2017 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs

Transcription

1 2017 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. The table below shows what your monthly plan premium will be if you get extra help. The following amounts do not include any Medicare Part B premium you may have to pay. New Jersey Bergen, Burlington, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic, Somerset, Union Amerivantage Dual Coordination (HMO SNP) $40.80 $0.00 $10.20 $20.40 $30.60 Amerivantage Dual Coordination (HMO SNP) is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in Amerivantage Dual Coordination (HMO SNP) depends on contract renewal. Page 1 of 8

2 New Jersey Atlantic, Cumberland, Gloucester, Mercer, Morris Amerivantage Dual Coordination (HMO SNP) $40.80 $0.00 $10.20 $20.40 $30.60 Amerivantage Dual Coordination (HMO SNP) is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in Amerivantage Dual Coordination (HMO SNP) depends on contract renewal. Bergen, Essex, Hudson, Middlesex, Monmouth, Ocean, Passaic, Somerset, Union Amerivantage ESRD (HMO-POS SNP) $40.80 $0.00 $10.20 $20.40 $30.60 Amerivantage ESRD (HMO-POS SNP) premium includes coverage for both medical services and prescription drug coverage. Amerivantage is a C-SNP plan with a Medicare contract. Enrollment in Amerivantage depends on contract renewal. Page 2 of 8

3 New Mexico Bernalillo, Sandoval, Santa Fe, Torrance, Valencia Amerivantage Classic (HMO) $0.00 $0.00 $0.00 $0.00 $0.00 AMERIGROUP Community Care of New Mexico, Inc. is an HMO plan with a Medicare contract. Enrollment in Amerivantage Classic depends on contract renewal. Tennessee Benton, Cannon, Cheatham, Claiborne, Clay, Davidson, De Kalb, Decatur, Dickson, Dyer, Fayette, Fentress, Gibson, Giles, Hamilton, Hardin, Henry, Hickman, Houston, Jackson, Jefferson, Knox, Lawrence, Lewis, Lincoln, Macon, Marshall, Maury, McNairy, Meigs, Montgomery, Overton, Perry, Polk, Robertson, Rutherford, Shelby, Stewart, Sumner, Tipton, Van Buren, Warren, Wayne, White, Williamson, Wilson Amerivantage Classic (HMO) $0.00 $0.00 $0.00 $0.00 $0.00 AMERIGROUP Tennessee, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Tennessee, Inc. depends on contract renewal. Page 3 of 8

4 Tennessee Anderson, Bedford, Bledsoe, Blount, Bradley, Campbell, Cocke, Coffee, Cumberland, Franklin, Grainger, Grundy, Hancock, Hawkins, Humphreys, Lauderdale, Loudon, Marion, Monroe, Moore, Morgan, Obion, Pickett, Rhea, Roane, Scott, Sequatchie, Sevier, Smith, Trousdale, Union, Weakley Amerivantage Classic (HMO) $25.00 $0.00 $6.20 $12.50 $18.70 AMERIGROUP Tennessee, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Tennessee, Inc. depends on contract renewal. Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Carroll, Carter, Cheatham, Chester, Claiborne, Clay, Cocke, Coffee, Crockett, Cumberland, Davidson, De Kalb, Decatur, Dickson, Dyer, Fayette, Fentress, Franklin, Gibson, Giles, Grainger, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hardin, Hawkins, Haywood, Henderson, Henry, Hickman, Houston, Humphreys, Jackson, Jefferson, Johnson, Knox, Lake Lauderdale, Lawrence, Lewis, Lincoln, Loudon, Macon, Madison, Marion, Marshall, Maury, McNairy, Meigs, Monroe, Montgomery, Moore, Morgan, Obion, Overton, Perry, Pickett, Polk, Rhea, Roane, Robertson, Rutherford, Scott, Sequatchie, Sevier, Shelby, Smith, Stewart, Sullivan, Sumner, Tipton, Trousdale, Unicoi, Union, Van Buren, Warren, Washington, Wayne, Weakley, White, Williamson, Wilson Amerivantage Dual Coordination (HMO SNP) $31.80 $0.00 $8.00 $15.90 $23.90 AMERIGROUP Tennessee, Inc. is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in AMERIGROUP Tennessee, Inc. depends on contract renewal. Page 4 of 8

5 Texas Bexar, Brazoria, Comal, Denton, El Paso, Fort Bend, Galveston, Harris, Hays, Hudspeth, Jefferson, Lubbock, Medina, Montgomery, Tarrant, Travis, Williamson Amerivantage Classic (HMO) $0.00 $0.00 $0.00 $0.00 $0.00 AMERIGROUP Texas, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Texas, Inc. depends on contract renewal. Bexar, El Paso, Fort Bend, Harris, Montgomery, Travis Amerivantage Select (HMO) $0.00 $0.00 $0.00 $0.00 $0.00 Amerivantage Select (HMO) premium includes coverage for both medical services and prescription drug coverage. AMERIGROUP Texas, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Texas, Inc. depends on contract renewal. Page 5 of 8

6 Texas Bexar, Brazoria, Comal, Denton, El Paso, Fort Bend, Galveston, Harris, Hays, Hudspeth, Jefferson, Lubbock, Medina, Montgomery, Tarrant, Travis, Williamson Amerivantage Dual Coordination (HMO SNP) $27.30 $0.00 $6.80 $13.60 $20.50 AMERIGROUP Texas, Inc. is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in AMERIGROUP Texas, Inc. depends on contract renewal. Bexar, Comal, El Paso, Hays, Travis, Williamson Amerivantage ESRD (HMO-POS SNP) $27.30 $0.00 $6.80 $13.60 $20.50 Amerivantage ESRD (HMO-POS SNP) premium includes coverage for both medical services and prescription drug coverage. AMERIGROUP Texas, Inc. is a C-SNP plan with a Medicare contract. Enrollment in AMERIGROUP Texas, Inc. depends on contract renewal. Page 6 of 8

7 Washington King, Snohomish Product Premium 100% 75% 50% 25% Amerivantage Classic (HMO) $0.00 $0.00 $0.00 $0.00 $0.00 AMERIGROUP Washington, Inc. is an HMO plan with a Medicare contract. Enrollment in AMERIGROUP Washington, Inc. depends on contract renewal. King, Snohomish Amerivantage Dual Coordination (HMO SNP) $34.80 $0.00 $8.70 $17.40 $26.10 AMERIGROUP Washington, Inc. is a D-SNP plan with a Medicare contract and a contract with the State Medicaid program. Enrollment in AMERIGROUP Washington, Inc. depends on contract renewal. Page 7 of 8

8 If you aren t getting extra help, you can see if you qualify by calling: MEDICARE ( ), or TTY/TDD users should call hours a day, 7 days a week, Your State Medicaid Office, or The Social Security Administration at or TTY/TDD users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Customer Service at , TTY/TTD 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. Our automated system is available anytime for self-service options, including after hours, weekends, and holidays. Y0114_17_28545_X 61918MUSENAGP Page 8 of 8