that administers Medicare—the Centers for Medicare & Medicaid Services—rates all Medicare Advantage plans on quality and performance. A 5-star rating is the highest rating possible from Medicare.

These ratings help our members and other Medicare beneficiaries know how good a job our plan is doing. You can use these Star Ratings to compare our plans' performance to other plans' performance using the Medicare Plan Finder tool.  

HMO Plan - Overall Rating
For 2020, our Generations Advantage Prime (HMO-POS), Value Plus (HMO), Value (HMO), and Focus DC (HMO SNP) plans received a 4.5-Star Overall Rating from Medicare. Only five plans earned 4.5 Stars or above in Maine and New Hampshire!


LPPO Plan - Overall Rating
For 2020, our Generations Advantage Select (LPPO) plan earned a 5-Star Overall Rating from Medicare—one of only two plans to earn 5 Stars in Maine and New Hampshire!1

5 Stars
RPPO Plan - Overall Rating
For 2020, our Generations Advantage Flex (RPPO) plan is too new to be rated.

Member Experience Ratings
Drug Plan Customer Service - All Plans

Member Experience with Health Plan - All Plans

Member Experience with Drug Plan - HMO Plans

Drug Safety and Accuracy of Drug Pricing – All Plans

For more rating information on the Generations Advantage Prime, Value Plus, Value, and Focus DC plans, see our CMS Plan Ratings Sheet for the Prime, Value Plus, Value, and Focus DC plans.

For rating information on the Generations Advantage Select plan, please see our CMS Plan Ratings Sheet for the Select plan.

1 Medicare evaluates plans based on a 5-star rating system. Star Ratings are calculated each year and may change from one year to the next.

Contract #H5591 (Generations Advantage Prime, Value Plus, Value, and Focus DC) earned 5-stars in 2019. Contract #H1365 (Generations Advantage Select) earned 4.5 stars in 2019. Contract #R0802 (Generations Advantage Flex) was too new to be measured for 2019.

Martin’s Point Health Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Martin’s Point Health Care does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Martin’s Point Health Care:

  • Provides free aids and services to people with disabilities to communicate effectively with us, such as:
    • Qualified sign language interpreters
    • Written information in other formats (large print, audio, accessible electronic formats, other formats)
  • Provides free language services to people whose primary language is not English, such as:
    • Qualified interpreters
    • Information written in other languages

If you need these services, contact the Martin's Point Generations Advantage Grievance Department.

If you believe that Martin’s Point Health Care has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:

Grievance Department
Martin’s Point Generations Advantage
PO Box 9746
Portland, ME 04104-8832

Phone: 1-866-544-7504, TTY: 711
Fax: 207-828-7874

You can file a grievance in person, by mail, or by fax. If you need help filing a grievance, the Martin’s Point Generations Advantage Grievance Specialist is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail or phone at:

U.S. Department of Health and Human Services
200 Independence Avenue, SW
Room 509F, HHH Building
Washington, D.C. 20201 
1-800-368-1019 (TDD: 1-800-537-7697)

Complaint forms are available at https://www.hhs.gov/hipaa/filing-a-complaint/index.html

Multi-language Interpreter Service (PDF)

At Martin’s Point, we are committed to providing our members a fair and timely process for resolving any complaints or disputes. We encourage Martin’s Point Generations Advantage members to contact us with questions, concerns, or problems related to any benefits or service. Please call us at 1-866-544-7504 (TTY: 711), 8 am to 8 pm, seven days a week from October 1–March 31, and Monday through Friday the rest of the year, to discuss your concerns.

Federal law guarantees our members’ rights to make complaints regarding concerns or problems with any part of the plan. The Medicare program has helped set the rules about what’s needed to make a complaint, and what we have to do when we receive a complaint. If a complaint is filed, we must be fair in how we handle it. As a Martin’s Point Generations Advantage member, you may not be disenrolled from your plan or penalized in any way for making a complaint.

