2016 Benefits Overview
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1 2016 Benefits Overview ASPIRE HEALTH ADVANTAGE VALUE (HMO) BENEFIT Monthly Plan Premium Out-of-Pocket Limit (In-Network Medicare-covered benefits) Annual Part C Deductible (all services except for Prescription Drugs) Doctor Office Visits Primary Care Physician (PCP) Specialty Care Physician Inpatient Care Inpatient Hospital (Acute) Days 1-5: $31 $5,000 in network In-Network $300 co-pay per day Days 6-90: Inpatient Mental Health Care Days 1-4: $300 co-pay per day Days 5-90: Skilled Nursing Facility (SNF) Days 1-20: Days : $150 co-pay per day Outpatient Care Home Health Services (must meet medical necessity criteria) Outpatient Hospital Surgery/Ambulatory Surgical Center (ASC) Services Other Outpatient Hospital Services (i.e., chemotherapy infusion visit, outpatient IV therapy and transfusion services and Part B drugs administered) $300 co-pay 1 l Aspire Health Plan 2016 H8764_MKT_Benefit Brochure_0815_CMS Accepted 08/23/2015
2 ASPIRE HEALTH ADVANTAGE (HMO) ASPIRE HEALTH ADVANTAGE PLUS (HMO-POS) $95 $4,500 in network $165 $3,600 in network only In-Network In-Network Out-of-Area $275 co-pay per day $250 co-pay per day 2016 Medicare-defined 2016 Medicare-defined $275 co-pay per day $250 co-pay per day 2016 Medicare-defined 2016 Medicare-defined $125 co-pay per day 2016 Medicare-defined $125 co-pay per day 2016 Medicare-defined $275 co-pay $250 co-pay Aspire Health Plan 2016 l 2
3 ASPIRE HEALTH ADVANTAGE VALUE (HMO) BENEFIT Cardiac & Pulmonary Rehabilitation Services Outpatient Mental Health (Individual/Group) Outpatient Substance Abuse (Individual/Group) Durable Medical Equipment (DME) Prosthetic Devices Rehabilitation Services Speech Therapy Physical Therapy Occupational Therapy Lab Services and Diagnostic Tests Diagnostic Tests & Procedures Lab Services X-rays Radiology (Diagnostic/Therapeutic) Emergency Services Urgently Needed Care (waived if admitted) Emergency Care (waived if admitted) Ambulance services (when medically necessary, waived if admitted) Wellness Exams & Screenings Medicare Covered Preventive Services Bone Mass Measurement (1 bone mass measurement every 2 years) Nutrition Therapy (for people with diabetes and kidney disease) Influenza Vaccine (1 per year) Mammogram (1 per year) Diabetes Monitoring Diabetes Supplies Diabetes - Therapeutic Shoes 10% co-insurance $65 co-pay $250 co-pay 3 l Aspire Health Plan 2016
4 ASPIRE HEALTH ADVANTAGE (HMO) ASPIRE HEALTH ADVANTAGE PLUS (HMO-POS) 10% co-insurance 10% co-insurance $65 co-pay $50 co-pay $50 co-pay $250 co-pay $250 co-pay Aspire Health Plan 2016 l 4
5 ASPIRE HEALTH ADVANTAGE VALUE (HMO) ADDITIONAL BENEFITS Preventive Dental Routine Cleaning (1 every 6 months) Oral Exam (1 every 6 months) X-rays (1 per year) Comprehensive Dental (optional buy-up) Deductible Network Coverage Additional Monthly Premium Vision Diagnostic Screenings (Medicare-covered benefits) Routine Eye Exam Contact Lenses Frames & Lenses Hearing Diagnostic Hearing Exams (Medicare-covered benefits) Chiropractic Services Manipulation of spine to correct subluxation (Medicare-covered benefits) Routine care Covered visits per year Acupuncture Routine care Covered visits per year PPO - Guardian DentalGuard Preferred Select Up to $1,000 per year $29 PRESCRIPTION BENEFITS Rx Deductible 30-Day Retail Co-pays Tier 1: Preferred generic Tier 2: Generic Tier 3: Preferred brand $280 (Tiers 2, 3, 4 and 5) $4 co-pay $45 co-pay 5 l Aspire Health Plan 2016
6 ASPIRE HEALTH ADVANTAGE (HMO) ASPIRE HEALTH ADVANTAGE PLUS (HMO-POS) PPO - Guardian DentalGuard Preferred Select Up to $1,000 per year $23 PPO - Guardian Dental Guard Preferred Select Up to $1,000 per year $23 $10 co-pay $10 co-pay 4 visits 12 visits 6 visits 12 visits $150 Brand Name & Specialty Drugs (tiers 3, 4, 5) No deductible $2 co-pay $5 co-pay $45 co-pay $2 co-pay $5 co-pay $45 co-pay Aspire Health Plan 2016 l 6
7 ASPIRE HEALTH ADVANTAGE VALUE (HMO) Tier 4: Non-preferred brand Tier 5: Specialty-tier Part B chemotherapy drugs 90-Day Co-pays (Retail and Mail Order) Tier 1: Preferred generic Tier 2: Generic Tier 3: Preferred brand Tier 4: Non-preferred brand Tier 5: Specialty-tier Part B chemotherapy drugs $85 co-pay 26% co-insurance $8 co-pay $90 co-pay $170 co-pay 26% co-insurance for all Part B drugs Initial Coverage- Our plan uses a formulary. You can get your prescriptions filled through Network Retail and Mail Order Pharmacies. Until the cost of Part D-covered drugs paid by you and us reaches $3,310 in 2016, you will pay the amount(s) listed. Transition Coverage for New Members - For outpatient drugs, up to one (1) 30 - day transition fills of Part D prescription medications, during the first 90 days of new membership in our plan. If you are in a Long Term Care Facility you can get up to three (3) 31-day transition fills of Part D prescription medications, during the first 90 days of new membership in our plan. Coverage Gap - After your total yearly drug costs reach $3,310, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 45% of the plan s costs for brand drugs and 58% of the plan s costs for generic drugs until your yearly out-of-pocket drug costs reach $4,850. Catastrophic Coverage - After your yearly out-of-pocket drug costs reach $4,850 in 2016, you pay the greater of: 5% co-insurance or $2.95 co-pay for generic (including brand drugs treated as generic) and a $7.40 co-pay for all other drugs. 7 l Aspire Health Plan 2016
8 ASPIRE HEALTH ADVANTAGE (HMO) $85 co-pay 29% co-insurance $4 co-pay $10 co-pay $90 co-pay $170 co-pay 29% co-insurance for all Part B drugs ASPIRE HEALTH ADVANTAGE PLUS (HMO-POS) $85 co-pay 33% co-insurance $4 co-pay $10 co-pay $90 co-pay $170 co-pay 33% co-insurance for all Part B drugs Aspire Health Plan is an HMO and HMO-POS plan sponsor with a Medicare contract. Enrollment in Aspire Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/ co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Aspire Health Plan 2016 l 8
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