Member Resources for 2021

Find additional information on using your benefits, after-hours and emergency care, prescription and pharmacies, reimbursements, and other forms to help you make the most of your health plan.

You can submit an online premium payment through PayTrace by clicking the button below. (Note: This will open in a new window.)

Please have a copy of your most recent statement handy before submitting an online payment request. You will need the following information (in addition to your payment method) to submit an online payment request:

  1. Member ID*
  2. ARAC #
  3. Member Name
  4. Email 

Submit Payment

For any plan-specific documents, please see your individual 2021 plan page below.

Prime (HMO-POS)

Flex (RPPO)

Alliance (HMO)

Value Plus (HMO)

Select (LPPO)

Focus DC (HMO SNP)

Martin’s Point Formulary (List of Covered Prescription Drugs)

Martin’s Point Generations Advantage uses a formulary. A formulary is a list of covered drugs selected by Martin’s Point Generations Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Martin’s Point Generations Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at a Martin’s Point Generations Advantage network pharmacy, and other plan rules are followed. For your coverage, click your plan page formulary below.

Formulary Changes 

Our formulary is reviewed and updated regularly by medical and pharmacy professionals. A formulary may change during the year if we: remove drugs from our formulary, add prior authorization, add quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier. Generally, if you are taking a drug on our formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during that same coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

We must notify you if a drug you are taking is changing at least 30 days before the change becomes effective. At the time you request a refill, you will receive a 30-day supply of the drug. Martin’s Point Generations Advantage covers both brand-name drugs and generic drugs. Generic drugs have the same active-ingredient formula as a brand-name drug. Generic drugs usually cost less than brand-name drugs and are rated by the Food and Drug Administration (FDA) to be as safe and effective as brand-name drugs.

View the 2021 Formulary Changes

Medication Transition Process

Find out what to do if your medication isn’t in our formulary (covered drug list).  Get details.

Coverage Determination and Exceptions Process

There are several ways to request a coverage determination or an exception. Find out more. 

Pharmacies and Out-of-Network Coverage

Learn more about the differences between in-network and out-of-network pharmacies. Get more info.

Request Part D Prior Authorization

Submit a request for a Medicare prescription drug coverage determination online. Submit request.

Request for Redetermination of Medicare Prescription Drug Denial

If Martins Point Generations Advantage denies your request for coverage of (or payment for) a prescription drug, you have the right to ask for a redetermination (appeal) of the decision.  Submit appeal.

Coverage Limits and Extra Help

Find out how prescription coverage limits impact you, and see if you qualify for assistance. Get details.

Medication Therapy Management

Qualified members can participate in this voluntary program that can help you get the greatest benefit from your medications. Find out more.

Prescription Utilization Management

Some covered drugs may have additional requirements or limits on coverage. Learn more.

Martin’s Point Health Care has teamed up with Foodsmart™ to provide you with free, unlimited chats with a registered dietitian—plus much more—to support healthy eating from the comfort of home.

You don’t need to use your health plan’s Wellness Wallet reimbursement program to take advantage of this benefit as your Generations Advantage plan covers 100% of the program cost. 

The Foodsmart program is tailored to your individual needs and preferences—from nutrition tips for managing a medical condition, to simply wanting to eat healthier, or just trying to save on groceries. 
Your Foodsmart dietitian and other resources can make healthy eating easier and more affordable.

To get started, call 1-888-837-5325 to schedule an appointment with a registered dietitian. If you are having online difficulties signing up, call 1-888-837-5325 for technical support. 
If you prefer to reach out online, you can:

  • Visit MartinsPoint.Zipongo.com to sign up.
  • Send an email requesting an appointment to[email protected].
  • Download the Foodsmart app in the App Store or Google Play. Click on “Sign Up.” Your Group is “Martin’s Point Generations Advantage.”

The evidence of coverage document outlines your medicare health benefits, services, and prescription drug coverage as a member of Martin's Point Generations Advantage.

