Brand New Day Brand New Day Brand New Day Brand New Day Bridges Drug Savings Bridges Extra Care Harmony Healthy Heart Drug Savings dementia. dementia. chronic and disabling mental health conditions. chronic heart failure. $0 Monthly Premium $28.80 Monthly Premium $28.80 Monthly Premium $0 Monthly Premium $3,400 In- $6,700 In- $6,700 In- $3,400 In- period. 90 days each 90 days each period. 60 lifetime reserve days. Days 1-20: $0/day. Days 21-100: $148/day. 100 days each 100 days each 100 days each $0 copay. 100 days each $ 0 copay. 190-day psychiatric $0 each session $0 each session $0 each session $0 each session Outpatient Hospital $65 - $100 each visit 0-20% of the cost each visit 0-20% of the cost each visit $0 each visit 20% of the cost each service 20% of the cost each service 20% of the cost each service $65 each service 20% of cost formedicare-covered items. 20% of the cost for each visit. 20% of the cost for each visit. 20% of cost formedicarecovered items. $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray Contact plan for additional Contact plan for additional Contact plan for additional Contact plan for additional exams. Routine exams and hearing aids not covered. aids aids aids $0 copay $0 copay See separate Chart See separate Chart See separate Chart See separate Chart Page 1 of 5
Brand New Day Brand New Day Brand New Day Brand New Day Healthy Heart Extra Care Hope Drug Savings In Control Drug Savings In Control Extra Care chronic heart failure. chronic and disabling mental health conditions. diabetes mellitus. diabetes mellitus. $28.80 Monthly Premium $0 Monthly Premium $0 Monthly Premium $28.80 Monthly Premium $6,700 In- $3,400 In- $3,400 In- $6,700 In- 90 days each Call plan for period. period. 60 lifetime reserve days. 90 days each 100 days each Call plan for $0 copay. 100 days each benefit period. $0 copay. 100 days each 100 days each Outpatient Hospital $0 each session $0 each session $0 each session $0 each session 0-20% of the cost each visit $0 each visit $0 each visit 20% of the cost each visit 20% of the cost each service $65 each service $65 each service 20% of the cost each service 20% of the cost for each visit. 20% of the cost for each visit $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray Contact plan for additional Contact plan for additional Contact plan for additional Contact plan for additional aids aids aids aids $0 copay $0 copay See separate Chart See separate Chart See separate Chart See separate Chart Page 2 of 5
CareMore Health Plan CareMore Health Plan CareMore Health Plan CareMore Health Plan Breathe ESRD Heart Reliance chronic lung disorders. endstage renal disease requiring any mode of dialysis. cardiovascular disorders and/or chronic heart failure. chronic diabetes mellitus. $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $3,000 In- $3,000 In- $3,000 In- $3,000 In- $0 copay. 250 days each 60 lifetime reserve days Days 1-5: $75/day, Days 6-90: $0/Day, $0/day after 90 days. 260 days each $0 copay. 250 days each 60 lifetime reserve days. $0 copay. 270 days each 60 lifetime reserve days. Days 1-5: $75/day, Days 6-150: $0/Day. 150 days each Outpatient Hospital $0 each session $0 each session $0 each session $0 each session $100 each service. $0-$100 each service, waived if admitted. $100 each service. $100 each service. $0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray $0 copay $0 copay $0 copay $0 copay Contact plan for additional Contact plan for additional Contact plan for additional Contact plan for additional exams. exams. exams. exams. $0 copay $0 copay $0 copay $0 copay See separate Chart See separate Chart See separate Chart See separate Chart Page 3 of 5
CareMore Health Plan Central Health Health Net SCAN Touch Focus Jade Heart First (Institutional) Medicare Health Plan with Prescription Drug Benefit for individuals residing in a long-term care setting. 866-314-2427 800-589-3147 centralhealthplan.com chronic diabetes mellitus. 800-877-4814 800-275-9737 healthnet.com/medicare cardiovascular disorders, chronic heart failure and/or diabetes. 877-452-5898 800-559-3500 scanhealthplan.com cardiovascular disorders and/or chronic heart failure. $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium 4501-5000 physicians and 3001-3500 physicians and 9001-10000 physicians and $3,000 In- $3,400 In- $3,400 In- $3,400 In- $0 copay. 245 days each 60 lifetime reserve days. $0 copay. 100 days each 65: $75/day. Days 66-100: $0. 100 days each $900 copay. 190-days psychiatric hospital lifetime limit. $0 copay. 190-days psychiatric Outpatient Hospital $0 each session $5 each session $25 each session $20 each session $0 each visit $0 each visit $0 - $60 each visit $0-$100 each visit $100 each service. $50 each service. $40 each service, waived if admitted. $200 each service $50 each visit, waived if admitted immediately. immediately admitted. $0 each visit $0 each visit $0 each visit 10% for each Medicarecovered $0 each visit cardiac $10 each visit all others procedures/tests. $60 for procedures/tests. $100 for $0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray cost for therapeutic radiology $0 each lab service. $50 for $0 copay 20% of the cost 20% of the cost $0 copay Preventive benefits Contact plan for additional Contact plan for additional Preventive benefits exams. exams. exams. exams. $0 copay $0 copay $0 copay $0 copay See separate Chart See separate Chart See separate Chart See separate Chart Page 4 of 5
