Health Alliance Plan of Michigan HAP Senior Plus HMO Benefit Summary

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1 1006 Benefit Code: SSKP Benefit Period, Annual Deductible, and Annual Co-insurance Maximums: Benefit Period: Calendar Year Annual Deductible Co-insurance (amount member pays) Annual Co-insurance Maximum Lifetime Maximum Preventive : Preventive Office Visit Immunizations Related Laboratory and Radiology Pap Smears and Mammograms Outpatient & Physician : NA Personal Care Physician Office Visit Specialty Physician Office Visit Gynecology Office Visit Audiology Office Visit Eye Examination Office Visit Allergy Treatment and Injections Laboratory and Radiology Dialysis Chemotherapy Radiation Therapy Outpatient Surgery Chiropractic Office Visit and Related Manipulation of the spine for subluxation only Page 1 of 3

2 Benefit Code: SSKP Emergency/Urgent Care: Emergency Room Urgent Care Facility Emergency Ambulance Emergency transport only Inpatient Hospital : Hospital Inpatient Stay in Semi-Private Room, Specialty Units as medically necessary, Physician, Surgery, Therapy, Laboratory, Radiology, Hospital and Supplies Bariatric Surgery & Related One procedure per lifetime Mental Health: Inpatient for 190 days per lifetime according to Medicare guidelines, then covered for 30 days renewable after 60 days Outpatient according to Medicare guidelines Chemical Dependency: Inpatient according to Medicare guidelines Outpatient according to Medicare guidelines Other : Home Health Care Does not include PT/OT/ST. See PT/OT/ST Coverage Hospice Care 210 days lifetime Skilled Nursing Care Up to 730 days per benefit period Durable Medical Equipment; Coverage provided for approved equipment based on Prosthetic & Orthotics Medicare guidelines Hearing Aid Hardware for authorized conventional hearing aids Page 2 of 3

3 Benefit Code: SSKP Vision Hardware Not Following cataract surgery, 1 pair of eyeglasses or contact lenses Physical, Occupational, and Speech Therapy (PT/OT/ST) May be rendered at home Pharmacy: Generic / Brand $10 Copay Members will pay the Brand Drug Copayment when a physician requests a Brand Drug as Dispense as Written and a Generic equivalent is available. Retail: 35 day supply for non-maintenance drugs at one Copay; 35 day supply or 100 doses, whichever is greater, for eligible maintenance drugs at 1 Copay Mail Order: 90 day supply of non-maintenance drugs at 3 Copays less $5.00; 90 day supply of eligible maintenance drugs at 1 Copay Benefit Code / Riders: SSKP / H288,S011,S013,S057,S095 * Please contact HAP if you are admitted to the hospital. In cases of conflict between this summary and your Evidence of Coverage, the terms and conditions of the Evidence of Coverage governs. Page 3 of 3

4 1106 Benefit Code: SSKL Benefit Period, Annual Deductible, and Annual Co-insurance Maximums: Benefit Period: Calendar Year Annual Deductible Co-insurance (amount member pays) Annual Co-insurance Maximum Lifetime Maximum Preventive : Preventive Office Visit Immunizations Related Laboratory and Radiology Pap Smears and Mammograms Outpatient & Physician : NA Personal Care Physician Office Visit Specialty Physician Office Visit Gynecology Office Visit Audiology Office Visit Eye Examination Office Visit Allergy Treatment and Injections Laboratory and Radiology Dialysis Chemotherapy Radiation Therapy Outpatient Surgery Chiropractic Office Visit and Related Manipulation of the spine for subluxation only Page 1 of 3

5 Benefit Code: SSKL Emergency/Urgent Care: Emergency Room Urgent Care Facility Emergency Ambulance Emergency transport only Inpatient Hospital : Hospital Inpatient Stay in Semi-Private Room, Specialty Units as medically necessary, Physician, Surgery, Therapy, Laboratory, Radiology, Hospital and Supplies Bariatric Surgery & Related One procedure per lifetime Mental Health: Inpatient for 190 days per lifetime according to Medicare guidelines, then covered for 30 days renewable after 60 days Outpatient according to Medicare guidelines Chemical Dependency: Inpatient according to Medicare guidelines Outpatient according to Medicare guidelines Other : Home Health Care Does not include PT/OT/ST. See PT/OT/ST Coverage Hospice Care 210 days lifetime Skilled Nursing Care Up to 730 days per benefit period Durable Medical Equipment; Coverage provided for approved equipment based on Prosthetic & Orthotics Medicare guidelines Hearing Aid Hardware for authorized conventional hearing aids Page 2 of 3