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

Prime (HMO POS) Evidence of Coverage

For Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo and Washington counties in Maine; and Belknap, Carroll, Coos and Grafton counties in New Hampshire (PDF)

For Cheshire, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan counties in New Hampshire (PDF)

For Androscoggin, Cumberland, Kennebec, Sagadahoc and York counties in Maine (PDF)

Flex (RPPO) Evidence of Coverage

For all counties in Maine and New Hampshire (PDF)

Alliance (HMO) Evidence of Coverage

For all counties in Maine and New Hampshire (PDF)

Value Plus (HMO) Evidence of Coverage

For all counties in Maine and New Hampshire (PDF)

Select (LPPO) Evidence of Coverage

For all counties in Maine and New Hampshire (PDF)

Focus DC (HMO SNP) Evidence of Coverage

For all counties in Maine and New Hampshire (PDF)

Please contact our Member Services number at 1-866-544-7504 for additional information. (TTY users should call 711)

Wellness Wallet reimbursement request

This form is for any services covered under your 2021 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2021 and you must submit your claim by March 31, 2022. 

2021 Wellness Wallet Member Reimbursement (PDF)

This form is for any services covered under your 2020 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2020 and you must submit your claim by March 31, 2021. 

2020 Wellness Wallet Member Reimbursement (PDF)

Reimbursement request for medical services

This form is for reimbursement for medical services that you received through a provider or at a medical facility.

Member Reimbursement Request for Medical Services (PDF)

Reimbursement request for Medicare prescription drug purchase

This form is the prescription drug reimbursement form.  It is used when you have paid out-of-pocket for your formulary prescription drug.

Reimbursement Request for Medicare Prescription Drug Purchase (PDF) 

When you need medical care quickly, it's good to know you have a wide range of quality options to choose from, depending on how severe your condition or injury may be. 

If you feel your condition is life-or-limb threatening, the emergency room is always the right choice. 

If not, we recommend your PCP or an urgent-care clinic—you could save time and money, while receiving excellent care from highly-trained medical professionals.

Find out more.
 

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.

For more information on this process, please visit our Grievances & Appeals page.

Amplifon will help you find a hearing aid provider near you, explain the process, help you schedule an appointment, and send information to you and the provider, ensuring your discount is applied. Call Amplifon, 8 am–8 pm, Monday through Friday to get started: 1-888-669-2167 (TTY: 1-763-268-4264) 

Learn more about your hearing aid benefit information. Click on your health plan link to learn more.

Prime (HMO POS) Plan

Flex (RPPO) Plan

Value Plus (HMO) Plan

Select (LPPO) Plan

Alliance (HMO) Plan

Focus (HMO SNP) DC Plan

Q: Where do I mail completed reimbursement forms to?

A: Martin’s Point Generations Advantage Claims Department
PO Box 11410
Portland, ME 04104-9863

Q: How long will it take for me to receive my reimbursement check?

A: If additional information is not needed, you should receive payment within 4 to 6 weeks.

Q: When is the deadline to submit my reimbursement?

A: For any services covered under your 2021 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2021 and you must submit your claim by March 31, 2022. 

Download your reimbursement form to mail in:

2021 Wellness Wallet Member Reimbursement (PDF)

Q: Where can I purchase fitness equipment?

A: You can purchase equipment from any licensed retail establishment. We will not approve reimbursement for fitness equipment that has been purchased from a nonretail source (example: yard sale or Craigslist). The safety of our members is important and we want to ensure there is no risk of injury from noncertified equipment. If members are seeking to save on the costs or prefer to purchase second-hand equipment, there are a number of retailers—such as Play-it-Again Sports—that offer used equipment that has been checked for proper function and safety.

Q: Is my sports club membership (tennis, golf, squash, etc.) eligible for reimbursement?

A: Yes! New for 2021, sports league fees and club memberships are eligible for reimbursement!

Q: Will the Wellness Wallet cover Silver Sneakers® reimbursement?

A: No. However, we cover a number of items and services comparable to SilverSneakers. New for 2021 the following classes, fees or memberships are now eligible for reimbursement under your 2021 Generations Advantage Plan Wellness Wallet benefit. See your individual plan page for your yearly reimbursement amount.

  • Exercise Classes such as Martial Arts, Dance Classes and Yoga Classes, etc.
  • Club/Team/Lesson fees such as Golf Course Fees, Cycling Club fees, Squash Club Fees, Horseback Riding, etc.
  • Pickleball
  • Pool or YMCA membership fees
  • Fitness club/Gym membership fees
  • Personal trainer fees at a facility

For a summary of what is covered by your Wellness Wallet benefit, please download our 2021 Wellness Wallet Coverage Checklist (PDF).

