2014 HICAP (714) Orange County Medicare Advantage (HMO, PPO) Comparison Chart Company Aetna Aetna Anthem Blue Cross Blue Shield

Transcription

1 Company Aetna Aetna Anthem Blue Cross Blue Shield Medicare Select Plan Medicare Value Plan Senior Secure Plan I 65 Plus Current members: aetnamedicare.com and hospitals Current members: aetnamedicare.com and hospitals Current members: anthem.com/ca/medicare and hospitals blueshieldca.com and hospitals. $0 $0 $0 $ physicians and physicians and physicians and physicians and $6,700 In-Network $2,000 In-Network $5,000 In-Network $2,800 In-Network $0 each visit $0 each visit $20 each visit $0 each visit $0 each visit $0 each visit $45 each visit $0 each visit Days 1-7: $264/day, Days 8-90: $0/day. Unlimited days each benefit each benefit Days 1-7: $211/day, Days 8-90: $0/day. Unlimited days each benefit each benefit Days 1-20: $25/day, Days : $152/day. No prior hospital stay required. 100 days covered each benefit $1,480 each stay. 190-day $40 each indiv. or group Days 1-20: $25/day, Days : $152/day. No prior hospital stay required. 100 days covered each benefit $1,480 each stay. 190-day $40 each indiv. or group 100: $152/day. No prior days each benefit Days 1-7: $211/day, Days 8-90: $0/day. 190-day $40 each indiv. or group Days 1-20: $0, Days : $75/day. No prior hospital stay required. 100 days covered each benefit $900 each stay. 190-day $30 each indiv. or group $0 - $264 each visit $0 each visit $0 - $200 each visit $0 - $100 each visit $400 each service $350 each service $300 each service $200 each service $65 each visit. Limited coverage worldwide. $65 each visit. $10, 000 limit outside of U.S. $0 each visit $0 each visit $50 each visit $20 each visit and tests. 20% of the cost for diagnostic and tests. 20% of the cost for diagnostic $0 to $220 for diagnostic procedures and tests. $65- $220 for diagnostic radiology $20-$45 copay may apply for additional and tests. $40 for diagnostic $0-$30 each X-ray $0-$10 each X-ray $65 each X-ray $0 each X-ray Lab $0 each lab service. 20% of the cost for therapeutic $0 each lab service. 20% of the cost for therapeutic $10 each lab service. 20% for $20 to $45 copay may apply for additional $0 each lab service. 20% for Dental Hearing exams. $0 copay for up to 1 routine exam/yr. Hearing aids not covered. routine exam/yr. Hearing aids not covered. $45 copay for diagnostic exams. Routine exams and hearing aids not covered. exams. $0 copay for routine exams. Hearing aids not covered. Vision 1 1 routine exam per year. $0 routine exam per year. $0 copay for one pair of eyewear copay for one pair of eyewear after cataract surgery. after cataract surgery. surgery. eye conditions. $20 for up to 1 routine exam/yr. $0 copay for surgery. $20 for up to 1 pair of lenses/yr. $20 for up to 1 pair of frames/2 yrs. ($75 limit/2 yrs.). Prescription Contact the plan to verify information. Page 1 of 10

2 Blue Shield Brand New Day Brand New Day Care1st 65 Plus Choice blueshieldca.com and hospitals. Enhanced Drug Savings for So. Cal brandnewdayhmo.com and hospitals. Extra Care brandnewdayhmo.com and hospitals. Care1st Medicare AdvantageOptimum Plan care1stmedicare.com and hospitals. $0 $0 $28.10 $ physicians and physicians and physicians and physicians and $2,000 In-Network $6,700 In-Network $6,700 In-Network $3,400 In-Network $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $3 each visit each benefit 100: $50/day. No prior $900 copay per Medicarecovered. 190-day psychiatric hospital lifetime limit. $0 copay for 60 lifetime reserve days. $30 each indiv. or group Days 1-60: $0/day, Days 61-90: $296/day, Days 61-90: $296/day. 90 days each benefit 60 lifetime reserve days at $592/day. 100: $148/day. No prior days each benefit Days 1-60: $0/day, Days 61-90, $296/day. 190-day limit. 60 lifetime reserve days at $592/day. $0 for professional Plan covers 90 days each benefit $0 for professional 3- day prior hospital stay required. 100 days each benefit 190-day psychiatric hopsital lifetime limit. Contact plan for more details. each benefit 100: $50/day. No prior Days 1-8: $50/day, Days 9-90, $0/day. $400 out-of-pocket limit per benefit 190-day limit. $0 copay for 60 lifetime reserve days. $10 each indiv. or group $0 - $50 each visit $75 - $125 each visit 20% of the cost for each visit $20-$50 each visit $100 each service $65 each visit. $10, 000 limit outside of U.S. $15 each visit 20% of the cost for each service. admitted within 1-day. Not covered outside of U.S. $10-20% of the cost for each visit. 