INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS

Transcription

1 INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, December 31, 2015 CARE1ST HEALTH PLAN California:,, San Bernardino and Counties Coordinated Choice California: Alameda, Fresno,,, San Bernardino,, Santa Clara Counties H5928_15_029_SB_SOCA_3 H5928_15_029_SB_SOCA_4

2 INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as or Coordinated Choice Plan (HMO). Tips for comparing your Medicare choices This Summary of s booklet gives you a summary of what and Coordinated Choice Plan (HMO) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of s booklets. Or, use the Medicare Plan Finder on medicare.gov. If you want to know more about the coverage and s of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About and Coordinated Choice Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital s Prescription Drug s This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (800) (TTY/TDD 711). Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número de teléfono indicado arriba. Things to Know About and Coordinated Choice Hours of Operation - Plan From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. SECTION I From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time. Hours of Operation - Coordinated Choice From October 1 to February 14, you can call us 7 days a week from 7:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 7:00 a.m. to 8:00 p.m. Pacific time. and Coordinated Choice Phone Numbers and Website If you are a member of this plan, call toll-free (800) (TTY/TDD 711). If you are not a member of this plan, call tollfree (800) (TTY/TDD 711). Our website: Who can join? To join Plan (HMO) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following county in California: *, *, San 2

3 INTRODUCTION TO SUMMARY OF BENEFITS SECTION I Bernardino* and Counties. * denotes partial county To join Coordinated Choice Plan (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following county in California: Alameda*, Fresno*, Los Angeles, Orange*, *, San Bernardino*, and Santa Clara. * denotes partial county Alameda County 94501; 94502; 94601; 94602; 94603; 94604; 94605; 94606; 94607; 94608; 94609; 94610; 94611; 94612; 94613; 94614; 94617; 94618; 94619; 94620; 94621; 94623; 94624; 94661; 94662; 94701; 94702; 94703; 94704; 94705; 94706; 94707; 94708; 94709; 94710; 94712; Fresno County 93242; 93606; 93609; 93611; 93612; 93613; 93616; 93619; 93625; 93626; 93630; 93648; 93650; 93652; 93657; 93662; 93667; 93701; 93702; 93703; 93704; 93705; 93706; 93707; 93708; 93709; 93710; 93711; 93712; 93714; 93715; 93716; 93717; 93718; 93720; 93721; 93722; 93723; 93724; 93725; 93726; 93727; 93728; 93729; 93730; 93737; 93740; 93744; 93745; 93747; 93750; 93755; 93761; 93765; 93771; 93772; 93773; 93774; 93775; 93776; 93777; 93778; 93779; 93786; 93790; 93791; 93792; 93793; Los Angeles County All ZIP Codes Orange County 90620; 90621; 90622; 90623; 90624; 90630; 90631; 90632; 90633; 90638; 90680; 90720; 90740; 90742; 90743; 92609; 92610; 92617; 92619; 92620; 92626; 92637; 92646; 92647; 92648; 92649; 92655; 92657; 92673; 92683; 92685; 92694; 92697; 92698; 92701; 92702; 92703; 92704; 92705; 92706; 92707; 92708; 92725; 92735; 92801; 92802; 92803; 92804; 92805; 92806; 92807; 92808; 92809; 92812; 92814; 92815; 92816; 92817; 92821; 92822; 92823; 92825; 92831; 92832; 92833; 92834; 92835; 92836; 92837; 92838; 92840; 92841; 92842; 92843; 92844; 92845; 92846; 92850; 92868; 92870; 92871; 92885; 92886; 92887; , 91719, 91720, 91752, 91760, 92028, 92201, 92202, 92203, 92210, 92211, 92220, 92223, 92230, 92234, 92235, 92236, 92240, 92241, 92247, 92248, 92253, 92254, 92255, 92258, 92260, 92261, 92262, 92263, 92264, 92270, 92274, 92276, 92282, 92292, 92320, 92324, 92373, 92399, 92501, 92502, 92503, 92504, 92505, 92506, 92507, 92508, 92509, 92513, 92514, 92515, 92516, 92517, 92518, 92519, 92521, 92522, 92530, 92531, 92532, 92536, 92539, 92543, 92544, 92545, 92546, , 92549, 92551, 92552, 92553, 92554, 92555, 92556, 92557, 92561, 92562, 92563, 92564, 92567, 92570, 92571, 92572, 92581, 92582, 92583, 92584, 92585, 92586, 92587, 92589, 92590, 92591, 92592, 92593, 92595, 92596, 92599, 92860, 92877, 92878, 92879, 92880, 92881, 92882, San Bernardino: 91701, 91708, 91709, 91710, 91730, 91737, 91739, 91761, 91762, 91763, 91764, 91784, 91786, 92301, 92307, 92308, 92313, 92316, 92318, 92324, 92334, 92335, 92336, 92337, 92344, 92345, 92346, 92350, 92354, 92357, 92359, 92368, 92369, 92371, 92373, 92374, 92376, 92377, 92392, 92394, 92395, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92418, 92420, 92423, 92424, County All ZIP Codes Santa Clara County All ZIP Codes

