Summary of Benefits 2015

Transcription

1 Touchstone Health Medicare Prestige Plan Summary of Benefits 2015 Orange County Y0064_H3327_THPSMK_2364 Accepted

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3 Table of Contents You have choices about how to get your Medicare benefits?...1 Tips for comparing your Medicare choices...1 Sections in this booklet...1 Things to Know About Touchstone Health Medicare Prestige (HMO SNP)...2 Hours of Operation...2 Touchstone Health Medicare Prestige (HMO SNP) Phone Numbers and Website...2 Who can join?...2 Which doctors, hospitals, and pharmacies can I use?...2 What do we cover?...2 How will I determine my drug costs?...2

4 Touchstone Health Medicare Prestige (HMO SNP) (a Medicare Advantage Health Maintenance Organization (HMO) offered by TOUCHSTONE HEALTH HMO, INC. with a Medicare contract) Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. 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 Touchstone Health Medicare Prestige (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Touchstone Health Medicare Prestige (HMO SNP) 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 Benefits booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs 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/TDD users should call Sections in this booklet Things to Know About Touchstone Health Medicare Prestige (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits 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: Prospective members should call us at or TTY/TDD 711. Current members should call us at or TTY/TDD 711. Esta información está disponible en un formato diferente. Si necesita información del plan en otro formato o lenguaje, por favor llame a la línea de Servicio al Miembro al número mencionado arriba. 1

5 Things to Know About Touchstone Health Medicare Prestige (HMO SNP) Hours of Operation From October 15 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to October 14, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Touchstone Health Medicare Prestige (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free or TTY/TDD 711. If you are not a member of this plan, call toll-free or TTY/TDD 711. Our website: Who can join? To join Touchstone Health Medicare Prestige (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and the New York State Medicaid program, and live in our service area. Our service area includes the following county in New York: Orange. Which doctors, hospitals, and pharmacies can I use? Touchstone Health Medicare Prestige (HMO SNP) 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 prescription for covered Part D drugs. You can see our plan s provider directory at our website ( You can see our plan s pharmacy directory at our website ( 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, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 2

6 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly $0 per month. In addition, you must keep paying your Medicare Part B premium? premium. * How much is the This plan does not have a deductible. deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? COVERED MEDICAL AND HOSPITAL BENEFITS Outpatient Care and Services Acupuncture and Other Not covered Alternative Therapies Ambulance 1 You pay nothing * Chiropractic Care 1 Dental Services 1 Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for some services, depending on your level of Medicaid eligibility. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing * Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing * Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1): You pay nothing Fluoride treatment (for up to 1 every six months): You pay nothing Oral exam (for up to 1 every six months): You pay nothing Plan offers additional comprehensive dental services. Please contact the plan or consult Touchstone Health s Dental Handbook for more details about these covered benefits. Note: Services with a 1 may require prior authorization Services with a 2 may require a referral from your doctor *Based on your level of Medicaid eligibility 3

7 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) COVERED MEDICAL AND HOSPITAL BENEFITS Outpatient Care and Services Diabetes Supplies and Diabetes monitoring supplies: You pay nothing * Services 1 Diabetes self-management training: You pay nothing * Therapeutic shoes or inserts: You pay nothing * Diagnostic Tests, Lab and Diagnostic radiology services (such as MRIs, CT scans): You pay Radiology Services, and nothing* X-Rays 1 Diagnostic tests and procedures: You pay nothing * Lab services: You pay nothing * Outpatient x-rays: You pay nothing * Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing * Doctor s Office Visits Primary care physician visit: You pay nothing * Specialist visit: You pay nothing * Durable Medical You pay Equipment (wheelchairs, nothing* oxygen, etc.) 1 Emergency Care You pay nothing * Foot Care (podiatry services) 1 Worldwide Emergency Coverage: You pay nothing * $50,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing * Routine foot care (for up to 4 visit(s) every year): You pay nothing Hearing Services Exam to diagnose and treat hearing and balance issues: You pay nothing * Routine hearing exam (for up to 1 every year): You pay nothing Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,000 every three years for hearing aids. Home Health Care 1 You pay nothing * 4

8 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) COVERED MEDICAL AND HOSPITAL BENEFITS Outpatient Care and Services Mental Health Care 1 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. The copays 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 these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. You pay nothing * Outpatient group therapy visit: You pay nothing * Outpatient individual therapy visit: You pay nothing * Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing * Occupational therapy visit: You pay nothing * Physical therapy and speech and language therapy visit: You pay nothing * Outpatient Substance Group therapy visit: You pay nothing * Abuse 1 Individual therapy visit: You pay nothing * Outpatient Surgery 1 Ambulatory surgical center: You pay nothing * Outpatient hospital: You pay nothing * Over-the-Counter Items Get $75 per month (maximum limit up to $900 per year) to purchase Over-the-Counter items. Please visit our plan website to see our list of covered OTC items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using the benefit. Prosthetic Devices (braces, Prosthetic devices: You pay nothing * artificial limbs, etc.) 1 Related medical supplies: You pay nothing * Note: Services with a 1 may require prior authorization Services with a 2 may require a referral from your doctor *Based on your level of Medicaid eligibility 5