SCAN SCAN VillageHealth Balance Healthy at Home VillageHealth 877-452-5898 800-559-3500 scanhealthplan.com diabetes mellitus. 877-452-5898 800-559-3500 scanhealthplan.com Benefit for those qualify for nursing home care but are deemed eligible to live in their own home. $0 Monthly Premium $0 Monthly Premium 9001-10000 physicians and 15001-16000 physicians and 877-916-1234 800-399-7226 villagehealthca.com endstage renal disease requiring any mode of dialysis. $28.80 Monthly Premium Contact Plan for health plan deductible 3001-3500 physicians and $0 each visit $10 each visit $0 each visit $0 each visit $20 each visit 20% of the cost each visit $3,400 In- $6,700 In- $6,700 In- Days 1-10: $150/day. Days 11-90: $0, $0/day after 90 days. Unlimited days each benefit period. 90 days each 100: $100/day. 100 days each 100 days each Outpatient Hospital $0 copay. 190-days psychiatric Days 1-10: $150/day. Days 11-90: $0. Contact plan for days beyond 90. 190-days psychiatric hospital lifetime limit. $20 each session $35 each session 20% of the cost each session $0-$100 each visit $20-$100 or 20% of the cost each visit 20% of the cost each visit $200 each service $110 each service 20% of the cost each service immediately admitted. immediately admitted. $65 each visit $0 each visit cardiac $10 each visit all others procedures/tests. $100 for $20 each visit 20% of the cost each visit procedures/tests. 20% of the costs for diagnostic radiology 20% of the cost for diagnostic procedures/tests. 20% of the cost for diagnostic radiology $0 each X-ray $0 each X-ray 20% of the cost each X-ray $0 each lab service. $50 for costs for therapeutic radiology cost for therapeutic radiology $0 copay $0 copay 20% of the cost 20% of the cost 20% of the cost 0% -20% of the cost Preventive benefits $20 for Medicare-covered Preventive benefits 20% of the cost for Medicarecovered Contact plan for additional exams. $20 for diagnostic exams. aids 20% of the cost for diagnostic exams. Routine exams and hearing aids 0-20% of the cost for diagnosis and treatment of eye conditions. Contact plan for additional $0 copay $0 copay See separate Chart See separate Chart See separate Chart Page 5 of 5
Prescription Drug Plans associated with Health Maintenance Organiazations (HMO's ) Organization Name Non-Member Telephone No. Plan Internet 2015 Medicare Part D Coverage Included in the Chroninc Illness and Institutional Special Needs Plans Beneficiary must have both Medicare Parts A and B to enroll in a Medicare Advantage Plan with the drug benefits shown below. For assistance, call Monthly Plan Premium* Annual Deductible for Part D Copayments** Coinsurance** Overall Quality Rating (Out of 5) Drug Plan Rating (Out of 5) Brand New Day Bridges Drug Savings $0 $0 $0 - $90 33% 3.5 3.0 Bridges Extra Care $28.80 $320 $0 - $10 25% 3.5 3.0 Harmony $28.80 $320 see coinsurance 25% 3.5 3.0 Healty Heart Drug Savings $0 $0 $0 - $90 33% 3.5 3.0 Healthy Heart Extra Care $28.80 $320 $0 - $10 25% 3.5 3.0 Hope Drug Savings $0 $0 $0 - $90 33% 3.5 3.0 In Control Drug Savings $0 $0 $0 - $90 33% 3.5 3.0 In Control Extra Care $28.80 $320 see coinsurance 25% 3.5 3.0 CareMore Breathe $0 $0 $0 - $85 33% 4.5 4.0 ESRD $0 $0 $0 - $85 33% 4.5 4.0 Heart $0 $0 $0 - $85 33% 4.5 4.0 Reliance $0 $0 $0 - $85 33% 4.5 4.0 Touch $0 $0 $0 - $85 33% 4.5 N/A*** Central Health Medicare Plan 866-314-2427 Central Health Focus Plan $0 $0 $0 - $50 33% 3.5 3.5 centralhealthplan.com Health Net 800-877-4814 Health Net Jade $0 $0 $0 - $95 33% 4.0 3.5 healthnet.com/medicare SCAN Health Plan Heart First $0 $0 $0 - $95 33% 4.0 4.0 877-452-5898 Balance $0 $0 $0 - $95 33% 4.0 4.0 scanhealthplan.com Healthy at Home $0 $0 $3 - $95 33% 3.5 3.5 VillageHealth 877-916-1234 VillageHealth $28.80 $320 see coinsurance 25% N/A*** 2.0 villagehealthca.com *Total premium cost is shown on the. **Amount you may be required to pay for each prescription, which may be either a dollar amount (copay) or a percentage (coinsurance). ***Information not available at time of publication. 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 Rev. 10/24/14 Page 1