20% of the cost for each service. admitted within 3-days. $125 each service, waived if admitted. $50 each visit, waived if admitted within 1-day. $25,000 limit outside of U.S. 20% of the cost for each visit. $10 each visit 0%- and tests. $0 for diagnostic 20% of the cost for diagnostic the cost for diagnostic 20% of the cost for diagnostic the cost for diagnostic and tests. $0 for diagnostic $0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray Lab $0 copay for lab 20% of cost for therapeutic $0 copay for lab 20% of cost for therapeutic $0 copay for lab 20% of cost for therapeutic $0 for lab 10% for Dental benefits. $5 - $16 for oral exams/yr., $20 up to 1 cleaning/6 mo., $5 for up to 2 fluoride treatment. $0-$10 for up to1 X-ray. 0% - 20% of the cost for Medicare-covered benefits. $0 for oral exams/yr., $0 -$25 up to 1 cleaning/6 mo., $0 - $12 for up to 1 fluoride treatment/yr., $0-$10 for up to1 X-ray. ($1000 limit for dental benefits/yr.) 0% - 20% of the cost for Medicare-covered benefits. $0 for up to 2 oral exams/yr, up to 1 cleaning/6 mo., up to 1 fluoride treatment/yr., up to 1 X-ray/yr. ($1000 limit for dental benefits/yr.) $8-$570 for Medicare-covered benefits. $8 copay for up to 1 oral exam/yr, up to 1 cleaning/6 mo. $13 for up to 1 fluoride treatment/6 mo.. $8 for up to 1 X-ray/2yrs. Hearing routine exam. $0 for up to 1 fitting-eval./2 yrs. $0 copay for hearing aids ($500 limit/2 yrs.). diagnostic exams. Routine exams. Hearing aids not covered. diagnostic exams. Routine exams and hearing aids not covered. $10 copay for diagnostic exams. $10 copay for up to 1 routine exam/yr. $0 for up to 1 hearing aid fitting-eval./yr. $0 copay for up to 2 hearing aids/2 yrs. ($1000 limit/yr.). Vision eye conditions. $0 for eye $20 for up to 1 routine exam/yr. $20 for up to1 pair of lenses/yr. $20 for up to 1 frame ($90 limit)/2 yrs. $25 copay to diagnose & treat eye conditions. $25 for up to 1 routine exam/yr. $0 copay for surgery. $0 copay for up to1 pair of lenses/yr., up to 1 pair of frames/2yrs. $40 limit for eyewear/yr. $25 copay to diagnose & treat eye conditions. $0 for up to 1 routine exam/yr. $0 copay for surgery. $0 copay for up to1 pair of lenses/yr., up to 1 pair of frames/2yrs. eye conditions. $0 for eye $0 copay for up to 1 pair of glasses/2 yrs. $5 copay for up to 1 routine exam/yr. $150 limit for eye wear/2 yrs. Prescription Contact the plan to verify information. Page 2 of 10

3 Care1st CareMore Health Plan CareMore Health Plan Central Health Coordinated Choice Plan Value Plus StartSmart Plan Medicare Plan care1stmedicare.com and hospitals caremore.com and hospitals caremore.com and hospitals centralhealthplan.com and hospitals. $26.30 $0 $0 $ physicians and physicians and physicians and physicians and $3,400 In-Network $3,400 In-Network $6,700 In-Network $3,400 In-Network $0 each visit $0 each visit $5 each visit $0 each visit $0 each visit $0 each visit $0 - $20 each visit $0 each visit Plan covers 90 days each benefit Contact plan for more details. $0 copay. 90 days each benefit $0 for 60 lifetime Days 1-5: $125/day, Days 6-90: $0/day. 90 days each benefit $0 copay for 60 lifetime each benefit Days 1-100: $50/day. No prior hospital stay required. 100 days each benefit 100: $25/day. No prior Days 1-20: $25/day, Days : $100/day. No prior 65: $75/day, Days : $0/day. No prior hospital stay required day psychiatric hopsital lifetime limit. Contact plan for more details. $0 copay. Contact plan for coverage beyond 190 days. $0 copay for 60 lifetime Days 1-5: $125/day, Days 6-60 lifetime Contact plan for coverage beyond 190 days. $0 copay. 190-day psychiatric hospital lifetime limit. 10% - 20% each indiv. or group $0-$20 each indiv. or group $5 each indiv. or group 20% of the cost for each visit $0 each visit $100 each visit $0 each visit 20% of the cost for each service. 20% of the cost (max $65) each visit. $25,000 limit outside of U.S. $100 each service. $100 each service. $50 each service $10,000 limit outside of U.S. $10,000 limit outside of U.S. $50 each visit, waived if $50,000 limit outside of U.S. $15 each visit $0 each visit $20 each visit $0 each visit 0%- 0%- 0%- and tests. 