2015 DECISION MAKING GUIDE. Your guide to making sound health care decisions. H9302 _DMG2015 Accepted

Transcription

1 2015 DECISION MAKING GUIDE Yor gide to making sond health care decisions H9302 _DMG2015 Accepted

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3 Decision Making Gide 2015 Yor gide to making sond health care decisions

4 There are so many choices that we cold make. We appreciated having a choice of plans and physicians. Selecting Sondpath Health was a no brainer. Nick and Sandy C. Actal Sondpath Health Members

5 We re not jst yor health plan, we re yor health partner. Sondpath Health is committed to helping yo live yor life to the fllest. We believe the best care doesn t come from one sorce; it happens in an open, active partnership between yo, yor doctor and Sondpath Health. When we re all working together, yo benefit the most. YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 02

6 What is the Sondpath Health Difference? PLANS THAT WORK FOR YOU We created a set of cstom, easy-tonderstand plans with featres that meet the needs of people jst like yo. We know how to make health care work for or members. COSTS YOU CAN CONTROL At Sondpath Health, or plans are designed to meet yor needs throgh reasonable, predictable costs. Yo ll get the care yo want withot paying for coverage yo don t need. PHYSICIANS WHO WORK WITH YOU Sondpath Health was fonded by doctors. This gives s a niqe advantage in helping or members achieve their optimm health. While yo and yor physician make the medical decisions, we re here to spport yo with easy access to the doctors, prescriptions and benefits yo need. LOCAL PEOPLE, READY TO RESPOND Washington is or home. As neighbors in yor commnity, we re committed to providing soltions for yor healthplanning needs. Yo can look to s for answers to yor qestions and expect answers promptly. 03 SOUNDPATH HEALTH DECISION MAKING GUIDE 2015

7 The nmber one reason why I am a member of Sondpath Health is becase of the network. When I was looking for a Medicare Advantage plan, the network was very important to me. After I became a member of Sondpath Health, the opportnity also came for me to become an employee and I am still very, very impressed by how members are treated. Gloria H. Actal Sondpath Health Member and Employee

8 For easy steps to choosing the right Sondpath Health Medicare Advantage plan. Selecting yor Medicare Advantage plan is an important decision, bt it doesn t have to be difficlt. 1 2 Find ot if yor primary care physician is in the Sondpath Health Network Call s at: TTY/TDD: 711, or visit In jst nine conties we have over 6,500 health care providers for yo to partner with. See if yor prescriptions are covered by Sondpath Health Nearly 700 pharmacies are in or network. Becase we ve chosen the stores where most people shop, yors is probably on the list.

9 3 4 Decide what is important to yo With or comprehensive list of services and programs sch as fitness center membership, vision, hearing, prescription drg coverage* and more we ensre each plan has yo covered. Choose the plan that meets yor needs Sondpath Health offers for different plans, three of which inclde prescription drg coverage. Each plan has different premims, copayments and otof-pocket limits. * Available with most plans

10 One of the otstanding featres of Sondpath Health is when yo call, yo do not get someone in a recording. Yo get a real person and they know what they are talking abot. It is fantastic! Rosemary W. Actal Sondpath Health Member

11 Keeping Yo Healthy Preventive Services Sondpath Health covers many Medicare-approved preventive services to help keep yo healthy. We even cover a spplemental Annal Physical Exam at no cost to yo! Preventive services can find health problems early, when treatment works best, and can keep yo from getting certain diseases or illnesses. Abdominal Aortic Anerysm Screening... $0 Annal Physical Exam*... $0 Bone Mass Measrement... $0 Cardiovasclar Screening... $0 Diabetes Screening... $0 Inflenza Vaccine... $0 Hepatitis B Vaccine... $0 Breast Cancer Screening... $0 (Mammogram) Cervical and Vaginal Cancer Screening... $0 (Pap Test and Pelvic Exam) Colorectal Cancer Screening**... $0 Medical Ntrition Therapy Services... $0 Prostate Cancer Screening... $0 Smoking Cessation... $0 *This is in addition to the Medicare-covered Annal Wellness Visit. **If dring screening polyps are identified and removed, procedre may become diagnostic and reslt in an otpatient srgery copay. YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 08