6 Benefit Code: SSKL Vision Hardware Not Following cataract surgery, 1 pair of eyeglasses or contact lenses Physical, Occupational, and Speech Therapy (PT/OT/ST) May be rendered at home Pharmacy: Generic / Brand $10 / $20 Copay Members will pay the Brand Drug Copayment when a physician requests a Brand Drug as Dispense as Written and a Generic equivalent is available. Retail: 35 day supply for non-maintenance drugs at one Copay; 35 day supply or 100 doses, whichever is greater, for eligible maintenance drugs at 1 Copay Mail Order: 90 day supply of non-maintenance drugs at 3 Copays less $5.00; 90 day supply of eligible maintenance drugs at 1 Copay Benefit Code / Riders: SSKL / H289,S011,S013,S057,S095 * Please contact HAP if you are admitted to the hospital. In cases of conflict between this summary and your Evidence of Coverage, the terms and conditions of the Evidence of Coverage governs. Page 3 of 3

7 1206 Benefit Code: SSKK Benefit Period, Annual Deductible, and Annual Co-insurance Maximums: Benefit Period: Calendar Year Annual Deductible Co-insurance (amount member pays) Annual Co-insurance Maximum Lifetime Maximum Preventive : Preventive Office Visit Immunizations Related Laboratory and Radiology Pap Smears and Mammograms Outpatient & Physician : NA Personal Care Physician Office Visit Specialty Physician Office Visit Gynecology Office Visit Audiology Office Visit Eye Examination Office Visit Allergy Treatment and Injections Laboratory and Radiology Dialysis Chemotherapy Radiation Therapy Outpatient Surgery Chiropractic Office Visit and Related Manipulation of the spine for subluxation only Page 1 of 3

8 Benefit Code: SSKK Emergency/Urgent Care: Emergency Room Urgent Care Facility Emergency Ambulance Emergency transport only Inpatient Hospital : Hospital Inpatient Stay in Semi-Private Room, Specialty Units as medically necessary, Physician, Surgery, Therapy, Laboratory, Radiology, Hospital and Supplies Bariatric Surgery & Related One procedure per lifetime Mental Health: Inpatient for 190 days per lifetime according to Medicare guidelines, then covered for 30 days renewable after 60 days Outpatient according to Medicare guidelines Chemical Dependency: Inpatient according to Medicare guidelines Outpatient according to Medicare guidelines Other : Home Health Care Does not include PT/OT/ST. See PT/OT/ST Coverage Hospice Care 210 days lifetime Skilled Nursing Care Up to 730 days per benefit period Durable Medical Equipment; Coverage provided for approved equipment based on Prosthetic & Orthotics Medicare guidelines Hearing Aid Hardware for authorized conventional hearing aids Page 2 of 3

9 Benefit Code: SSKK Vision Hardware Not Following cataract surgery, 1 pair of eyeglasses or contact lenses Physical, Occupational, and Speech Therapy (PT/OT/ST) May be rendered at home Pharmacy: Generic / Brand $5 Copay Members will pay the Brand Drug Copayment when a physician requests a Brand Drug as Dispense as Written and a Generic equivalent is available. Retail: 35 day supply for non-maintenance drugs at one Copay; 35 day supply or 100 doses, whichever is greater, for eligible maintenance drugs at 1 Copay Mail Order: 90 day supply of non-maintenance drugs at 3 Copays less $5.00; 90 day supply of eligible maintenance drugs at 1 Copay Benefit Code / Riders: SSKK / H287,S011,S013,S057,S095 * Please contact HAP if you are admitted to the hospital. In cases of conflict between this summary and your Evidence of Coverage, the terms and conditions of the Evidence of Coverage governs. Page 3 of 3

10 1306 Benefit Code: SSKN Benefit Period, Annual Deductible, and Annual Co-insurance Maximums: Benefit Period: Calendar Year Annual Deductible Co-insurance (amount member pays) Annual Co-insurance Maximum Lifetime Maximum Preventive : Preventive Office Visit Immunizations Related Laboratory and Radiology Pap Smears and Mammograms Outpatient & Physician : NA Personal Care Physician Office Visit Specialty Physician Office Visit Gynecology Office Visit Audiology Office Visit Eye Examination Office Visit Allergy Treatment and Injections Laboratory and Radiology Dialysis Chemotherapy Radiation Therapy Outpatient Surgery Chiropractic Office Visit and Related Manipulation of the spine for subluxation only Page 1 of 3