20% of the cost for diagnostic and tests. $0 - $75 for diagnostic and tests. $0-$150 for diagnostic $5-$20 copay for office visit may apply. and tests. $0 for diagnostic 20% of cost for X-rays $0 each X-ray $0 each X-ray $0 each X-rays Lab $0 for lab 20% for $0 copay for lab $60 for $0 for lab 20% of the cost for $5 -$20 copay for office visit may apply. $0 for lab 20% of cost for Dental Hearing Vision Prescription $5-$415 for Medicare-covered benefits. $5 for oral exams. $5 for up to 2 cleanings/yr. $5 for up to 2 fluoride treatments/yr. $5 for up to 1 X-ray every 2 yrs. $10 copay for diagnostic exams. $10 copay for up to 1 routine exam/yr. $0 for up to 1 hearing aid fitting-eval./yr. $0 copay for 2 hearing aids/ 2 yrs. ($1000 limit/yr.) $20 copay to diagnose & treat eye conditions. $20 for eye $20 copay for up to 1 pair of glasses/yr. $20 copay for up to 1 routine exam/yr. $250 limit for eye wear/yr. $0 for Medicare-covered benefits. $5-$15 for oral exams. $35 for up to 2 cleanings/yr. $5 for up to 2 fluoride treatments/yr. $0-$10 copay for up to 1 X-ray/3 yrs. routine exam. $0 for up to 1 fitting-eval./yr. $0 copay for hearing aids ($250 limit/yr.). 1 routine exam/yr. $0 for eye $0 for 1 pair of frames/2 yrs., $20 for 1 pair of lenses/2 yrs. ($100 limit for eye glass frames/2 yrs.). $0 for 1 pair of contacts/2 yrs. ($100 limit/2 yrs.) $5-$20 for Medicare-covered benefits. $5-$15 for oral exams. $35 for up to 2 cleanings/yr. $5 for up to 2 fluoride treatments/yr. $0-$10 for up to 1 X-ray every 3 yrs. $0 copy for diagnostic exams. $0 copay for up to 1 routine exam and 1 hearing aid fittingeval./yr. Hearing aids not covered. $5-$20 copay to diagnose & treat eye conditions. $0 for up to 1 routine exam/yr. $0 for surgery. $20 for up to 1 pair of lenses/2 yrs. $0 for up to 1 pair of frames/2 yrs.($100 limit for eye glass frames/2 yrs.). $0 for up to 1 pair of contacts/2 yrs. ($100 limit/2 yrs.) $0 for Medicare-covered benefits. $0 for oral exams, up to 2 cleanings/2 flouride treatments/yr. and up to 1 X- ray every 6 months. routine exam and 1 hearing aid fitting-eval./yr. $0 copay for up to 1 hearing aid/yr.($500 limit/yr.) exams and for eye wear after cataract surgery. $0 for up to 1 pair of glasses/contacts/lenses/and frames/yr. ($150 limit/yr.) Contact the plan to verify information. Page 3 of 10

4 Central Health Citizens Choice Easy Choice Easy Choice Premier Plan Healthplan Best Plan Plus Plan centralhealthplan.com and hospitals. $28.10 ($500 Deductible In- Network) physicians and ext: ext: 5550 citizenschoicehealth.com and hospitals easychoicehealthplan.com and hospitals easychoicehealthplan.com and hospitals. $0 $0 $ physicians and physicians and physicians and $6,700 In-Network $3,400 In-Network $6,700 In-Network $6,700 In-Network 20% of the cost each visit $0 each visit $0 each visit $0 each visit 20% of the cost each visit $0 each visit $0 each visit $0 each visit $0 for professional Unlimited days each benefit Days 1-10: $0/day, Days 11-45: $100/day, Days 46-90: $75/day. Unlimited days each benefit Days 1-90: $0/day. 90 days each benefit $0 for 60 lifetime Days 1-3: $500/day, Days 4-90: $0/day. 90 days each benefit $0 for 60 lifetime $0 for professional No prior hospital stay required. 100 days each benefit 190-day psychiatric hopsital lifetime limit. Contact plan for more details. 100: $85/day. No prior $250 copay each Medicarecovered stay. Days 1-10: $120/day, Days 11-90: $0/day. $0 copay for 60 lifetime reserve days. 190-day psychiatric hospital lifetime limit. $0 - $40 each indiv. or group Days 1-100: $0/day. No prior hospital stay is required. 100 Days 1-90: $0/day. 190-day 20% of the cost for each visit $0 - $100 each visit $0 - $50 each visit 20% of the cost of each service 20% of the cost (max $65) each visit, waived if admitted within 24-hrs. $50,000 limit outside of U.S. $0-$125 each service, waived if admitted. $0- $7,500 limit outside of U.S. $50 each service, waived if admitted. 100: $152/day. No prior Days 1-3: $494/day, Days 4-90: $0/day.190-day $0 [or 0%-20% of the cost] each visit 20% of the cost of each service, waived if admitted. 20% of the cost (max $65) each visit, waived if admitted within 24-hrs. 20% of the cost for each visit $0 each visit $0 each visit $0 each visit 0%- 20% of the cost for diagnostic the cost for diagnostic and tests. $0 for diagnostic and tests. $50 for diagnostic and tests. 