/ / Summary of Benefits January 1, 2016 December 31, 2016 The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. s pharmacy network offers limited access to pharmacies with preferred sharing in rural Washington. The lower s advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including pharmacies with preferred sharing, please call 1-877-750-3350 or consult the online pharmacy directory at HealthAllianceMedicare.org. This information is available for free in other languages. Please call our Member Services at 1-877-750-3350, (TTY: 711), 8 a.m. to 8 p.m. daily from October 1 to February 14 and weekdays the rest of the year. Esta información está disponible sin cargo en otros idiomas. Para obtener información adicional, llamar a nuestro número de servicio al cliente al 1-877-750-3350 (TTY: 711). Nuestro horario es de 8 a.m. a 8 p.m., los 7 días de la semana, 1 de octubre a 14 de febrero, y lunes a viernes el resto del año. Call toll-free 1-877-561-1463 8 a.m. to 8 p.m., 7 days a week October 1 to February 14 and 8 a.m. to 8 p.m., Monday Friday the rest of the year. TTY/TDD 711 HealthAllianceMedicare.org med-wachmorxsob-0615 H3471_16_34970 Accepted H3471_16_34971 Accepted H3471_16_34972 Accepted
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 benefi ts through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefi ts by joining a Medicare health plan (such as Companion Basic Rx [HMO], Companion Rx [HMO] or Companion Plus Rx [HMO]). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefi ts booklet gives you a summary of what, Companion Rx (HMO) and cover and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefi ts booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. If you want to know more about the coverage and s of Original Medicare, look in your current Medicare & You handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. SECTIONS IN THIS BOOKLET Things to Know About, or Monthly Premium, Deductible and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefi ts Prescription Drug Benefi ts 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, call us at 1-877-561-1463 or, for TTY users, 711. Esta información está disponible sin cargo en otros idiomas. Para obtener información adicional, llamar a nuestro número de servicio al cliente al 1-877-933-2564 (TTY: 711). Nuestro horario es de 8 a.m. a 8 p.m., los 7 días de la semana, 1 de octubre a 14 de febrero, y lunes a viernes el resto del año. THINGS TO KNOW ABOUT HEALTH ALLIANCE MEDICARE COMPANION BASIC RX (HMO), COMPANION RX (HMO) AND COMPANION PLUS RX (HMO) HOURS OF OPERATION From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. 1
HEALTH ALLIANCE MEDICARE COMPANION BASIC RX (HMO), COMPANION RX (HMO) AND COMPANION PLUS RX (HMO) PHONE NUMBERS AND WEBSITE If you are a member of this plan, call toll-free 1-877-750-3350 or, for TTY users, 711. If you are not a member of this plan, call toll-free 1-877-561-1463 or, for TTY users, 711. Our website: http://www.healthalliancemedicare.org WHO CAN JOIN? To join, or, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. Our service area includes the following counties in Washington: Chelan, Douglas, Grant, and Okanogan. WHICH DOCTORS, HOSPITALS AND PHARMACIES CAN I USE?, and have 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 prescriptions for covered Part D drugs. Some of our network pharmacies have preferred -sharing. You may pay less if you use these pharmacies. You can see our plan s provider and pharmacy directory at our website (http://www.healthalliancemedicare.org). 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, http://www.healthalliancemedicare.org. Or, call us and we will send you a copy of the formulary. HOW WILL I DETERMINE MY DRUG COSTS? Our plan groups each medication into one of fi ve tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will you. The amount you pay depends on the drug s tier and what stage of the benefi t you have reached. Later in this document we discuss the benefi t stages that occur after you meet your deductible: Initial Coverage, Coverage Gap and Catastrophic Coverage. 2
MONTHLY PREMIUM, DEDUCTIBLE AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? $25 per month. In addition, you must keep paying your Medicare Part B premium. $360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. $59 per month. In addition, you must keep paying your Medicare Part B premium. $360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. $99 per month. In addition, you must keep paying your Medicare Part B premium. $360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket s for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Your yearly limit(s) in this plan: $2,900 for services you receive from in-network providers. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. If you reach the limit on out-ofpocket s, you keep getting covered hospital and medical services and we will pay the full for the rest of the year. Please note that you will still need to pay your monthly premiums and sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefi ts. Contact us for the services that apply. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefi ts. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefi ts. Contact us for the services that apply. 3
COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture Not covered Not covered Not covered Ambulance $300 $300 $225 Chiropractic Care 1, 2 Dental Services Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Limited dental services (this does not include services in connection with care, treatment, fi lling, removal, or replacement of teeth): $50 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Limited dental services (this does not include services in connection with care, treatment, fi lling, removal, or replacement of teeth): $40 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 Limited dental services (this does not include services in connection with care, treatment, fi lling, removal, or replacement of teeth): $30 Preventive dental services: Cleaning: $0 Dental X-ray(s): $0 Fluoride treatment: $0 Oral exam: $0 $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. Preventive dental services: Cleaning: $0 Dental X-ray(s): $0 Fluoride treatment: $0 Oral exam: $0 $100 benefit maximum every plan year for supplemental dental, vision and hearing combined. Preventive dental services: Cleaning: $0 Dental X-ray(s): $0 Fluoride treatment: $0 Oral exam: $0 $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. 4
Diabetes Supplies and Services Diabetes monitoring supplies: 0-20% of the, depending on the Diabetes monitoring supplies: 0-20% of the, depending on the Diabetes monitoring supplies: 0-20% of the, depending on the Diabetes self-management training: You pay nothing Diabetes self-management training: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% of the Therapeutic shoes or inserts: 20% of the Therapeutic shoes or inserts: 20% of the Manufacturer limitation applies only to Blood Glucose Meters and Strips, and these items have a member coinsurance of 0%. All other diabetic supplies have a member coinsurance of 20%. Standard Exception and Transition processes will apply. Manufacturer limitation applies only to Blood Glucose Meters and Strips, and these items have a member coinsurance of 0%. All other diabetic supplies have a member coinsurance of 20%. Standard Exception and Transition processes will apply. Manufacturer limitation applies only to Blood Glucose Meters and Strips, and these items have a member coinsurance of 0%. All other diabetic supplies have a member coinsurance of 20%. Standard Exception and Transition processes will apply. Diagnostic Tests, Lab and Radiology Services and X-rays (Costs for these services may vary based on place of service) Diagnostic radiology services (such as MRIs, CT scans): $300 Diagnostic tests and procedures: $15 Lab services: $15 Diagnostic radiology services (such as MRIs, CT scans): $200 Diagnostic tests and procedures: $10 Lab services: $10 Diagnostic radiology services (such as MRIs, CT scans): $150 Diagnostic tests and procedures: $5 Lab services: $5 Outpatient X-rays: $30 Outpatient X-rays: $30 Outpatient X-rays: $15 Therapeutic radiology services (such as radiation treatment for cancer): $60 Therapeutic radiology services (such as radiation treatment for cancer): $30 Therapeutic radiology services (such as radiation treatment for cancer): $15 Doctor s Office Visits 2 Primary care physician visit: $15 Primary care physician visit: $10 Primary care physician visit: $10 Specialist visit: $50 Specialist visit: $45 Specialist visit: $30 5
Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care 20% of the 20% of the 20% of the $75 $75 $75 If you are immediately admitted to the hospital, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. If you are immediately admitted to the hospital, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. If you are immediately admitted to the hospital, you do not have to pay your share of the for emergency care. See the Inpatient Hospital Care section of this booklet for other s. Foot Care (Podiatry Services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 Hearing Services Exam to diagnose and treat hearing and balance issues: $50 Exam to diagnose and treat hearing and balance issues: $40 Exam to diagnose and treat hearing and balance issues: $30 Routine hearing exam: $0 Routine hearing exam: $0 Routine hearing exam: $0 Hearing aid fi tting/evaluation: $0 Hearing aid fi tting/evaluation: $0 Hearing aid fi tting/evaluation: $0 Hearing aid: $0 Hearing aid: $0 Hearing aid: $0 $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. $100 benefit maximum every plan year for supplemental dental, vision and hearing combined. Home Health Care 1 You pay nothing You pay nothing You pay nothing $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. 6
