Member Resources

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.

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

PRIME (HMO-POS)

FLEX (RPPO)

VALUE (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.

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)

 

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. Download 2020 Formulary Changes. (PDF)

 

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.

Wellness Wallet reimbursement request

This form is for any services covered under your Wellness Wallet reimbursement benefit.

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.

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: To be eligible for payment, you must submit your claim by March 31, 2021. Note: The date of service or purchase must be in 2020.

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 (Portland)—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: No, sports club memberships are not eligible for reimbursement. While sports clubs do keep members physically active and engaged in their communities, we are unable to reimburse for them as they fall under the recreation category per Medicare guidelines.

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

A: The Wellness Wallet is a fitness reimbursement program offered by Generations Advantage.
Silver Sneakers is a national fitness network program offered by businesses and health plans and is not available to individuals through Generations Advantage plans.

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.

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

A: Per Medicare guidelines, only weight management programs 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 2020 and 2021 (for example, a full year membership from July 2020 through June 2021), you will be reimbursed for the entire amount of the membership, up to your 2020 Wellness Wallet dollar limit. If you are still a member of a plan with the Wellness Wallet benefit in 2021, you may resubmit the remaining amount at that time.

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.

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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)

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