20% of the cost for diagnostic 20% of cost for X-rays $0 each X-ray $0 each X-ray $0 each X-ray Lab 20% of the cost for lab 20% of cost for $0 copay for lab $50 $0 copay for lab 20% of the cost for $0 copay for lab 20% of the cost for Dental Hearing $0 for Medicare-covered benefits. $0 for oral exam, up to 2 fluoride treatments/yr, up to 2 cleaning/yr and 1 X- ray every 6 months. 20% of the cost for diagnostic routine exam and 1 hearing aid fitting-eval./yr. $0 copay for up to 1 hearing aid/yr.($2,000 limit/yr.) $0-$425 for Medicare-covered benefits. $0 copay for1 oral exams/6 mo. $0-$30 copay for 1 X-ray/3 yrs. $0 for 1 cleaning/6mo. $0-$20 for1 fluoride treatment/6 mo. routine exam and hearing aid fitting-eval./ yr. $0 copay for up to 1 hearing aids/yr. benefits.$0-$40 copay/1 benefits. $0 copay for oral exams/6mo. $0-$30 for 1 X- up to 1 oral exam/1 ray. $10-$55 copay/1 cleaning /6 cleaning/1 fluoride mo. $9-$20 copay/1 fluoride treatment/6 mo. ($1,000 treatment/6 mo., $0 copay for limit/yr.) 1 X-ray. ($1,000 limit/yr). routine exam and hearing aid fitting-eval./yr. $0 for up to 1 hearing aid/yr.($350 limit/yr.) routine exam and hearing aid fitting-eval./ yr. $0 copay for up to 1 hearing aids/yr. ($350 limit/yr.) Vision 20% of the cost to diagnose & treat eye conditions. 20% of the cost for eye wear after cataract surgery. $0 for up to 1 routine exam/yr. $0 for up to 1 pair of glasses /contacts /lenses /and frames/yr. ($300 limit/yr.). surgery. $0 copay for up to 1 routine exam/yr. $0 copay for up to 1 pair of glasses/contacts/lenses and frames/2 yrs. ($75 limit/2yr.). surgery. $0 copay for up to 1 routine exam/yr. $0 copay for up to 1 pair of glasses/contacts/lenses and frames/yr. ($100 limit/yr.) surgery. $0 copay for up to 1 routine exam/yr. $0 copay for up to 1 pair of glasses/contacts/lenses and frames/yr. ($100 limit/yr.) Prescription Contact the plan to verify information. Page 4 of 10

5 Golden State Health Net Health Net Health Net Medicare Health Plan, Golden GoldenStateMHP.com and hospitals. Healthy Heart healthnet.com/medicare and hospitals. Seniority Plus Ruby Plan healthnet.com/medicare and hospitals. Gold Select healthnet.com/medicare and hospitals. $0 $0 $0 $ physicians and physicians and physicians and physicians and $3,400 In-Network $3,400 In-Network $3,400 In-Network $2,200 In-Network $0 each visit $0 each visit $8 each visit $0 each visit $0 each visit $0 each visit $10 each visit $0 each visit each benefit each benefit Days 1-4: $150/day, Days 5-90: $0/day. Unlimited days each benefit each benefit 100: $65/day. No prior 100: $75/day. No prior 100: $75/day. No prior 100: $75/day. No prior $0 copay. 190-day psychiatric hospital lifetime limit. $900 copay. 190-day $25 each indiv. or group $900 copay. 190-day $25 each indiv. or group $900 copay. 190-day $25 each indiv. or group $0 each visit $0 - $60 each visit $0 - $150 each visit $0 -$60 each visit $100 each service $250 each service $210 each service $250 each service $10,000 limit outside of U.S. $50,000 limit outside of U.S. $50,000 limit outside of U.S. $50,000 limit outside of U.S. $0 each visit $0 each visit $0 each visit $0 each visit 0%-20% for Medicarecovered and tests. $0 for diagnostic and tests. $60 for diagnostic and tests. $60 for diagnostic and tests. $60 for diagnostic $0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray Lab $0 copay for lab $0 $0 copay for lab $60 $0 copay for lab $60 $0 copay for lab $60 Dental benefits. $0 copay for oral exams/1 fluoride treatment/1 X-rays and up to 2 cleanings/yr. Hearing exams. $0 copay for 1 routine test/yr. $0 copay for 1 hearing aid fitting-eval./2 yrs. $0 copay for hearing aids. ($200 limit for hearing aids/2 yrs.) $30 copay for diagnostic exams. $30 copay for up to 1 routine exam/yr. Hearing aids not covered. $10 copay for diagnostic exams. $10 copay for up to 1 routine exam/yr. Hearing aids not covered. routine exam/yr., 1 hearing aid fitting-eval./3 yrs., 2 hearing aids/ 3 yrs. ($1,000 limit/3 yrs.) Vision eye conditions and up to 1 routine exam/yr. $0 copay for surgery. $0 for glasses/contacts. ($150 limit for eye wear/2 yrs.) $0-$30 copay to diagnose & treat eye conditions. $0 copay for surgery. $30 copay for up to 1 routine exam/yr. $0-$10 copay to diagnose & treat eye conditions. $0 copay for surgery. $10 copay for up to 1 routine exam/yr. $0-$25 copay to diagnose & treat eye conditions. $0 copay for surgery. $25 copay for up to 1 routine exam/yr. $0 copay for up to 1 pair of glasses/contacts/lenses/fram es/2 yrs. ($100 limit/2 yrs.) Prescription Contact the plan to verify information. Page 5 of 10

