CenterLight Healthcare Direct

Frequently Asked Questions

What is the difference between Medicare Advantage Prescription Drug Plans and Special Needs Plans (SNP HMO)?

CenterLight Healthcare Direct Value and CenterLight Healthcare Direct Choice are Medicare Advantage Health Maintenance Organizations that offer all the benefits of an original Medicare Plan plus much more, including full prescription drug coverage; quality medical care from an extensive network of physicians, specialists and hospitals; emergency room coverage; no monthly premium; vision and dental care and free health screenings.

CenterLight Healthcare Direct Complete Plan is a Special Needs Plan for Medicare beneficiaries who require a nursing home level of care whether they reside in a nursing home, assisted living facility or in their own home and community.

CenterLight Healthcare Total Plan is a Medicare Advantage Health Maintenance Organization Special Needs Plan for Medicare beneficiaries who receive full Medicaid (are dual eligible) and require a nursing home level of care in their own home and community.

Where are CenterLight Healthcare Direct Plans available?

The service area for this plan includes: Bronx, Kings (Brooklyn), New York (Manhattan), Queens, Richmond (Staten Island), Nassau, Suffolk and Westchester counties. You must live in one of these areas to join the plan.

When can I join CenterLight Healthcare Direct?

For specific enrollment dates, please click here.

Can I choose my own doctors?

CenterLight Healthcare Direct has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time.

You can ask for a current provider directory by calling us at 1-877-226-8500 (TTY 711) or click here for an up-to-date list.

What happens if I go to a doctor who's not in your network?

If you choose to go to a doctor outside of our network, you must pay for these services yourself except in limited situations (for example, emergency care). Neither the CenterLight Healthcare Direct plan nor the Original Medicare Plan will pay for these services.

Where can I get my prescriptions if I join this plan?

CenterLight Healthcare Direct has a large network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time.

You can ask for a pharmacy directory by calling us at 1-877-226-8500 (TTY 711) or click here to view online.

Does my plan cover Medicare Part B or Part D drugs?

Yes, CenterLight Healthcare Direct Plans cover both Medicare Part B and Medicare Part D prescription drugs.

What is a Prescription Drug Formulary?

CenterLight Healthcare Direct uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you if you call us at 1-877-226-8500 (TTY 711) or you can view our complete formulary by clicking here.

How can I get extra help with my Prescription Drug Plan costs or get extra help with other Medicare costs?

To see if you qualify for getting extra help, call:

1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare & You.

The Social Security Administration at 1-800-772-1213 between 7:00 a.m. and 7:00 p.m. Monday through Friday. TTY/TDD users should call 1- 800-325-0778

Your State Medicaid Office

Elderly Pharmaceutical Insurance Coverage (EPIC), a New York State program that assists residents 65 or older with drug costs.

What is a Medication Therapy Management (MTM) Program?

A Medication Therapy Management (MTM) Program is a free service we offer, if you have high drug costs. Contact CenterLight Healthcare Direct at 1-877-226-8500 (TTY 711) for more details.

What types of drugs may be covered under Medicare Part B?

Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact CenterLight Healthcare Direct at 1-877-226-8500 (TTY 711) for more details.

Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.

Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.

Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia.

Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.

Injectable Drugs: Most injectable drugs administered incident to a physician’s service.

Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.

Some Oral Cancer Drugs: If the same drug is available in injectable form.

Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.

Inhalation and Infusion Drugs provided through DME.

Where can I find information on plan ratings?

The Medicare program rates how well plans perform in different categories. If you have access to the web, you may use the web tools on www.medicare.gov and select “Compare Medicare Prescription Drug Plans” or “Compare Health Plans and Medigap Policies in Your Area” to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. You can also call CenterLight Healthcare Direct at 1-877-226-8500 (TTY 711).

What are my protections in these plans?

All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.

For more information or to enroll in CenterLight Healthcare contact one of our dedicated Member Services representatives at 1-877-226-8500 (TTY users call 711) from 8:00 am to 8:00 pm EST, 7 days a week or email us at MemberServices@centerlight.org.

For more information about Medicare you can also call 1-800-MEDICARE (1-800-633-4227).

CenterLight Healthcare has a Medicaid partial capitation managed long term care plan contract with NY State. Additional benefits and restrictions may apply.

Members may be liable for the cost of services not authorized by your CenterLight Healthcare program.