Q: Will any nutritional/dietary program be eligible for reimbursement?

A: Any individual or group education and counseling is eligible for reimbursement, as long as the services are provided by licensed or certified practitioners furnishing services within the scope of their license or certificate.

Generations Advantage plan members are eligible to use their Wellness Wallet amount toward a dietary program with Good Measures™. This 12-month program provides dietary services through a registered dietitian and tools to help improve your eating and exercise habits. The program is covered at no cost for members with chronic kidney disease, pre-diabetes, or diabetes. How to use: Call Good Measures at 1-833-733-1163 to enroll.

Q: Will the Wellness Wallet cover NutriSystem® or other meal programs?

A: Per Medicare guidelines, only weight management programs, such as Weight Watchers®—that include weekly structured lessons with regular feedback and monitoring tailored to individual goals qualify. We cannot cover any food for reimbursement.

Q: If I enroll in my Generations Advantage plan mid-year, do I still receive the entire Wellness Wallet benefit amount?

A: Yes! You receive the entire Wellness Wallet amount that is offered under your Generations Advantage plan even if you join the plan mid-year. As a reminder, dates for received services or purchased items must be within the current plan year in order to be reimbursed under that year's Wellness Wallet benefit. (See next FAQ for details on gym memberships.)

Q: Will my 2020 Wellness Wallet cover a gym membership than spans into 2021?

A: If you pay for a gym membership that spans months in 2021 and 2022 (for example, a full year membership from July 2021 through June 2022), you will be reimbursed for the entire amount of the membership, up to your 2021 Wellness Wallet dollar limit. If you are still a member of a plan with the Wellness Wallet benefit in 2022, you may resubmit the remaining amount at that time.

Q: Can I be reimbursed for shipping and/or assembly fees?

A: Yes! Under your 2021 Wellness Wallet benefit, the costs of shipping, delivery and assembly can be reimbursed.

Q: What happens if I place an order, but my payment isn’t processed until a later date?

A: If you place an order for an item, but payment is not taken until a later date, the date you placed the order is considered the date of purchase so long as your receipt shows the date you placed the order.  For example, if you place an order for an item on 12/31 but payment is not taken from your account until 1/1, your purchase date would be considered 12/31 provided that your receipt lists the 12/31 order date.

If you are not sure whether your expense is eligible for reimbursement, please call Martin's Point Generations Advantage Member Services at 1-866-544-7504.

All Generations Advantage plans cover many  important preventive services at $0 copays—including your Medicare Annual Wellness Visit and your Annual Physical Exam.

Ask your doctor to schedule both visits in one, longer “comprehensive visit” appointment and save a trip to the doctor while taking good care of your health.

Find a provider.
 

Better Access to Your Health Information!

As part of the 21st Century Cures Act regulations, the Centers for Medicare and Medicaid (CMS) policy now requires that new systems be put in place next year to make it easier for you to see your important health data. Under the new systems, you’ll be able to:

  • Easily access your health claims information, including treatment and prescription history and costs
  • Find an up-to-date list of in-network providers
  • Know which providers have agreed to provide electronic access to your health information

Click HERE to learn more

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Have questions? We’re here to help.
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)
Plan Benefit Details and Documents
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Additional Resources

Medicare
1-800-MEDICARE (1-800-633-4227)
(TTY/TDD: 1-877-486-2048)
24 hours a day, 7 days a week

Social Security
1-800-772-1213
(TTY/TDD: 1-800-325-0778)

Maine State Health Insurance Assistance Program
1-800-262-2232
(TTY/TDD: 1-800-606-0215)

MaineCare (Medicaid)
207-287-2674
(TTY/TDD: 711)

Maine Low Cost Drugs for the Elderly or Disabled Program (DEL) and Maine Rx Plus
1-866-796-2463
(TTY/TDD: 1-800-423-4331)

New Hampshire ServiceLink Resource Center Network
1-866-634-9412

New Hampshire Medicaid
1-800-852-3345 ext 4344 or
603-271-4344

New Hampshire Medication Bridge Program
603-225-0900