6 Humana Inter Valley Kaiser SCAN Gold Plus OC Preferred Senior Advantage Scan Classic humana-medicare.com and hospitals ivhp.com and hospitals kp.org/medicare and hospitals scanhealthplan.com and hospitals. $0 $0 $0 $ physicians and physicians and physicians and physicians and $3,400 In-Network $3,400 In-Network $5,900 In-Network $3,400 In-Network $0 each visit $0 each visit $5 each visit $0 each visit $0 each visit $0-$15 each visit $5 each visit $0 each visit each benefit each benefit Days 1-7: $210/day, Days 8-90: $0/day. Unlimited days each benefit each benefit Days 1-100: $0/day. No prior $0 copay. 190-day psychiatric hospital lifetime limit. $0 copay for 60 lifetime reserve days. $25 each indiv. or group $0-$40 [or 20% of cost] each visit. Days 1-13: $0/day, Days : $50/day. No prior $450 out-of-pocket limit each stay. Days 1-6: $75/day, Days 7-90: $0/day. 190-day psychiatric hospital lifetime limit. $0 copay for 60 lifetime $10 each indiv. or group Days 1-20: $25/day, Days : $50/day. No prior Days 1-7: $210/day, Days 8-90: $0/day. Contact plan for coverage beyond 190 days. $5 each individual visit. $2 each group 100: $25/day. No prior $0 copay. 190-day psychiatric hospital lifetime limit. $0 copay for 60 lifetime reserve days. $25 each indiv. or group $50 each visit $0-$210 each visit $0 - $100 each visit $50 each service $200 each service $200 each service $200 each service $20,000 limit outside of U.S. $0 each visit $10 each visit $5 each visit $15 each visit 0% - 20% of cost for Medicare-covered 0%- Lab Dental and tests. $0-$40 for diagnostic and tests. $0-$60 for diagnostic (see limit under Lab row) $0-$30 for diagnostic procedures and tests. $150 for diagnostic radiology $5 copay may apply for additional and tests. $50 copay for diagnostic $0 each X-ray $0-$60 each X-ray $30 each X-ray $0 for each X-ray $0 copay for lab 20% of cost for therapeutic $0 copay for lab $15 ($1,000 out-of-pocket limit for Outpatient Diagnostic and Therapeutic Radiology/yr.) $15 copay for Medicarecovered benefits. $4-$10 copay for 1 oral exam/6 mo., $10 copy for 1 cleaning/6 mo., $10-$20 copay for 1 fluoride treatment/6 mo., $0- $10 copay for 1 X-ray/ 3 yrs. $0-$30 copay for lab $0 $5 copay may apply for additional $0-$45 copay for Part B $5 copay for Medicarecovered $0 copay for lab $25 Hearing exams. Routine exams and hearing aids not covered. $15 copay for diagnostic routine exam/yr., 1 hearing aid fitting-eval./yr., 1 hearing aid/3 yrs.($250 limit/3 yrs.) $5 copay for diagnostic exams. Routine exams and hearing aids not covered. routine exam/yr. and up to 1 hearing aid fitting-eval./2 yrs. $0 copay for up to 2 hearing aids/2yrs.($500 limit/ 2 yrs.) Vision Prescription surgery. $0-$15 copay to diagnose & treat eye conditions. $0 copay for surgery. $15 copay for up to 1 routine exam/yr. $25 copay for up to 1 pair of eyeglasses/ 2 yrs. ($100 limit/2 yrs.) $5 copay to diagnose & treat eye conditions. $0 for eye $5 copay for routine exams. $0 copay for glasses/contacts ($50 limit/2 yrs.). eye conditions. $0 for up to 1 routine exam/yr. $0 for eye $35 for up to 1 pair of glasses/contacts/lenses and frames/2 yrs. ($105 limit for contacts/2 yrs. And $105 limit for frames/2 yrs.) Contact the plan to verify information. Page 6 of 10

7 SCAN UnitedHealthcare UnitedHealthcare UnitedHealthcare Scan Plus scanhealthplan.com and hospitals. Medicare Complete SecureHorizons Plan AARPMedicarePlans.com and hospitals. MedicareComplete Premier Plan AARPMedicarePlans.com and hospitals. Medicare Complete SecureHorizons Plan AARPMedicarePlans.com and hospitals. $24.90 $0 $0 $ physicians and physicians and physicians and physicians and $6,700 In-Network $3,400 In-Network $4,900 In-Network $6,700 In-Network 20% of the cost each visit $0 each visit $5 each visit 20% of the cost each visit 20% of the cost each visit $0 each visit $10 each visit 20% of the cost each visit $0 for professional 90 days each benefit each benefit Days 1-5: $150/day, Days 6-90: $0. Unlimited days each benefit $1,220 copay for each Medicare-covered stay. Unlimited days each benefit $0 for professional No prior hospital stay required. 