12 Sondpath Health Benefit Comparison Chart Sondpath Health Plans at a Glance Make a side-by-side comparison. Whatcom Alpine Charter + Rx Sond + Rx Plan Availability by Conty Snohomish Alpine Peak + Rx Sond + Rx King Alpine (HMO) Charter + Rx (HMO) Peak + Rx (HMO) Sond + Rx (HMO) Chelan Alpine Charter + Rx Peak + Rx Doglas Alpine Charter + Rx Peak + Rx Thrston Alpine Charter + Rx Peak + Rx Sond + Rx Pierce Alpine Charter + Rx Peak + Rx Sond + Rx Grant Alpine Charter + Rx Peak + Rx Lewis Alpine Charter + Rx Peak + Rx Sond + Rx 09 SOUNDPATH HEALTH DECISION MAKING GUIDE 2015

13 Sondpath Health was fonded by doctors and they know what patients need, which makes a difference in the whole organization. I fond that, besides being doctor-oriented and patient-centered, it is the best vale among all the plans available to me. Kathryn E. Actal Sondpath Health Member OPEN HERE TO SEE BENEFITS

14 BENEFITS Monthly Premim Ot-of-Pocket Maximm Primary Care Office Visits Specialist Office Visits ALPINE Offered in Chelan, Doglas, Grant, King, Lewis, Pierce, Snohomish, Thrston & Whatcom conties only $45 monthly premim $3,400 ot-of-pocket limit every year for all member cost sharing $5 copay $0 copay for annal wellness visit $30 copay CHARTER+Rx Offered in all conties EXCEPT Snohomish $140 monthly premim $3,400 ot-of-pocket limit every year for all member cost sharing exclding Part D pharmacy $5 copay $0 copay for annal wellness visit $30 copay PEAK+Rx Offered in all conties EXCEPT Whatcom $0 monthly premim $6,700 ot-of-pocket limit every year for all member cost sharing exclding Part D pharmacy $15 copay $0 copay for annal wellness visit $50 copay SOUND+Rx Offered in King, Lewis, Pierce, Snohomish, Thrston & Whatcom $43 monthly premim $4,900 ot-of-pocket limit every year for all member cost sharing exclding Part D pharmacy $5 copay $0 copay for annal wellness visit $50 copay *All plans cover yo for worldwide coverage. con t.

15 BENEFITS Amblance Services Medically necessary amblance services Emergency Care Yo may go to any emergency room if yo reasonably believe yo need emergency care Inpatient Hospital Care Incldes sbstance abse & rehabilitation services ALPINE Offered in Chelan, Doglas, Grant, King, Lewis, Pierce, Snohomish, Thrston & Whatcom conties only $250 copay; waived if admitted $65 copay; waived if admitted within 24 hors for same condition incldes worldwide coverage $300 copay per day days 1-7 $0 copay per day days 8-90 $0 copay for additional days CHARTER+Rx Offered in all conties EXCEPT Snohomish $250 copay; waived if admitted $65 copay; waived if admitted within 24 hors for same condition incldes worldwide coverage $300 copay per day days 1-7 $0 copay per day days 8-90 $0 copay for additional days PEAK+Rx Offered in all conties EXCEPT Whatcom $300 copay; waived if admitted $65 copay; waived if admitted within 24 hors for same condition incldes worldwide coverage $430 copay per day days 1-4 $0 copay per day days 5-90 $0 copay for additional days SOUND+Rx Offered in King, Lewis, Pierce, Snohomish, Thrston & Whatcom $300 copay; waived if admitted $65 copay; waived if admitted within 24 hors for same condition incldes worldwide coverage $345 copay per day days 1-5 $0 copay per day days 6-90 $0 copay for additional days con t.

16 BENEFITS Otpatient Services/Srgery Lab Services Tiered, these are per visit limits Diagnostic Tests, X-Rays, & Radiology Services ALPINE Offered in Chelan, Doglas, Grant, King, Lewis, Pierce, Snohomish, Thrston & Whatcom conties only $100 copay at ASC* $200 copay at otpatient hospital facility $30 copay for O/P clinic $0 pt/inr (Comadin) $5 diabetes panel/ A1C (diabetes) $10 all other lab services per day $10 copay for diagnostic procedres, test, x-ray and nclear medicine per day maximm $250 for MRI/MRA/CT/CTA/ PET/SPECT scans $30 copay for therapetic radiology services CHARTER+Rx Offered in all conties EXCEPT Snohomish $100 copay at ASC* $200 copay at otpatient hospital facility $30 copay for O/P clinic $0 pt/inr (Comadin) $5 diabetes panel/ A1C (diabetes) $10 all other lab services per day $10 copay for diagnostic procedres, test, x-ray and nclear medicine per day maximm $250 for MRI/MRA/CT/CTA/ PET/SPECT scans $30 copay for therapetic radiology services PEAK+Rx Offered in all conties EXCEPT Whatcom $300 copay at ASC* $350 copay at otpatient hospital facility $50 copay for O/P clinic $15 pt/inr (Comadin) $15 diabetes panel/ A1C (diabetes) $30 all other lab services per day $30 copay for diagnostic procedres, test, x-ray and nclear medicine per day maximm $300 for MRI/MRA/CT/CTA/ PET/SPECT scans $60 copay for therapetic radiology services SOUND+Rx Offered in King, Lewis, Pierce, Snohomish, Thrston & Whatcom $175 copay at ASC* $300 copay at otpatient hospital facility $50 copay for O/P clinic $0 pt/inr (Comadin) $10 diabetes panel/ A1C (diabetes) $20 all other lab services per day $20 copay for diagnostic procedres, test, x-ray and nclear medicine per day maximm $300 for MRI/MRA/CT/CTA/ PET/SPECT scans 20% coinsrance for therapetic radiology services *Amblatory Srgical Center con t.