9 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) COVERED MEDICAL AND HOSPITAL BENEFITS Outpatient Care and Services Renal Dialysis 1 You pay nothing * Transportation 1 You pay nothing for 36 one-way trips to approved locations every year Urgent Care You pay nothing * Vision Services 1 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing * Routine eye exam (for up to 1 every year): You pay nothing Contact lenses (for up to 1 every two years): You pay nothing Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing Eyeglass frames (for up to 1 every two years): You pay nothing Eyeglass lenses (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing * Our plan pays up to $100 every two years for eyewear. 6

10 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) COVERED MEDICAL AND HOSPITAL BENEFITS Preventive Care Preventive Care 1 You pay nothing 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 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 Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing Hospice Hospice You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the cost for drugs and respite care. Note: Services with a 1 may require prior authorization Services with a 2 may require a referral from your doctor *Based on your level of Medicaid eligibility 7

11 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) COVERED MEDICAL AND HOSPITAL BENEFITS Inpatient Care Inpatient Hospital Care 1 The copays 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 an unlimited number of days for an inpatient hospital stay. You pay nothing * Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing * 8

12 TOUCHSTONE HEALTH PRESTIGE (HMO SNP) PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : You pay nothing * Initial Coverage Catastrophic Coverage Other Part B drugs 1 : You pay nothing * Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay, or $1.20 copay, or $2.65 copay For all other drugs, either: $0 copay, or $3.60 copay, or $6.60 copay You may get your drugs at network retail pharmacies and mail order pharmacies. 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 at the same cost as an in-network pharmacy. You pay nothing Note: Services with a 1 may require prior authorization Services with a 2 may require a referral from your doctor *Based on your level of Medicaid eligibility 9

13 Summary Of Benefits For Touchstone Health Medicare Prestige (HMO-SNP) People who qualify for Medicare and Medicaid are known as dual eligibles. As a dual eligible, you are eligible for benefits under both the federal Medicare program and the state-operated Medicaid program. The following chart applies to enrollees who are Full Benefit Dual Eligible. The chart compares services available through Medicaid and also available through Touchstone Health Medicare Prestige (HMO-SNP). You must use your Touchstone Health Member ID card to get the services shown in this chart. BENEFIT MEDICAID FEE-FOR-SERVICE TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN Inpatient Hospital Care including Substance Abuse and Rehabilitation Services Inpatient Mental Health in excess of 190-Day Lifetime Limit Doctor Office Visits Home Health Services Up to 365 days per year (366 days for leap year) All inpatient mental health services, including voluntary or involuntary admissions, over the Medicare 190-Day Lifetime Limit. Medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non-medicare covered home health services (e.g., home health aide services with nursing supervision to medically unstable individuals). In Network $0 copay Covers up to 365 days per year (366 days for leap year) In Network $0 copay Covers all inpatient mental health services, including voluntary or involuntary admissions, over the Medicare 190-Day Lifetime Limit. In Network In Network $0 copay Covers medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non-medicare covered home health services (e.g., home health aide services with nursing supervision to medically unstable individuals). 10

14 BENEFIT Private Duty Nursing Services Ambulance Services Emergency Care MEDICAID FEE-FOR-SERVICE Covers medically necessary private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private practitioner. Nursing services may be intermittent, part time or continuous and must be provided in an enrollee s home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN Covers medically necessary private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private practitioner. Nursing services may be intermittent, part time or continuous and must be provided in an enrollee s home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. Urgently Needed Care Outpatient Services/Surgery Outpatient Rehabilitation Services Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. $0 copay Covers Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. 11

15 BENEFIT MEDICAID FEE-FOR-SERVICE TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN Non-Medicare Covered Durable Medical Equipment Prosthetic Devices Over the Counter Drugs Covers durable medical equipment, including devices and equipment other than medical/surgical supplies, enteral formula, and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period of time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual s use. Must be ordered by a qualified practitioner. No homebound prerequisite and including non-medicare DME covered by Medicaid (e.g. tub stool; grab bars). coinsurance. Medicaid covers prosthetics, orthotics, and orthopedic footwear. Certain Over the Counter medications are covered. $0 copay Covers durable medical equipment, including devices and equipment other than medical/surgical supplies, enteral formula, and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period of time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual s use. Must be ordered by a qualified practitioner. No homebound prerequisite and including non- Medicare DME covered by Medicaid (e.g. tub stool; grab bars). $0 copay Covers prosthetics, orthotics, and orthopedic footwear. Get $75 per month (maximum limit up to $900 per year) to purchase Over-the-Counter items. Please visit our plan website to see our list of covered Overthe-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. Some health products may be available to you through Medicaid using your Medicaid Benefit ID card. 12

16 BENEFIT MEDICAID FEE-FOR-SERVICE TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN Hearing Services Vision Services Medicaid covers hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing aid selecting, fitting, and dispensing, hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, ear molds, special fittings and replacement parts. Services of optometrists, ophthalmologists and ophthalmic dispensers including eyeglasses, medically necessary contact lenses and poly-carbonate lenses, artificial eyes (stock or custom-made), low vision aids and low vision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged or destroyed. Covers hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing aid selecting, fitting, and dispensing, hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, ear molds, special fittings and replacement parts. $0 copay Covers services of optometrists, ophthalmologists and ophthalmic dispensers including eyeglasses, medically necessary contact lenses and poly-carbonate lenses, artificial eyes (stock or custom-made), low vision aids and low vision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged or destroyed. 13