For more information on coverage determinations, including exceptions, grievances, and appeals processes, please see the Evidence of Coverage for your plan. For Prime (HMO-POS), Flex (RPPO), Select (LPPO), Value Plus (HMO), and Focus DC (HMO SNP) plans, look at Chapter 9 of the Evidence of Coverage. For Value (HMO) plan, see Chapter 7 of the Evidence of Coverage. You can access the Evidence of Coverage for your plan on the plan detail page.

You are entitled to obtain an aggregate number of grievances, appeals, and exceptions filed with Martin's Point Generations Advantage. You may do so by filing a written request with Martin's Point Generations Advantage and sending it to:

Martin's Point Generations Advantage Grievance Department.
PO Box 9746
Portland, ME 04104

 

To get more information on your plan and benefits, please see the Evidence of Coverage document on your plan detail page:

As a Martin’s Point Generations Advantage member, you have a right to file a complaint if you think you aren’t getting quality service from us or you have quality of care issues with a plan provider. This type of complaint is called a “grievance.” It is a formal complaint or dispute you have with Martin’s Point Generations Advantage or one of our plan providers. There could be many reasons, such as: you could have a problem with the quality or timeliness of services you receive; you could have a problem with how and when you were enrolled in or disenrolled from the plan; you could have difficulty getting through on the telephone; or you could have a complaint about the cleanliness or condition of the doctor’s office or pharmacy.
You or your authorized representative may file a formal grievance either verbally or in writing by contacting our Member Services department or mailing your request to Martin’s Point Generations Advantage. To file a grievance verbally, please call us at 1-866-544-7504 (TTY: 711). We are available 8 am–8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year. 
 
You can mail your written grievance to:

Martin’s Point Generations Advantage
Grievances
PO Box 9746
Portland, ME, 04104-9861
 
If your request for a fast appeal (sometimes called, an “expedited organization determination” or “expedited reconsideration”) is denied by Martin’s Point Generations Advantage, you have the right to submit a fast grievance request. If you file a fast grievance, our Grievance Coordinator will respond to your request within 24 hours.
The parties who may request a standard or expedited redetermination include an enrollee, an enrollee’s representative, or an enrollee's prescribing physician or other prescriber.  If you are appointing a representative, the Medicare Appointment of Representative form (PDF) is required to be sent in with the appeal.

Requesting an Appeal from Martin’s Point Generations Advantage:

As a Martin’s Point Generations Advantage member, you have the right to ask us to reconsider our decisions. An appeal is a formal complaint or dispute regarding our decision not to pay for, not to provide, or to stop paying for or providing an item or service that you believe is needed. When you file an appeal, you are asking us to reconsider and change an initial decision (also called an "initial organization determination") we have made about what services we will cover for you. An appeal can also be called a “request for reconsideration.”

The appeals process would apply in situations such as:

  • The plan denies payment for services you believed to be an emergency or urgent. 
  • Either the plan or a plan medical provider refuses to provide services to you that you believe should be provided, arranged, or paid for by the plan. 
  • The plan refuses to pay for any basic benefit for any reason, including medical necessity. 
  • Either the plan or a plan medical provider decides to stop or reduce coverage for a treatment or service you have been getting, and you feel that this decision could harm your health.

If you file a standard appeal request for care or treatment that you have not yet received, it will be processed within 30 calendar days of receiving your appeal. However, if your request is for a decision about care that you have already received, your appeal request will be processed within 60 calendar days of receiving your request. If either you or we find that some information is missing which can help you, we can take up to 14 more calendar days to make our decision.

When making an appeal the first level of appeal is with the plan. We review the coverage decision we have made to check to see if we are following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. If we say no to all or part of your Level 1 appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal. Whether you can take the next step may depend on the dollar value of the requested service.

Who can request an appeal?

The parties who may request a standard or expedited redetermination include an enrollee, an enrollee’s representative, or an enrollee's prescribing physician or other prescriber.  If you are appointing a representative, the Medicare Appointment of Representative form (PDF) is required to be sent in with the appeal.