100 days each benefit 190-day psychiatric hopsital lifetime limit. 20% of the cost for each indiv. or group 43: $150/day, Days : $0/day. No prior hospital stay required. 100 $0 copay. 190-day psychiatric hospital lifetime limit. $0 copay for 60 lifetime reserve days. $30 each indiv. or group 20% of cost for each visit $0 - $50 each visit 20% of the cost for each service $65 each visit. Days 1-20: $25/day, Days 21-49: $152/day, Days : $0/day. No prior hospital stay required. 100 Days 1-5: $150/day, Days 6-90: $0/day. 190-day $30 each indiv. or group $0 - $125 [or 20% of the cost] each visit $250 each service $250 each service admitted within 24-hours. admitted within 24-hours. $0 copay. No prior hospital stay required. 100 days covered each benefit $1,220 each stay. 190-day 20% of the cost for each indiv. or group 0% - 20% of the cost each visit 20% of the cost for each service admitted within 24-hours. 20% of the cost for each visit $0 each visit $10 each visit 20% of the cost for each visit 20% of cost for diagnostic cost for diagnostic radiology procedures and tests. $50 copay for diagnostic radiology 20% of cost for diagnostic cost for diagnostic radiology $5 - $10 copay may apply for additional services 20% of cost for diagnostic cost for diagnostic radiology A separate cost sharing of 20% may apply. 20% of cost for each X-ray $0 each X-ray $0 each X-ray 20% of cost for each X-ray Lab $0 copay for lab 20% of cost for therapeutic $0 for lab $50 copay for $13 for lab 20% of cost for $5 - $10 copay may apply for additional services $0 for lab 20% of cost for A separate cost sharing of 20% may apply. Dental benefits. $0 copay for oral exams. $0 for up to 2 cleanings/yr. $0 copay for up 1 X-ray/6 mo. $10 copay for Medicarecovered benefits. $0 copay for up to 1 oral exams and cleaning/6 mo. and 1 X- ray/yr. Hearing Vision Prescription 20% of the cost for diagnostic routine exam/yr. and up to 1 hearing aid fitting-eval./2 yrs. $0 copay for up to 2 hearing aids/2yrs.($1,400 limit/ 2 yrs.) 0%-20% of the cost to diagnose & treat eye conditions. $0 for up to 1 routine exam/yr. 20% of the cost for eye wear after cataract surgery. $0 for up to 1 pair of glasses/contacts/lenses/2 yrs. ($175 limit for frames/ 2 yrs. And $175 limit for contacts/2 yrs.) exams. $0 for up to 1 routine exam/yr. $380 copay each for up to 2 inner-ear hearing aids/yr. $330 copay each for up to 2 over-the-ear hearing aids/yr. eye conditions. $0 for eye wear after cataract surgery. $0 for up to 1 routine exam/yr. $30 copay contacts ($105 limit/2 yrs.). $0 for up to 1 pair of lenses/2 yrs. $30 for up to 1 pair of frames/2 yrs. ($70 limit/2 yrs.) $10 copay for diagnostic exams. $5 for up to 1 routine exam/yr. $450 copay each for up to 2 inner-ear hearing aids/yr. $390 copay each for up to 2 over-the-ear hearing aids/yr. $0-$10 copay to diagnose & treat eye conditions. $0 for eye $10 for up to 1 routine exam/yr. $30 copay for contacts ($105 limit/2 yrs.). $0 for up to 1 pair of lenses/2 yrs. $30 for up to 1 frames/2 yrs. ($70 limit/2 yrs.) diagnostic exams. Routine exams and hearing aids not covered. 20% of the cost to diagnose & treat eye conditions. $0 for surgery. $0 for up to 1 routine exam/2 yrs. $0 for contacts ($105 limit/2 yrs.). $0 for up to 1 pair of lenses/frames/2 yrs. ($70 limit for frames/2 yrs.). Contact the plan to verify information. Page 7 of 10

8 Lab Dental Hearing UnitedHealthcare Anthem Blue Cross MedicareComplete Essential Plan Current Members: AARPMedicarePlans.com MA ONLY (HMO) Medicare Advantage Plan only. Plan does NOT have Prescription Drug Benefit. Must and hospitals. $ physicians and Medicare Preferred Standard Current members: anthem.com/ca/medicare MA-PD (PPO) Preferred Provider Plan with Prescription Drug Benefit. May choose any provider. Plan Network at lower cost. $100 ($300 Deductible In and Out-of-network) and above physicians and $4,900 In-Network $4,500 In-Network. $6,700 In&Out $5 each visit In-Network: $15 Out: $35 $10 each visit In-Network: $45 Out: $55 $50 copay for each Medicarecovered/stay. $0 for each non- Medicare covered day. Unlimited days each benefit Days 1-20: $25/day, Days 21-49: $152/day, Days : $0/day. No prior hospital stay required. 