2017 Benefits at a Glance

Transcription

1 2017 at a Glance Signature, Signature With Drugs,, Monthly Plan Premium $138 $176 $176 $46 Inpatient Hospital Care Skilled Nursing Care Days 1-20 $0, each Days 1-20 $0, each Days 1-20 $0, each $200 copay day(s) 1-7; $0 after day 7 (in network); $0 per day copay, day(s) 1-20, $155 days 21-42, $0 days Home Health Care $0 copay $0 copay $0 copay $0 copay Primary Care $0 copay (in network) $0 copay (in network) $0 copay (in network) $20 copay (in network) Doctor Visit Specialist Visit $35 copay (in network) $35 copay (in network) $35 copay (in network) $40 copay (in network) Urgent Care $30 copay $30 copay $30 copay $30 copay Podiatry Services $0 copay (in network) up to $0 copay (in network) up to $0 copay (in network) for unlimited podiatry visits $20 copay (in network) up to Ambulance $150 copay $150 copay $150 copay $225 copay Emergency Room $65 copay (waived if

2 Signature, Signature With Drugs,,, continued Lab Services and X-Rays $10 copay lab $50 copay Diagnostic Radiology Part B Drugs 10% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance Outpatient Ambulatory/ $50 copay (in network) $50 copay (in network) $50 copay (in network) $250 copay Hospital Surgical Services Outpatient $0 copay (in network) $0 copay (in network) $0 copay (in network) $20 copay (in network) Rehabilitation Services Durable Medical 20% coinsurance 20% coinsurance $0 copay 20% coinsurance Equipment Diabetes Supplies 20% coinsurance 20% coinsurance $0 copay 20% coinsurance Preventive Care $0 copay $0 copay $0 copay $0 copay Prescription Drugs See below for more details See below for more details See below for more details See below for more details Hearing Aids

3 Signature, Signature With Drugs,,, continued Eyewear Allowance Up to $100 every 24 months Up to $100 every 24 months Up to $100 every 24 months Up to $100 every 24 months Routine Transportation $0 copay per trip up to 24 Falls Prevention Program Dental Benefit Out-of-Pocket Maximum $0 copay per trip up to 24 $0 copay per trip up to 24 $5,000 in network $5,000 in network $5,000 in network $3,400 in network

4 Prescription Drug Coverage * * * Amount you pay before the plan starts to pay for your covered prescriptions drugs. Annual Deductible $0 $0 $0 Amounts you and the plan pay in total covered prescription drug costs up to $3,700, which includes your copays and deductibles (also called the Initial Coverage Limit ). 30 day supply from an in-network preferred pharmacy 90-day supply from our network mail-order service $5 copay for Preferred Generic $0 for Preferred Generic drugs$0 $0 copay for Preferred Generic $0 for Preferred Generic drugs; $0 $5 copay for Preferred Generic $0 for Preferred Generic drugs; $0 You pay the copayments shown above until your total drug costs equal $3,700. Once you reach $3,700 in drug expenses you will pay: 51% of the total cost for generic drugs 40% of the total cost for brand name drugs if you are not already receiving Extra Help The total drug expenses in the coverage gap counts towards your out of pocket expenses All your copayments and the costs of the drugs in the coverage gap count towards your out of pocket expenses. Premiums not included. Amount you pay after you have paid $4,950 out of your pocket for covered prescription drugs. 30-day supply from an in-network preferred pharmacy *If you have prescription drug coverage through an employer, talk with your benefits administrator before you join this plan.

5 Support Services for Members Member Service Representative All members have access to a member service representative in the community. Our member service representative is available to answer questions about benefits or any health plan paperwork. Nurse Care Coordinator Also available is a nurse care coordinator who provides our members with information and education on a variety of conditions and health-related issues. Our nurse care coordinator can answer health related questions and help prepare our members for upcoming medical procedures. Our nurse care coordinator assists members during admissions and discharges from the hospital and/or a skilled nursing stay. Unlike Original Medicare, the plans do not require a three-day hospital stay before skilled nursing services will be covered in the long-term care setting.** If you have prescription drug coverage through an employer, talk with your benefits administrator before you join this plan. **Copays and coinsurances may apply Medicare Coverage Gap Discount Program. Discounts apply to drug manufacturers who have agreed to participate in this program. To view the list of the drugs our plan covers, visit The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You are not required to use OptumRx home delivery for a 90-day supply of your maintenance medication. If you have not used OptumRx home delivery, you must approve the first prescription order sent directly from your doctor to OptumRx before it can be filled. New prescriptions from OptumRx should arrive within ten business days from the date the completed order is received, and refill orders should arrive in about seven business days. Contact OptumRx anytime at OptumRx is an affiliate of UnitedHealthcare Insurance Company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply., premiums, and/or copayments/coinsurance may change on January 1 of each year. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan s contract renewal with Medicare. These plans are available to all people meeting certain eligibility requirements, such as living in a contracted nursing home or having a qualifying chronic care condition. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. H5652_150701_ Accepted