2015 Plan Guide ALLEGIAN ADVANTAGE (HMO) H8554_ Accepted

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1 2015 Plan Guide ALLEGIAN ADVANTAGE (HMO) H8554_ Accepted

2 Allegian Advantage is an HMO plan. We proudly serve Texas residents in Cameron, Hidalgo and Willacy counties, offering doctor, hospital and prescription drug coverage. Allegian Advantage (HMO) Call to learn more: Toll Free (855) TTY users call a.m. to 8 p.m., 7 days a week Join Us Online Online enrollment is safe and secure.

3 ABOUT ALLEGIAN ADVANTAGE (HMO) Our Medicare-approved plan is based right here in Texas. For a $0 monthly premium, we offer doctor, hospital, and prescription drug coverage and provide open access to specialists. OUR $0 PREMIUM PLAN OFFERS MORE THAN ORIGINAL MEDICARE Open access to in-network specialists Personalized medical management Coverage for annual screenings Diabetic monitoring supplies, theraputic shoes and inserts Nationwide emergency and urgent care coverage Maximum Out of Pocket (MOOP) $4,000 Vision, benefit with low exam co-pay OTC drug allowance up to $25 per quarter

4 OUR MEMBER SERVICE REPRESENTATIVES ARE HERE TO HELP Friendly and helpful member service representatives are available seven days a week. Our first priority is supporting our members and helping them manage their health care effectively.

5 MEDICARE BASICS Medicare is health insurance for the following: People 65 or older People under 65 with certain disabilities, restrictions may apply People of any age with End-Stage Renal Disease (ESRD) (permanent kidney failure requiring dialysis or a kidney transplant) THE DIFFERENT PARTS OF MEDICARE The different parts of Medicare help cover specific services: MEDICARE PART A (Hospital Insurance) Helps cover inpatient care in hospitals, skilled nursing facilities, hospice, and home health care. Most people don t have to pay a premium for Medicare Part A because they or a spouse paid Medicare taxes while working in the United States. If you don t automatically get premium-free Part A, you may still be able to enroll, and pay a premium.

6 MEDICARE PART B (Medical Insurance) Helps cover doctors and other health care providers services, outpatient care, durable medical equipment, and home health care. Helps cover some preventive services. Most people pay up to the standard monthly Medicare Part B premium. MEDICARE PART C (also known as Medicare Advantage) Offers health plan options run by Medicare-approved private insurance companies. Medicare Advantage Plans are a way to get the benefits and services covered under Part A and Part B. Most Medicare Advantage Plans offer Medicare prescription drug coverage (Part D). Some Medicare Advantage Plans may include extra benefits for an extra cost.

7 MEDICARE PART D (Medicare Prescription Drug Coverage) Helps cover the cost of prescription drugs. May help lower your prescription drug costs and help protect against higher costs. Run by Medicare-approved private insurance companies. Costs and benefits vary by plan. Information provided by Centers for Medicare & Medicaid Services,

8 LOW INCOME SUBSIDY (LIS) YOU MAY QUALIFY FOR EXTRA HELP If you meet certain income and resource requirements, you may qualify for Extra Help to help pay the costs of Medicare prescription drug coverage. You automatically qualify for Extra Help if you have Medicare and meet one of these conditions: You have full Medicaid coverage, or You get help from your state Medicaid program to pay your Part B premiums (in a Medicare Savings Program), or You get Supplemental Security Income (SSI) benefits. APPLY FOR EXTRA HELP Apply online at or by calling Social Security toll free at , 7 a.m. to 7 p.m. Monday through Friday. TTY users should call You can also call MEDICARE (800) (TTY users should call (877) ), 24 hours a day/7 days a week or visit to review Programs for People with Limited Income and Resources in the publication Medicare & You.

9 ALLEGIAN ADVANTAGE (HMO) Covers all Original Medicare services, includes prescription drug coverage and at no cost to you, all extras for a $0 monthly premium. (You must continue to pay your Medicare Part B premium.)

10 ALLEGIAN ADVANTAGE (HMO) BENEFITS AT A GLANCE Medicare-Covered Benefit Primary Care Provider (PCP) Office Visit Specialist Office Visit Inpatient Hospital Stay Plan Covers 90 days Each benefit period Urgently Needed Care Emergency Care X-Rays, Diagnostic Procedures, Tests Allegian Advantage (HMO) $0 co-pay $30 co-pay Days 1-6 $175 co-pay per day Days 7-90 $0 co-pay per day 60 lifetime reserve days, at $0 co-pay per day $30 co-pay $65 co-pay* $0 co-pay X-rays, lab services, diagnostic procedures and tests *$0 co-pay If admitted within 24-hours for the same condition.

11 PRESCRIPTION DRUG BENEFITS AT A GLANCE Retail Pharmacy Tier Levels* 30 Days 60 Days 90 Days Preferred Generics* $4.00 $8.00 $12.00 Non- Preferred Generics* $10.00 $20.00 $30.00 Preferred Brand* $45.00 co-pay $90.00 co-pay $ co-pay Non- Preferred Brand* $95.00 co-pay $ co-pay $ co-pay Specialty Tier 33% Cost Sharing 33% Cost Sharing 33% Cost Sharing Medicare Part B Drugs including Chemotherapy Drugs 20% co-insurance *Use the mail order service to receive a threemonth prescription for the cost of a two-month prescription.