100 $50 each stay. 190-day $30 each indiv. or group $0 [or 0%-20% of the cost] each visit In-Network: $795 copay/ Medicarecovered stay. $0 additional days. Out-of-Network: 20% of cost/ stay. Unlimited days each benefit In-Network: Days 1-20: $0, Days : $135/day. Out-of-Network: 20% of cost/stay. No prior hospital required. 100 days each benefit period In-Network: $795/stay. Out-of- Network: 20% of cost/stay day In-Network: $40 each visit. Out-of- Network: 30% of cost each visit. In-Network: $0-$45 or 0%-20% of the cost, each visit. Out-of-Network: 30% of cost each visit. $250 each service $300 each service: In/Out admitted within 24-hours. $10 each visit 20% of cost for diagnostic cost for diagnostic radiology $5-$10 copay may apply for additional $0 each X-ray $0 for lab 20% of cost for $5-$10 copay may apply for additional $10 copay for Medicarecovered $10 copay for diagnostic exams. $5 for up to 1 routine exam/yr. $380 copay each for 2 inner-ear hearing aids/yr. $330 copay each for 2 overthe-ear hearing aids/yr. $65 each visit. Worldwide coverage. In-Network: $50 each visit. Out-of- Network: 30% of cost for each visit In-Network: 20% of cost for Medicare-covered Out-of- Network: 25% of cost for Medicarecovered items In-Network: $0-$225 for diagnostic procedures and tests. $85-$225 for diagnostic $15- $45 may apply for additional Out-of-Network: 30% of cost In-Network: $85 each X-ray. Out-of- Network: 30% of cost for each X- ray. In-Network: $5 for lab 20% for $15-$45 may apply for additional Out-of- Network: 30% for lab services and. 19% of the cost for Part B. In or Out. In-Network: Out-of- Network: comprehensive benefits. In-Network: $45 for diagnostic exams. Routine exams and hearing aids not covered. Out-of-Network: 30% of cost for diagnostic exams. Notes: : All local MA plans must establish a mandatory maximum out-ofpocket (MOOP) amount for all Medicare Parts A and B services to mirror the same outof-pocket costs an average beneficiary would have under Original Medicare s fee for service program. After meeting the MOOP, a beneficiary s MA plan will cover his/her remaining Medicare-covered costs for the rest of the calendar year. The mandatory MOOP is $6,700, but plans can voluntarily set a lower MOOP at $3,400 in exchange for more flexibility in setting their costsharing amounts. Medicare Advantage Plans: These plans are also called Medicare Health Plans and are offered by private companies that contract with Medicare to provide Part A and Part B benefits to people with Medicare. There are several different types of Medicare Advantage Plans incuding HMO's and PPO's. In this chart you will find the type of plan, offered by each company, in the "" row. Dental Coverage: The dental coverage benefit section of this chart details the standard dental coverage from each plan. Standard coverage does not require an additional premium. Please verify all information with the respective plan. Vision Prescription $0-$10 copay to diagnose & treat eye conditions. $0 for In-Network: $0 copay to diagnose & treat eye conditions. surgery. $10 for up to 1 $0 for 1 pair of eye wear after routine exam/yr. $0 for cataract surgery. Out-ofcontacts ($125 limit/yr.). $0 Network: $0 for exams. $0 for for up to 1 pair of eye wear. lenses/frames/yr. ($130 limit for frames/yr.). None See separate chart Contact the plan to verify information. Page 8 of 10

9 Orange 2014 MA-PD Medicare Advantage (HMO & PPO) Prescription Drug Plans For Assistance, call HICAP County Beneficiary must have both Medicare Part A and B to enroll in a the drug benefits shown below HICAP Prescription Drug Plans associated with Health Maintenance Organizations (HMOs) or Monthly Annual Overall Drug Plan Organization Name Plan Deductible Co-Payments after deductible has been met Coverage Mail Quality Quality Non-Member Telephone No. Premium* for and prior to reaching $2,850 in full drug cost in Gap Order Rating Rating Plan Internet Part D Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 / 6 (Out of 5) (Out of 5) Aetna Medicare Select Plan Aetna Medicare Select Plan $0 $0 $10 25% 50% 33% $0 Few Gen Yes aetnamedicare.com Aetna Medicare Value Plan $0 $0 $5 25% 50% 33% $0 Many Gen Yes Anthem Blue Cross anthem.com/ca/medicare Blue Shield of California blueshieldca.com/findmedicareplan