4 INTRODUCTION TO SUMMARY OF BENEFITS Which doctors, hospitals, and pharmacies can I use? and Coordinated Choice has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider and pharmacy directory at our website ( care1stmedicare.com). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, care1stmedicare.com. Or, call us and we will send you a copy of the formulary. How will I determine my drug s? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan s benefits or s, please contact Health Plan for details. SECTION I 4

5 SUMMARY OF BENEFITS Section II - How much is the monthly premium? How much is the deductible? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Coordinate Choice $28.80 per month. In addition, you must keep paying your Medicare Part B premium. $320 per year for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. 5

6 Coordinate Choice MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES (continued) Is there any limit on how much I will pay for my covered services? (continued) Is there a limit on how much the plan will pay? If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and -sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Health Plan depends on contract renewal. 6

7 Coordinate Choice OUTPATIENT CARE AND SERVICES COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Acupuncture and Other Alternative Therapies Ambulance 1 Chiropractic Care 1,2 Not covered Not covered Not covered For up to 15 visits every year: You pay $125 If you are admitted to the hospital, you do not have to pay for the ambulance services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $5 $125 If you are admitted to the hospital, you do not have to pay for the ambulance services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $5 $180 If you are admitted to the hospital, you do not have to pay for the ambulance services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $5 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Routine chiropractic services not covered Routine chiropractic services not covered Routine chiropractic services not covered Routine chiropractic services not covered 7

8 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Dental Services 1,2 Diabetes Supplies and Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): $5 Oral exam: You pay Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-5, depending on the service Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): $5 Oral exam: You pay Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-15, depending on the service Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): $5 Oral exam: You pay Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-415, depending on the service Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): You pay Oral exam: You pay Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: 8

9 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Diabetes Supplies and Services 1,2 (continued) Diagnostic radiology services (such as MRIs, CT scans): You pay If training takes place at the PCP office, there is no. If training takes place at the specialist office, then the specialist office visit of $5 applies. Diagnostic radiology services (such as MRIs, CT scans): You pay If training takes place at the PCP office, there is no. If training takes place at the specialist office, then the specialist office visit of $15 applies. Diagnostic radiology services (such as MRIs, CT scans): You pay Diagnostic radiology services (such as MRIs, CT scans): 20% of the Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: 20% of the Doctor s Office Visits 1,2 Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: You pay Specialist visit: You pay Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: You pay Specialist visit: $5 Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: You pay Specialist visit: $15 Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: Specialist visit: 20% of the 9

10 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 1,2 0-, depending on the equipment If you go to a preferred vendor, your may be less. Contact us for a list of preferred vendors. $0 for a standard Medicare Covered item; 20% coinsurance for a nonstandard Medicare covered item $65 If you are admitted to the hospital within 1 day, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $5 Routine foot care: $5 0-, depending on the equipment If you go to a preferred vendor, your may be less. Contact us for a list of preferred vendors. $0 for a standard Medicare Covered item; 20% coinsurance for a nonstandard Medicare covered item $65 If you are admitted to the hospital within 1 day, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $5 Routine foot care: $5 0-, depending on the equipment If you go to a preferred vendor, your may be less. Contact us for a list of preferred vendors. $0 for a standard Medicare Covered item; 20% coinsurance for a nonstandard Medicare covered item $65 If you are admitted to the hospital within 1 day, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $5 Routine foot care: $5 If you go to a preferred vendor, your may be less. Contact us for a list of preferred vendors. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 20% of the Routine foot care not covered. 10