11 Benefit Code: SSKN Emergency/Urgent Care: Emergency Room Urgent Care Facility Emergency Ambulance Emergency transport only Inpatient Hospital : Hospital Inpatient Stay in Semi-Private Room, Specialty Units as medically necessary, Physician, Surgery, Therapy, Laboratory, Radiology, Hospital and Supplies Bariatric Surgery & Related One procedure per lifetime Mental Health: Inpatient for 190 days per lifetime according to Medicare guidelines, then covered for 30 days renewable after 60 days Outpatient according to Medicare guidelines Chemical Dependency: Inpatient according to Medicare guidelines Outpatient according to Medicare guidelines Other : Home Health Care Does not include PT/OT/ST. See PT/OT/ST Coverage Hospice Care 210 days lifetime Skilled Nursing Care Up to 730 days per benefit period Durable Medical Equipment; Coverage provided for approved equipment based on Prosthetic & Orthotics Medicare guidelines Hearing Aid Hardware for authorized conventional hearing aids Page 2 of 3

12 Benefit Code: SSKN Vision Hardware Not Following cataract surgery, 1 pair of eyeglasses or contact lenses Physical, Occupational, and Speech Therapy (PT/OT/ST) May be rendered at home Pharmacy: Generic / Brand $15 / $30 Copay Members will pay the Brand Drug Copayment when a physician requests a Brand Drug as Dispense as Written and a Generic equivalent is available. Retail: 35 day supply for non-maintenance drugs at one Copay; 35 day supply or 100 doses, whichever is greater, for eligible maintenance drugs at 1 Copay Mail Order: 90 day supply of non-maintenance drugs at 3 Copays less $5.00; 90 day supply of eligible maintenance drugs at 1 Copay Benefit Code / Riders: SSKN / H290,S011,S013,S057,S095 * Please contact HAP if you are admitted to the hospital. In cases of conflict between this summary and your Evidence of Coverage, the terms and conditions of the Evidence of Coverage governs. Page 3 of 3

13 1406 Benefit Code: SSKH Benefit Period, Annual Deductible, and Annual Co-insurance Maximums: Benefit Period: Calendar Year Annual Deductible Co-insurance (amount member pays) Annual Co-insurance Maximum Lifetime Maximum Preventive : Preventive Office Visit Immunizations Related Laboratory and Radiology Pap Smears and Mammograms Outpatient & Physician : NA $10 Copay Personal Care Physician Office Visit Specialty Physician Office Visit Gynecology Office Visit Audiology Office Visit Eye Examination Office Visit Allergy Treatment and Injections Laboratory and Radiology Dialysis Chemotherapy Radiation Therapy Outpatient Surgery Chiropractic Office Visit and Related $10 Copay $10 Copay $10 Copay $10 Copay $10 Copay $10 Copay Manipulation of the spine for subluxation only Page 1 of 3

14 Benefit Code: SSKH Emergency/Urgent Care: Emergency Room $50 Copay Copay will be waived if admitted Urgent Care Facility $25 Copay Emergency Ambulance Emergency transport only Inpatient Hospital : Hospital Inpatient Stay in Semi-Private Room, Specialty Units as medically necessary, Physician, Surgery, Therapy, Laboratory, Radiology, Hospital and Supplies Bariatric Surgery & Related One procedure per lifetime Mental Health: Inpatient according to Medicare guidelines Outpatient $10 Copay according to Medicare guidelines Chemical Dependency: Inpatient according to Medicare guidelines Outpatient $10 Copay according to Medicare guidelines Other : Home Health Care Does not include PT/OT/ST. See PT/OT/ST Coverage You must get care from a Medicare-certified hospice. When you enroll in a Medicare certified Hospice Care hospice program, your hospice services and your Original Medicare services are paid for by Original Medicare, not HAP Senior Plus. Skilled Nursing Care Up to 730 days per benefit period Durable Medical Equipment; Coverage provided for approved equipment based on Prosthetic & Orthotics Medicare guidelines Hearing Aid Hardware for authorized conventional hearing aids Page 2 of 3

15 Benefit Code: SSKH Vision Hardware Not Following cataract surgery, 1 pair of eyeglasses or contact lenses Physical, Occupational, and Speech Therapy (PT/OT/ST) May be rendered at home Pharmacy: There is no 90 day supply coverage for Spercialty (Biotech) Drugs Retail: 30 day supply for non-maintenance drugs at 1 $15 / $30 / Specialty (Biotech): Plan Pays 70% and Generic / Brand Member pays no more than $60 Copay; 90 day supply for eligible maintenance drugs at 2 Copays Mail Order: 90 day supply for both eligible maintenance and non-maintenance drugs at 2 Copays Benefit Code / Riders: SSKH / S000,S011,S013,S049,S052,S054,S057,H602 * Please contact HAP if you are admitted to the hospital. In cases of conflict between this summary and your Evidence of Coverage, the terms and conditions of the Evidence of Coverage governs. Page 3 of 3

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