12 PRESCRIPTION DRUG BENEFITS (Continued) Coverage Gap After your total drug costs reach $2,960, you pay 45% of the plan s cost for covered brand name drugs and 65% of the plan s cost for covered generic drugs until your yearly out-of-pocket drug costs reach $4,700. Catastrophic Coverage After your total yearly out-of-pocket drug costs reach $4,700, you pay the greater of: 5% of the cost, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. Traveling in the U.S.? Allegian Advantage (HMO) offers nationwide in-network prescription drug coverage.

13 OUT-OF-NETWORK COVERAGE GAP COSTS GENERIC DRUGS You will be reimbursed up to 35% of the plan s allowable cost for generic drugs purchased out of network until your total yearly out-of-pocket drug costs reach $4,700. BRAND DRUGS You will be reimbursed up to 55% of the plan s allowable cost for brand name drugs purchased out-of-network until your total yearly out-orpocket drug costs reach $4,700. OUT-OF-NETWORK CATASTROPHIC COVERAGE COSTS After your total yearly out-of-pocket drug costs reach $4,700, you will be reimbursed for drugs purchased out-of-network up to the plan s cost of the drug minus your cost share, which is the greater of: 5% coinsurance or $2.65 co-pay for generic drugs, including brand drugs treated as generic. For all other drugs, your copay is $6.60.

14 OVER-THE-COUNTER (OTC) UP TO $100 PER YEAR OTC items such as ointments, aspirin and healing creams can also leave a dent in your budget if you have to pay for them out of pocket. But with Allegian Advantage (HMO), you receive a generous $100 annual allowance for the OTC supplies you need. That s $25 every three months to fill your medicine cabinet with everything from vitamins to first aid supplies and more.

15 OUR PLAN OFFERS DIABETIC PROGRAMS AND SUPPLIES AT NO EXTRA COST TO YOU, INCLUDING: DIABETES PROGRAMS AND SUPPLIES Original Medicare 20% coinsurance 20% coinsurance Allegian Advantage (HMO) $0 co-pay for diabetes self-management training $0 co-pay for diabetes monitoring supplies 20% coinsurance $20% of the cost for therapeutic shoes and inserts

16 MORE ALLEGIAN ADVANTAGE (HMO) EXTRAS AT NO EXTRA COST TO YOU HOME HEALTH VISITS* $0 co-pay for Medicare-covered visits, including medically-necessary intermittent skilled nursing care, home health aide services and rehabilitation services. OUTPATIENT MENTAL HEALTH* $25 co-pay each Medicare-covered visit, including: Individual Therapy Psychiatrist (Individual) Group Therapy Psychiatrist (Group Therapy) $20 co-pay for Medicarecovered partial hospitalization program services *Authorization rules may apply

17 GOOD HEALTH BEGINS WITH PREVENTIVE CARE Allegian Advantage (HMO) members receive all of these preventive services at no extra cost to them: Abdominal Aortic Screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Screening PAP Test and Pelvic Exam Colorectal Cancer Screening Diabetes Screening HIV Screening Influenza & Hepatitis B Vaccine Mammogram Medical Nutritional Therapy Services Annual Wellness Visits Pneumococcal Vaccine Prostate Cancer Screening Smoking Cessation Welcome to Medicare Physical Exam Educational/Health Newsletters 24 Hour Nurse Advice Line

18 WHEN CAN YOU ENROLL IN ALLEGIAN ADVANTAGE (HMO)? INITIAL ENROLLMENT PERIOD (IEP) Your IEP begins three months before the month you get Medicare, during the month you get Medicare and ends three months after the month you get Medicare. ANNUAL ELECTION PERIOD (AEP) You may join or switch from your current plan during the Annual Election Period that begins October 15 and ends December 7 annually. SPECIAL ENROLLMENT PERIOD (SEP) A Special Enrollment Period allows you to change your Medicare Advantage and Medicare prescription drug coverage when certain events happen in your life, for example, if you move out of your plan s service area or leave coverage from your employer or union. There are many situations that might qualify you for a Special Enrollment Period. For more SEP information, call Medicare at , 24 hours a day, 7 days a week. TTY users should call Or visit Medicare online at

19 JOIN US $0 PREMIUM WITH THE EXTRAS YOU CAN T GET FROM ORIGINAL MEDICARE! Contact Allegian Advantage (HMO) Today! By Phone Toll Free TTY users call a.m. to 8 p.m., 7 days a week. Online Visit us at to learn more or enroll online.

20 ENROLL ONLINE! Visit our website at to complete and submit your 2015 enrollment application online. CALL TO ENROLL Allegian Advantage (HMO) Toll Free TTY users call a.m. to 8 p.m., 7 days a week Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network,, provider network, premium and/or co-payments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. This information is available for free in other languages. Please contact Member Services at (855) for additional information. (TTY users should call 711). Hours are 8 a.m. to 8 p.m., seven days a week. Esta información está disponible gratuitamente en otros lenguajes. Por favor comuníquese al número para servicio al cliente a o TTY 711, 8 a.m.- 8 p.m., 7 días a la semana.