11 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Exam to diagnose and treat hearing and balance issues: $10 Exam to diagnose and treat hearing and balance issues: $10 Exam to diagnose and treat hearing and balance issues: $10 Exam to diagnose and treat hearing and balance issues: Hearing Services 1,2 Routine hearing exam (for up to 1 every year): $10 Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Our plan pays up to $500 every year for hearing aids. Limit 2 hearing aids every two years. Routine hearing exam (for up to 1 every year): $10 Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Our plan pays up to $500 every year for hearing aids. Limit 2 hearing aids every two years. Routine hearing exam (for up to 1 every year): $10 Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Our plan pays up to $500 every year for hearing aids. Limit 2 hearing aids every two years. Routine hearing exam (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Our plan pays up to $1,500 every year for hearing aids. Limit 2 hearing aids every two years. Home Health Care 1,2 You pay You pay You pay You pay 11

12 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Mental Health Care 1,2 Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. The s for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. 12

13 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) $50 per day for days 1 through 8 You pay per day for days 9 through 90 $200 per day for days 1 through 8 You pay per day for days 9 through 90 $200 per day for days 1 through 8 You pay per day for days 9 through 90 There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Mental Health Care 1,2 (continued) Outpatient group therapy visit: $15 Outpatient individual therapy visit: $15 Outpatient group therapy visit: $25 Outpatient individual therapy visit: $25 Outpatient group therapy visit: $25 Outpatient individual therapy visit: $25 Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In 2014 the amounts for each benefit period were: $1,216 deductible for days 1 through 60 $304 per day for days 61 through 90 $608 per day for 60 lifetime reserve days These amounts may change for

14 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Mental Health Care 1,2 (continued) Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $10 Occupational therapy visit: $10 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $10 Occupational therapy visit: $10 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $10 Occupational therapy visit: $10 Outpatient group therapy visit: Outpatient individual therapy visit: Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 20% of the Occupational therapy visit: Outpatient Substance Abuse 1,2 Physical therapy and speech and language therapy visit: $10 Group therapy visit: $10 Individual therapy visit: $10 Physical therapy and speech and language therapy visit: $10 Group therapy visit: $25 Individual therapy visit: $25 Physical therapy and speech and language therapy visit: $10 Group therapy visit: $25 Individual therapy visit: $25 Physical therapy and speech and language therapy visit: Group therapy visit: 20% of the Individual therapy visit: 20% of the 14

15 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Outpatient Surgery 1,2 Over-the-Counter Items Ambulatory surgical center: $50 Ambulatory surgical center: $50 Ambulatory surgical center: $175 Ambulatory surgical center: Outpatient hospital: Outpatient hospital: Outpatient hospital: Outpatient hospital: $50 $50 $175 Not Covered Not Covered Not Covered Please visit our website to see our list of covered over-thecounter items. Our plan pays up to $50 per quarter for allowable items. Prosthetic devices: 20% of the Prosthetic devices: 20% of the Prosthetic devices: 20% of the Prosthetic devices: 20% of the Prosthetic Devices (braces, artificial limbs, Related medical supplies: 20% Related medical supplies: 20% Related medical supplies: 20% Related medical supplies: 20% etc.) 1 of the of the of the of the $10 $10 $10 Renal Dialysis 1,2 15

16 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) You pay You pay You pay You pay Transportation 1 Urgent Care $0 for up to 32 oneway trips to plan approved locations. offers transportation to planapproved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plandesignated vendor or Member Services Department. $25-45, depending on the service If you are admitted to the hospital within 1 day, you do not have to pay your share of the for urgent care. See the Inpatient Hospital Care section of this booklet for other s. $0 for up to 24 round trips to plan approved locations. offers transportation to planapproved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plandesignated vendor or Member Services Department. $15-25, depending on the service If you are admitted to the hospital within 1 day, you do not have to pay your share of the for urgent care. See the Inpatient Hospital Care section of this booklet for other s. $0 for 12 one-way trips to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plandesignated vendor or Member Services Department. Plan limits trips to 20 miles each way. $15-25, depending on the service If you are admitted to the hospital within 1 day, you do not have to pay your share of the for urgent care. See the Inpatient Hospital Care section of this booklet for other s. $0 for up to 32 oneway trips to plan approved locations. offers transportation to planapproved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plandesignated vendor or Member Services Department. If you are admitted to the hospital within 1 day, you do not have to pay your share of the for urgent care. See the Inpatient Hospital Care section of this booklet for other s. 16

