2016 Riverside Medical Clinic Contracted Medicare Advantage Health Plan Benefit Comparison
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1 Riverside Medical Clinic Contracted Medicare Advantage Health Plan AARP Medicare Complete Plan 1 [Secure Horizons] Anthem MediBlue Select Health Net Healthy Heart ** Inter Valley Health Plan Service to Seniors SCAN Classic II PBP # - CMS Plan Code H H H H H H H H Plan Web Site: aarpmedicareplans.com anthem.com/ca/medicare Healthnet.com/medicare humana-medicare.com humana-medicare.com humana-medicare.com ivhp.com scanhealthplan.com Monthly Plan Premium $30 $48 Part D Monthly Premium.00 NA Out of Pocket Limit $4,900 $3,400 $3,000 $3,400 $3,400 $6,700 $2,000 $5,000 Inpatient Care Hospital Days 1-7 $250/Day Days 8+ $200 Days (1-5) Days (6-90+) $250 Days (1-5) Days (6-90+) $200 Day 1-5 Outpatient Care Physician Visit Urgent Care $30 - $50 $10 $20 Specialist Visit $15 Chiropractic Services $10 Podiatry Services $10 Lab $10 X-rays to $50 Diagnostic Radiology 20% to $50 $60 to $40 to $40 - $100 $60 $200 Therapeutic Radiology 20% 20% $60 20% 20% 20% $15 20% Emergency Room $75 $75 $75 $75 $75 $75 $75 $75 Ambulance Services $250 $215 $250 $100 $50 $100 $200 $250 Ambulatory Surgi-Center $225 $100 $100 - $100 Hospital Facility $225 - $45 $200 $150 -$200 or 20% Medical Services & Supplies Durable Medical Equipment 20% 20% 20% 0 to 20% to 20% for high cost items 20% 10% 20%
2 HMO Senior 2016 Riverside Medical Clinic Contracted Medicare Advantage Health Plan AARP Medicare Complete Plan 1 [Secure Horizons] Anthem MediBlue Select Health Net Healthy Heart ** Inter Valley Health Plan Service to Seniors SCAN Classic II PBP # - CMS Plan Code H H H H H H H H Prescription Drug Coverage RX-Initial Coverage Limit $3,310 $3,100 $3,310 $3,310 $3,310 NO Rx $3,310 $3,310 Discounts offered Discounts offered Discounts offered Discounts offered Discounts offered $25 Medicare Discounts offered Discounts offered thru Gap thru Gap thru Gap thru Gap thru Gap Part B Premium thru Gap thru Gap Rx-Catastrophic Coverage $4,850 $4,850 $4,850 $4,850 $4,850 Reduction $4,850 $4,850 Retail Pharmacy (30-day supply) Tier 1 Generic (Preferred) $4 $8 $10 $5 $7 Tier 2 Generic (Non-Preferred) $8 $15 $20 $10 $10 $17.50 $12 Tier 3 Brand (Preferred) $47 $47 $47 $35 $30 $47 $47 Tier 4 Brand (Non-Preferred) $100 $100 $100 $100 $100 $95 $100 Specialty Injectibles 33% 33% 33% 33% 33% 33% 33% Retail Pharmacy (90-day supply) Tier 1 Generic (Preferred) $12 $24 $30 $15 $14 Tier 2 Generic (Non-Preferred) $24 $45 $60 $30 $30 $52.50 $24 Tier 3 Brand (Preferred) $141 $141 $141 $105 $90 $141 $141 Tier 4 Brand (Non-Preferred) $300 $300 $300 $300 $300 $285 $300 Specialty Injectibles 33% 33% Mail-Order (90-day supply) Preferred/Standard N/A Preferred/Standard Preferred/Standard Preferred/Standard N/A N/A Tier 1 Generic (Preferred) / $12 $9 $10 / $30 / $10 $14 Tier 2 Generic (Non-Preferred) / $24 $30 $20 / $60 / $30 / 30 $35 $24 Tier 3 Brand (Preferred) $131 / $141 $126 $101 / $141 $70 / $105 $60 / $90 $ $ Tier 4 Brand (Non-Preferred) $290 / $300 $285 $260 / $300 $200 / $300 $200 / $300 $ $290 Specialty Injectibles 33% OTHER Services Available Dental Benefits Limited Limited Not Available Oral Exam 1 pr yr - 2 pr / yr - 2 pr / yr $4-2 pr / yr Cleaning 1 pr yr - 2 pr / yr - 2 pr / yr $10-2 pr / yr Fluoride N/A $10 - $12 Dental X-rays - 1 / yr - 2 / yr -$10 1 /3 yrs