Mental Health Care 1, 2 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. 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. 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. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. 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. 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. 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. $500 per day for days 1 through 7 days 8 through 90 $215 per day for days 1 through 7 days 8 through 90 $300 per day for days 1 through 5 days 6 through 90 Outpatient group therapy visit: $40 Outpatient group therapy visit: $40 Outpatient group therapy visit: $30 Outpatient individual therapy visit: $40 Outpatient individual therapy visit: $40 Outpatient individual therapy visit: $30 7
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): $50 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $15 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $15 Occupational therapy visit: $40 Occupational therapy visit: $35 Occupational therapy visit: $30 Physical therapy and speech and language therapy visit: $40 Physical therapy and speech and language therapy visit: $35 Physical therapy and speech and language therapy visit: $30 Outpatient Substance Abuse 1 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $40 Individual therapy visit: $40 Group therapy visit: $30 Individual therapy visit: $30 Outpatient Surgery Ambulatory surgical center: $300 Ambulatory surgical center: $400 Ambulatory surgical center: $150 Over-the-Counter Items Prosthetic Devices (Braces, Artificial Limbs, etc.) 1 Outpatient hospital: $300 Outpatient hospital: $400 Not covered Not covered Not covered Prosthetic devices: 20% of the Related medical supplies: 20% of the Prosthetic devices: 20% of the Related medical supplies: 20% of the Outpatient hospital: $150 Prosthetic devices: 20% of the Related medical supplies: 20% of the Renal Dialysis You pay nothing You pay nothing You pay nothing Transportation Not covered Not covered Not covered Urgently Needed Services $50 $40 $30 8
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $50 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $40 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $30 Routine eye exam: $0 Routine eye exam: $0 Routine eye exam: $0 Contact lenses: $0 Contact lenses: $0 Contact lenses: $0 Eyeglesses (frames and lenses): $0 Eyeglesses (frames and lenses): $0 Eyeglesses (frames and lenses): $0 Eyeglass frames: $0 Eyeglass frames: $0 Eyeglass frames: $0 Eyeglass lenses: $0 Eyeglass lenses: $0 Eyeglass lenses: $0 Eyeglasses or contact lenses after cataract surgery: $50 Eyeglasses or contact lenses after cataract surgery: $0 Eyeglasses or contact lenses after cataract surgery: $0 $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. $100 benefit maximum every plan year for supplemental dental, vision and hearing combined. $100 benefi t maximum every plan year for supplemental dental, vision and hearing combined. 9
Preventive Care You pay nothing You pay nothing 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 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit 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 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit 10 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 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit
Preventive Care (continued) Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Any additional preventive services approved by Medicare during the contract year will be covered. Hospice You pay nothing for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the s for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. INPATIENT CARE Inpatient Hospital Care Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. $430 per day for days 1 through 4 days 5 through 90 days 91 and beyond $300 per day for days 1 through 7 days 8 through 90 days 91 and beyond $275 per day for days 1 through 7 days 8 through 90 days 91 and beyond Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. days 1 through 20 $160 per day for days 21 through 100 days 1 through 20 $160 per day for days 21 through 100 days 1 through 20 $150 per day for days 21 through 100 11
PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the For Part B drugs such as chemotherapy drugs 1 : 20% of the Other Part B drugs 1 : 20% of the 12
Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s paid by both you and our Part D plan. After you pay your yearly deductible, you pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s paid by both you and our Part D plan. After you pay your yearly deductible, you pay the following until your total yearly drug s reach $3,310. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. You may get your drugs at network retail pharmacies and mail order pharmacies. You may get your drugs at network retail pharmacies and mail order pharmacies. Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $100 $200 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $100 $200 Preferred Retail Cost-Sharing Tier One-month Threemonth Tier 1 $0 $0 Generic) Tier 2 $20 $40 (Generic) Tier 3 $47 $94 Preferred Retail Cost-Sharing Tier One-month Threemonth Tier 1 $0 $0 Generic) Tier 2 $20 $40 (Generic) Tier 3 $47 $94 Preferred Retail Cost-Sharing Tier One-month Threemonth Tier 1 $0 $0 Generic) Tier 2 $20 $40 (Generic) Tier 3 $47 $94 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $100 $200 13
Initial Coverage (continued) Tier 1 Generic) Tier 2 (Generic) Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $19.50 $58.50 $20 $60 $47 $141 $100 $300 Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $47 $141 $100 $300 Standard Retail Cost-Sharing Tier One-month Threemonth Standard Retail Cost-Sharing Tier One-month Threemonth Tier 1 $19 $57 Generic) Tier 2 (Generic) $20 $60 Standard Retail Cost-Sharing Tier One-month Threemonth Tier 1 $18 $54 Generic) Tier 2 (Generic) $20 $60 Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $47 $141 $100 $300 14
Initial Coverage (continued) Standard Mail-Order Cost-Sharing Tier One-month Threemonth Tier 1 Generic) Tier 2 (Generic) Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $19.50 $58.50 $20 $60 $47 $141 $100 $300 Standard Mail-Order Cost-Sharing Tier One-month Threemonth Tier 1 $19 $57 Generic) Tier 2 (Generic) $20 $60 Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $47 $141 $100 $300 Standard Mail-Order Cost-Sharing Tier One-month Threemonth Tier 1 $18 $54 Generic) Tier 2 (Generic) $20 $60 Tier 3 Tier 4 (Non- Preferred Tier 5 (Specialty Tier) $47 $141 $100 $300 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. 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-ofnetwork pharmacy at the same as an in-network pharmacy. You may get drugs from an out-ofnetwork pharmacy at the same as an in-network pharmacy. You may get drugs from an out-ofnetwork pharmacy at the same as an in-network pharmacy. 15
Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $3,310. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $3,310. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 58% of the plan s for covered generic drugs until your s total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 58% of the plan s for covered generic drugs until your s total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. After you enter the coverage gap, you pay 45% of the plan s for covered brand name drugs and 58% of the plan s for covered generic drugs until your s total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. 5% of the, or $2.95 for generic (including brand drugs treated as generic) and a $7.40 ment for all other drugs. is an HMO plan with a Medicare Contract. Enrollment in HMO depends on contract renewal. 16
ABOUT US partners with doctors throughout North Central Washington to bring you local health care and a local health plan. Change your plan and change your life when you choose. TRUE SERVICE When you call, you ll speak with a helpful member services representative based in Wenatchee. They know our plans inside and out. They will: Answer your questions. Sign you up for a seminar. Arrange for someone to meet with you. Help you enroll over the phone. Stop by 8 a.m. to 5 p.m., weekdays. We re at 316 Fifth Street in Wenatchee, down Chelan Avenue from Confl uence Health s Mares Clinic, formerly Wenatchee Valley Medical Center. Chelan Ave. Fifth St. KEEP YOUR DOCTOR With so many doctors in our network and more being added all the time chances are you can keep seeing the doctors you know and trust. Use our provider search at HealthAllianceMedicare.org or call today to learn more. With our HMO plans, your Primary Care Physician (PCP) helps you keep track of the care you need and connects you with specialists when you need them. EXTRAS SilverSneakers means free fitness club membership or at-home exercise kits. Information and support at SilverSneakers.com, too. Assist America helps with access to medical services while traveling. This free feature helps replace lost prescriptions and get members back home if they get sick. Plus, our members can call our 24-hour Anytime Nurse Line when their doctor s office is closed. 17