Blue Cross Senior Secure Plan I $0 $0 $5 $14 $40 $90 33% No Yes Blue Shield 65 Plus $0 $0 $0 $5 Blue Shield 65 Plus Choice $0 $0 $0 $45 $35 $70 $85 25% / 33% Many Gen Yes % 33% Many Gen Yes Brand New Day brandnewdayhmo.com Enhanced Drug Savings for So. Cal. $0 $0 $3 $9 $45 $90 33% Many Gen Yes Extra Care $28.10 $310 25% 25% 25% 25% 25% No Yes Care1st AdvantageOptimum Plan $0 $0 $0 $5 $30 $50 30% Many Gen Yes care1stmedicare.com Coordinated Choice Plan $26.30 $310 $0 25% 25% 25% 25% Few Gen Yes CareMore Health Plan Value Plus $0 $0 $0 $5 $30 $85 33% / $0 Many Gen Yes caremore.com StartSmart with CareMore $0 $0 $5 $10 $45 $95 33% / $10 No Yes Central Health Medicare Plan centralhealthplan.com Medicare Plan $0 $0 $0 $5 $25 $50 33% All Gen Yes Premier Plan $28.10 $310 $0 $0 25% 25% 25% Many Gen Yes Citizens Choice Health Plan citizenschoicehealth.com Citizens Choice Healthplan $0 $0 $5 $30 $75 33% 33% No Yes Easy Choice Health Plan Easy Choice Best Plan $0 $0 $0 $10 $45 $95 33% Many Gen Yes easychoicehealthplan.com Easy Choice Plus Plan $28.10 $310 $0 25% 25% 25% 25% Some Gen Yes Golden State Medicare Health Plan goldenstatemhp.com Golden State Medicare Health Plan, Golden $0 $0 $4 $40 $80 33% n/a Many Gen Yes * The premiums listed on the document are the same as the premiums listed on the Medicare Advantage HMO, PPO and are not in addition to those amounts. Not enough data availabe 4.0 Rev.10/15/2012 Information subject to change. Contact plans to verify information. Generally, Tier 1 = Generics Tier 2 = Generics and Preferred Brands Tier 3 = Non-Preferred Brands Tiers 4 and 5 = Specialties and Injectables 9 of 10

10 Orange 2014 MA-PD Medicare Advantage (HMO & PPO) Prescription Drug Plans For Assistance, call HICAP County Beneficiary must have both Medicare Part A and B to enroll in a the drug benefits shown below. HICAP or Prescription Drug Plans associated with Health Maintenance Organizations (HMOs) continued Monthly Annual Overall Drug Plan Organization Name Plan Deductible Co-Payments after deductible has been met Coverage Mail Quality Quality Non-Member Telephone No. Premium* for and prior to reaching $2,850 in full drug cost in Gap Order Rating Rating Plan Internet Part D Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 / 6 (Out of 5) (Out of 5) Health Net of California Healthy Heart $0 $0 $4 $10 $45 $95 33% Many Gen Yes Seniority Plus Ruby Plan $0 $0 $4 $10 $45 $95 33% / $0 Many Gen Yes healthnet.com Gold Select $0 $0 $0 $10 $45 $95 33% Many Gen Yes Humana Health Plan of CA, Inc. Some Gen & Gold Plus $0 $0 $0 $0 $45 $95 33% humana-medicare.com Few Brands Yes Inter Valley Health Plan ivhp.com OC Preferred $0 $0 $5 $15 $39 $89 33% Some Gen Yes Kaiser Permanente Senior Advantage kp.org/medicare SCAN Health Plan scanhealthplan.com UnitedHealthcare aarpmedicareplans.com Senior Advantage LA, Orange Co. $0 $0 $3 $10 $45 $95 25% / $0 All Gen & Few Brands Yes SCAN Classic $0 $0 $5 $10 $40 $85 33% / $10 Many Gen Yes SCAN Plus $24.90 $310 25% 25% 25% 25% 25% No Yes AARP MedciareComplete SecureHorizons Plan 2 AARP MedciareComplete SecureHorizons Plan 3 $0 $0 $0 $7 $45 $95 33% Some Gen Yes $16.20 $310 25% 25% 25% 25% 25% No Yes AARP MedicareComplete $0 $0 $4 $8 $45 $95 33% No Yes SecureHorizons Premier * The premiums listed on the document are the same as the premiums listed on the Medicare Advantage HMO, PPO and are not in addition to those amounts. Prescription Drug Plans associated with Preferred Provider Organizations (PPOs) Monthly Annual Overall Drug Plan Organization Name Plan Deductible Co-Payments after deductible has been met Coverage Mail Quality Quality Non-Member Telephone No. Premium* for and prior to reaching $2,850 in full drug cost in Gap Order Rating Rating Plan Internet Part D Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 (Out of 5) (Out of 5) Anthem Blue Cross Anthem Medicare Preferred anthem.com/ca/medicare Standard $100 $135 $5 $17 $40 $90 33% No Yes * The premiums listed on the document are the same as the premiums listed on the Medicare Advantage HMO, PPO and are not in addition to those amounts. Rev.10/15/2012 Information subject to change. Contact plans to verify information. Generally, Tier 1 = Generics Tier 2 = Generics and Preferred Brands Tier 3 = Non-Preferred Brands Tiers 4 and 5 = Specialties and Injectables 10 of 10