17 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Urgent Care (continued) $25 for In network urgent care facilities $45 Out-of-Network urgent care facilities Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every year): You pay $15 for In network urgent care facilities $25 Out-of-Network urgent care facilities Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every two years): You pay $15 for In network urgent care facilities $25 Out-of-Network urgent care facilities Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every two years): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every two years): You pay Vision Services 1 Eyeglasses (frames and lenses) (for up to 1 every two years): You pay Eyeglasses (frames and lenses) (for up to 1 every two years): You pay Eyeglasses (frames and lenses) (for up to 1 every two years): You pay Eyeglasses (frames and lenses) (for up to 1 every two years): You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Our plan pays up to $150 every two years for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $150 every two years for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $150 every two years for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $300 every two years for contact lenses and eyeglasses (frames and lenses). 17

18 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Vision Services 1 (continued) Preventive Care 1,2 Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. You pay Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. You pay Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. You pay Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. covers the refraction test once every two years when the eye doctor has determined that the member may need prescription glasses. You pay Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening 18

19 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Preventive Care 1,2 (continued) Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit 19

20 Coordinate Choice OUTPATIENT CARE AND SERVICES (continued) Preventive Care 1,2 (continued) Hospice Any additional preventive services approved by Medicare during the contract year will be covered. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Any additional preventive services approved by Medicare during the contract year will be covered. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Any additional preventive services approved by Medicare during the contract year will be covered. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Any additional preventive services approved by Medicare during the contract year will be covered. You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. 20

21 Coordinate Choice INPATIENT CARE Inpatient Hospital Care 1,2 Our plan covers an unlimited number of days for an inpatient hospital stay. You pay Our plan covers an unlimited number of days for an inpatient hospital stay. $25 per day for days 1 through 5 You pay per day for days 6 through 90 You pay per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. $150 per day for days 1 through 5 You pay per day for days 6 through 90 You pay per day for days 91 and beyond The s for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use 21

22 Coordinate Choice INPATIENT CARE (continued) Inpatient Hospital Care 1,2 (continued) these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In 2014 the amounts for each benefit period were: $1,216 deductible for days 1 through 60 $304 per day for days 61 through 90 $608 per day for 60 lifetime reserve days Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. These amounts may change for For inpatient mental health care, see the Mental Health Care section of this booklet. 22

23 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. Skilled Nursing Facility (SNF) 1,2 $0 per day for days 1 through 20 $50 per day for days 21 through 100 $0 per day for days 1 through 20 $50 per day for days 21 through 100 $25 per day for days 1 through 20 $75 per day for days 21 through 100 In 2014 the amounts for each benefit period were: You pay for days 1 through 20 $152 per day for days 21 through 100 These amounts may change for PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the For Part B drugs such as chemotherapy drugs 1 : 20% of the For Part B drugs such as chemotherapy drugs 1 : 20% of the For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the Other Part B drugs 1 : 20% of the Other Part B drugs 1 : 20% of the Other Part B drugs 1 : 20% of the 23

24 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) You pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. You pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. You pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. After you pay your yearly deductible, you pay the following until your total yearly drug s reach $2,960. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Initial Coverage Standard Retail Cost- - One-month supply $0 - Three-month supply $0 Standard Retail Cost- - One-month supply $0 - Three-month supply $0 Standard Retail Cost- - One-month supply $0 - Three-month supply $0 Standard Retail Cost- - One-month supply $0 - Three-month supply $0 Tier 2 (Non-Preferred Generic) - One-month supply $5 - Three-month supply $10 Tier 3 (Preferred Brand) - One-month supply $30 - Three-month supply $60 Tier 2 (Non-Preferred Generic) - One-month supply $5 - Three-month supply $10 Tier 3 (Preferred Brand) - One-month supply $40 - Three-month supply $80 Tier 2 (Non-Preferred Generic) - One-month supply $7 - Three-month supply $14 Tier 3 (Preferred Brand) - One-month supply $35 - Three-month supply $70 Tier 2 (Non-Preferred Generic) - One-month supply 25% of the - Three-month supply 25% of the 24