17 BENEFIT MEDICAID FEE-FOR-SERVICE TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN Dental Services Outpatient Substance Abuse Care Outpatient Mental Health Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Bone Mass Measurement Colorectal Screening Exams Medicaid covered dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or impatient surgical dental services subject to prior authorization. Covers individual and group visits. Covers individual and group visits. Covers dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or impatient surgical dental services subject to prior authorization. In Network $0 copay Covers individual and group visits. Enrollee must be able to self refer for one assessment from a network provider in a twelve (12) month period. In Network $0 copay Covers individual and group visits. Enrollee must be able to self refer for one assessment from a network provider in a twelve (12) month period. 14

18 Immunizations Mammograms BENEFIT Pap Smears and Pelvic Exams Prostate Cancer Screening Exams End Stage Renal Disease MEDICAID FEE-FOR-SERVICE TOUCHSTONE HEALTH MEDICARE PRESTIGE PLAN 15

19 Medicaid Services Not Covered By Our Plan You can get these services from any provider who accepts Medicaid by using your Medicaid Benefit ID Card: Out of Network Family Planning services provided under the direct access provisions of the waiver Skilled Nursing Facility (SNF) days not covered by Medicare Personal Care Services Medicaid Pharmacy Benefits allowed by State law (select drug categories excluded from the Medicare Part D benefit and certain medications included in the Part D benefit when the Enrollee is unable to receive them from his/her Medicare Advantage Plan), also certain Medical Supplies and Enteral Formula when not covered by Medicare. Methadone Maintenance Treatment Programs Certain Mental Health Services, including: Intensive Psychiatric Rehabilitation Treatment Programs Day Treatment Continuing Day Treatment Case Management for Seriously and Persistently Mentally Ill (sponsored by state or local mental health units) Partial Hospitalizations Assertive Community Treatment (ACT) Personalized Recovery Oriented Services (PROS) Rehabilitation Services Provided to Residents of OMH Licensed Community Residences (CRs) and Family Based Treatment Programs Office for People with Developmental Disabilities (OPWDD) Services Comprehensive Medical Case Management Directly Observed Therapy for Tuberculosis Disease AIDS Adult Day Health Care HIV COBRA Case Management Adult Day Health Care Personal Emergency Response Services (PERS) 16

20 Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы 17

21 воспользоваться услугами переводчика, позвоните нам по телефону Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. دول أو ق أس أي ن ا ا وري ا ر م د ت دم إ : Arabic ا ل وى ك س وري ر م ول. د ا دو. د ھذه. د ك ا ر دث ما ص وم Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Português: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer Ta usługa jest bezpłatna. Hindi: हम र व य य दव क य जन क ब र म आपक कस भ न क जव ब द न क लए हम र प स म त द भ षय स व ए उपल ध ह. एक द भ षय त करन क लए, बस हम पर फ न कर. क ई य त ज ह द ब लत ह आपक मदद कर सकत ह. यह एक म त स व ह. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサービ スです Y0064_H3327_THPSMK_1819 CMS Accepted Touchstone Health is a Medicare approved Health Maintenance Organization with a Medicare Advantage Prescription Drug contract with the Federal Government and a contract with the New York Medicaid Program. Touchstone Health is an HMO plan with a Medicare contract. Enrollment in Touchstone Health depends on contract renewal. 18

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24 Touchstone Health One North Lexington Ave. 12th Floor White Plains, NY Prospective members should call or TTY/TDD hours a day, 7 days a week Current members should call or TTY/TDD 711 Hours are 8:00AM to 8:00PM, 7 days a week from October 15, 2014 to February 14, We are available for phone calls 8:00AM to 8:00PM, Monday through Friday from February 15, 2015 to October 14, facebook.com/touchstoneh twitter.com/touchstoneh youtube.com/touchstonehealth Y0064_H3327_THPSMK_2364 Accepted Touchstone Health is a Medicare approved Health Maintenance Organization with a Medicare Advantage Prescription Drug contract with the Federal Government and New York State Medicaid program. Enrollment in Touchstone Health depends on contract renewal. Your prescriptions are covered under Touchstone Health only if they are filled at a network pharmacy or through mail order pharmacy service. We will fill prescriptions at non-network pharmacies under certain circumstances. Enrollees may receive prescription drugs shipped to their homes through our mail order pharmacy service. The shipment will arrive days from the date the order is mailed. If the shipment has not arrived during this time period please contact Integrated HMO Services customer service at This information is available for free in other languages. Please contact our customer service number at (TTY/TDD: 711) for additional information. Esta información está disponible en un formato diferente, incluyendo CD y español, y también puede obtenerse a través de correo electrónico. Si necesita información del plan en otro formato o lenguaje, por favor llame a la línea de Servicio al Miembro al número mencionado arriba.