How do I request an appeal?

Your appeal must be made in writing.  Simply mail or fax us a letter indicating what it is you would like to appeal, along with any documents that support your appeal, such as a copy of a bill you are receiving, medical records, or pictures of your injury.  You must request your appeal no later than 60 days following our original denial of coverage unless you have good cause for us to open a case beyond 60 days.  Some good cause reasons include a serious illness that would have prevented you from filing on time, death or serious illness in your immediate family, an accident that caused your records to be destroyed, among others. 

Please fax your request to us at: 207-828-7874.

Please mail your request to us at:
Martin’s Point Generations Advantage Appeals Department
P.O. Box 8832
Portland, ME 04104-9861

You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to 30 days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your physician’s supporting statement. For more information about expedited appeals, please call the Generations Advantage Member Services team.
An enrollee, enrollee’s representative or enrollee’s prescribing physician or other prescriber may request a standard redetermination by filing a written request with the Part D plan sponsor.  The request must be filed within 60 calendar days from the date printed or written on the written coverage determination denial notice.

The request may be verbal, by calling our office, or in writing by mailing it to:

CVS Caremark–Martin’s Point Generations Advantage
Medicare Appeals Department
MC109
PO Box 52000
Phoenix, AZ 85072-2000

Or by faxing to 1-855-633-7673

You can also use our Redetermination form (PDF).  You are not required to use this form but it may be a helpful guide.
As a member of a Martin’s Point Generations Advantage, plan you can generally appeal our decision not to cover a drug, vaccine, or other Part D benefit. You may also appeal our decision not to reimburse the payment for a Part D drug. In addition, if you think we should have paid or reimbursed more than you received, or the amount paid is more than you are supposed to pay under the plan, you can appeal. Finally, if we deny an exception request, you can appeal.

There are five levels to the appeals process for Martin’s Point Generations Advantage members. At each level, the request for Part D benefits or payment is considered and a decision is made. The decision may be partly or completely in your favor (giving some or all of what you asked for), or it may be completely denied (turned down). If you are unhappy with the decision, there may be another step to get further review of the request. Whether you can take the next step may depend on the dollar value of the requested drug or on other factors.
 
You can request an expedited (fast) exception if you or your doctor believe that your health could be seriously harmed by waiting up to seven days for a decision. If your request to expedite is granted, we must give you a decision no later than 72 hours after we get your prescribing physician’s supporting statement. For more information about expedited appeals call 1-888-296-6961 (TTY: 711).
We must provide written notice of your redetermination (appeal), whether favorable or adverse, as expeditiously as the enrollee’s health condition requires, but no later than 7 calendar days from the date the Part D plan sponsor receives the request for a standard redetermination.
If you ever have any issues with your Generations Advantage plan, we hope you will let us know so we can help.

To file a complaint with Martin's Point Generations Advantage:
Call Member Services at 1-866-544-7504 (TTY: 711).
We are available 8 am–8 pm, seven days a week from October 1 to March 31; and Monday through Friday the rest of the year. 

Fax a written complaint to 207-828-7874.

You may also mail your complaint to:
Martin's Point Generations Advantage
ATTN: Member Services - Grievances
PO Box 9746
Portland, ME 04101-5040

If you suspect fraud, waste or abuse, please call the Martin's Point Compliance Hotline at: 1-800-297-8616.

Medicare Complaint Form
You can submit a complaint directly to Medicare if you’d like by filling out the Medicare Complaint Form

Medicare Website
Medicare’s official website includes the Medicare and You handbook and ratings of all Medicare health plans. Find out more.  

Medicare Ombudsman
The Office of the Medicare Ombudsman (OMO) helps you with complaints, grievances, and information requests. Visit the Medicare Ombudsman website.
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Talk to a Member Service representative 8 am–8 pm, Monday-Friday.

Current Members:
1-866-544-7504

Enroll:
1-800-603-0652 
(TTY: 711)

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