3 Riverside Medical Clinic Contracted Medicare Advantage Health Plan AARP Medicare Complete Plan 1 [Secure Horizons] Anthem MediBlue Select Health Net Healthy Heart ** Inter Valley Health Plan Service to Seniors SCAN Classic II PBP # - CMS Plan Code H H H H H H H H Eyewear /Vision Benefits Eye Exam $15 Eyewear Allowance $70 every 2 yrs $100 limit every year $100 limit every year Hearing Benefits Not Available $5 per Eval $100 limit every 2 yrs. $105 limit every 2 yrs Hearing Aid Allowance $390-$450 copay up to 2 every yr Up to $1,000 every year Up to $2,000 every 3 yrs $400 every 3 yrs through specified Vendors $250 every 3 yrs through specified Vendors Up to $500 every 2 yrs Transportation Not covered Not covered up to 12 one-way trips up to 12 one-way trips up to 24 one-way trips Not covered Supplemental Benefit Packages Optional Dental $3.50/ month High Option $17 / month Pkg:1 $12/month Pkg:2 $29/month Pkg:3 $37/month Pkg: 1 $22/month HMO Buy-Up 3 of the following: Dental+Eyewear+ Chiro+Acupuncture Pkg: 2 $32/month HMO Buy-Up 5: DPPO+Eyewear+ Chiro/Acupuncture: Chiropractic: Dental Pkg 1: $31.70/month LifeCard Plans, Vitality Healthy Food Discount, Life Fitness Discount, Dental Discount, Hearing Discount, Jenny Craig Discount, Lifeline Discount, NutriSystems Discount LifeCard Plans, Alternative Medicine Discounts, Vitality Healthy Food Discount, Life Fitness Discount, Biggest Loser Resort Discount, Dental Discount, Hearing Discount, Jenny Craig Discount, LifeLine Program - Up to $20/ monthly Value for Over-the-Counter Drugs & Supplies, Meal Delivery benefit included, 24-Hour Nurse Advise Line included Pkg 1: $11.50/month Enhanced Dental Pkg 1: $8/month: Basic Dental Pkg #2: $16/month: Enhanced Dental
4 Riverside Medical Clinic Contracted Medicare Advantage Health Plan PBP # - CMS Plan Code Plan Web Site: Monthly Plan Premium Part D Monthly Premium Out of Pocket Limit Inpatient Care IEHP DualChoice / Cal Medi-Connect (Medicare-Medical Eligible Only) H iehp.org Hospital Outpatient Care Physician Visit Urgent Care Specialist Visit Chiropractic Services Podiatry Services Lab X-rays Diagnostic Radiology Therapeutic Radiology Emergency Room Ambulance Services Ambulatory Surgi-Center Hospital Facility Medical Services & Supplies Durable Medical Equipment
5 Riverside Medical Clinic Contracted 2016 HMO Medicare Senior Advantage Health Plan PBP # - CMS Plan Code Prescription Drug Coverage RX-Initial Coverage Limit IEHP DualChoice / Cal Medi-Connect (Medicare-Medical Eligible Only) H Rx-Catastrophic Coverage Retail Pharmacy (30-day supply) Tier 1 Generic (Preferred) Tier 2 Generic (Non-Preferred) Tier 3 Brand (Preferred) Tier 4 Brand (Non-Preferred) Specialty Injectibles Retail Pharmacy (90-day supply) Tier 1 Generic (Preferred) Tier 2 Generic (Non-Preferred) Tier 3 Brand (Preferred) Tier 4 Brand (Non-Preferred) Specialty Injectibles Mail-Order (90-day supply) Tier 1 Generic (Preferred) Tier 2 Generic (Non-Preferred) Tier 3 Brand (Preferred) Tier 4 Brand (Non-Preferred) Specialty Injectibles OTHER Services Available Dental Benefits Oral Exam Cleaning Fluoride Dental X-rays TO $2.95 TO $2.95 TO $2.95 TO $7.40 TO $2.95 TO $2.95 TO $2.95 TO $7.40 TO $2.95 TO $2.95 TO $2.95 TO $ pr yr 2 pr yr 2 pr yr 1 pr yr
6 Riverside Medical Clinic Contracted Medicare Advantage Health Plan IEHP DualChoice / Cal Medi-Connect (Medicare-Medical Eligible Only) PBP # - CMS Plan Code Eyewear /Vision Benefits Eye Exam Eyewear Allowance Hearing Benefits H $100 limit every 2 yrs. Hearing Aid Allowance Plan covers $1,510 Transportation Supplemental Benefit Packages
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