25 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) Initial Coverage (continued) Tier 4 (Non-Preferred Brand) - One-month supply $50 - Three-month supply $100 Tier 5 (Specialty Tier) - 33% of the - 33% of the Standard Mail Order Cost- - Three-month supply $0 Tier 2 (Non-Preferred Generic) - Three-month supply $10 Tier 3 (Preferred Brand) - Three-month supply $60 Tier 4 (Non-Preferred Brand) - Three-month supply $100 Tier 5 (Specialty Tier) - 33% of the Tier 4 (Non-Preferred Brand) - One-month supply $80 - Three-month supply $160 Tier 5 (Specialty Tier) - 33% of the - 33% of the Standard Mail Order Cost- - Three-month supply $0 Tier 2 (Non-Preferred Generic) - Three-month supply $10 Tier 3 (Preferred Brand) - Three-month supply $80 Tier 4 (Non-Preferred Brand) - Three-month supply $160 Tier 5 (Specialty Tier) - 33% of the Tier 4 (Non-Preferred Brand) - One-month supply $80 - Three-month supply $160 Tier 5 (Specialty Tier) - 33% of the - 33% of the Standard Mail Order Cost- - Three-month supply $0 Tier 2 (Non-Preferred Generic) - Three-month supply $14 Tier 3 (Preferred Brand) - Three-month supply $70 Tier 4 (Non-Preferred Brand) - Three-month supply $160 Tier 5 (Specialty Tier) - 33% of the Tier 3 (Preferred Brand) - One-month supply 25% of the - Three-month supply 25% of the Tier 4 (Non-Preferred Brand) - One-month supply 25% of the - Three-month supply 25% of the Tier 5 (Specialty Tier) - 25% of the - 25% of the Standard Mail Order Cost- - Three-month supply $0 Tier 2 (Non-Preferred Generic) - Three-month supply 25% of the 25

26 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Tier 3 (Preferred Brand) - Three-month supply 25% of the Initial Coverage (continued) You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Tier 4 (Non-Preferred Brand) - Three-month supply 25% of the Tier 5 (Specialty Tier) - Three-month supply 25% of the If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. 26

27 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $2,960. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 65% of the plan s for covered generic drugs until your s total $4,700, which is the end of the coverage gap. Not everyone will enter the coverage gap. 27

28 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will you. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will you. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will you. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will you. Coverage Gap (continued) Standard Retail Cost- - Drugs Covered All - One-month supply $0 -Three-month supply $0 Standard Retail Cost- - Drugs Covered All - One-month supply $0 -Three-month supply $0 Standard Retail Cost- - Drugs Covered All - One-month supply $0 -Three-month supply $0 Standard Retail Cost- - Drugs Covered All - One-month supply $0 -Three-month supply $0 Tier 2 (Non-Preferred Generic) - Drugs Covered All - One-month supply $5 - Three-month supply $10 Tier 2 (Non-Preferred Generic) - Drugs Covered All - One-month supply $5 - Three-month supply $10 Tier 2 (Non-Preferred Generic) - Drugs Covered All - One-month supply $7 - Three-month supply $14 28

29 Coordinate Choice PRESCRIPTION DRUG BENEFITS (continued) Coverage Gap (continued) Standard Mail Order Cost- - Drugs Covered All - Three-month supply $0 Standard Mail Order Cost- - Drugs Covered All - Three-month supply $0 Standard Mail Order Cost- - Drugs Covered All - Three-month supply $0 Standard Mail Order Cost- - Drugs Covered All -Three-month supply $0 Catastrophic Coverage Tier 2 (Non-Preferred Generic) - Drugs Covered All - Three-month supply $10 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. Tier 2 (Non-Preferred Generic) - Drugs Covered All - Three-month supply $10 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. Tier 2 (Non-Preferred Generic) - Drugs Covered All - Three-month supply $14 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the, or $2.65 for generic (including brand drugs treated as generic) and a $6.60 ment for all other drugs. 29