17 BENEFITS Physical Therapy Skilled Nrsing No prior hospital stay reqired Rotine Vision Services $120 limit for eyewear every 24 months with $25 copay ALPINE Offered in Chelan, Doglas, Grant, King, Lewis, Pierce, Snohomish, Thrston & Whatcom conties only $30 copay per visit $40 copay per day days 1-20 $100 copay per day days $0 copay per day days $0 copay for 1 rotine eye exam per year $0 copay for one pair of standard eyeglasses or contact lenses after cataract srgery $30 copay for exams to diagnose and treat diseases and conditions of the eye CHARTER+Rx Offered in all conties EXCEPT Snohomish $30 copay per visit $40 copay per day days 1-20 $100 copay per day days $0 copay per day days $0 copay for 1 rotine eye exam per year $0 copay for one pair of standard eyeglasses or contact lenses after cataract srgery $30 copay for exams to diagnose and treat diseases and conditions of the eye PEAK+Rx Offered in all conties EXCEPT Whatcom $40 copay per visit $0 copay per day days 1-20 $155 copay per day days $0 copay for 1 rotine eye exam per year $0 copay for one pair of standard eyeglasses or contact lenses after cataract srgery $50 copay for exams to diagnose and treat diseases and conditions of the eye SOUND+Rx Offered in King, Lewis, Pierce, Snohomish, Thrston & Whatcom $40 copay per visit $0 copay per day days 1-20 $155 copay per day days $0 copay for 1 rotine eye exam per year $0 copay for one pair of standard eyeglasses or contact lenses after cataract srgery $50 copay for exams to diagnose and treat diseases and conditions of the eye YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 13

18 I had a 34-year career in cstomer service, and was delighted to find very good cstomer service at Sondpath Health. They are all abot people working with people to forge sccessfl relationships. Sylvia C. Actal Sondpath Health Member

19 Choosing the right plan for yor prescription drgs Sondpath Health offers three plans with prescription drg coverage. Make a side-by-side comparison. YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 16

20 Prescription Drgs Choosing the right plan Dedctible Initial Coverage Limit (ICL) Gap Coverage Catastrophic Coverage CHARTER+Rx Offered in all conties EXCEPT Snohomish $320 annal dedctible $4 Tier 1 throgh the dedctible 33% Tier 5 throgh the dedctible $2,960 $4,700 total ot-ofpocket maximm Tier 1 covered in the gap with same cost shares as pre-icl* $2.65 copay for generic (inclding brand drgs treated as generic) and $6.60 copay for all other drgs, or 5% coinsrance PEAK+Rx Offered in all conties EXCEPT Whatcom $320 annal dedctible $4 Tier 1 throgh the dedctible 33% Tier 5 throgh the dedctible $2,960 $4,700 total otof-pocket maximm. No Gap Coverage $2.65 copay for generic (inclding brand drgs treated as generic) and $6.60 copay for all other drgs, or 5% coinsrance SOUND+Rx Offered in King, Lewis, Pierce, Snohomish, Thrston & Whatcom $320 annal dedctible $4 Tier 1 throgh the dedctible 33% Tier 5 throgh the dedctible $2,960 $4,700 total otof-pocket maximm. No Gap Coverage $2.65 copay for generic (inclding brand drgs treated as generic) and $6.60 copay for all other drgs, or 5% coinsrance *Initial coverage limit 17 SOUNDPATH HEALTH DECISION MAKING GUIDE 2015

21 Prescription Drg Tiers Copayments and coinsrance Tiers Retail or Mail Order 31-Day Spply Retail or Mail Order 62-Day Spply Retail 93-Day Spply Mail Order 93-Day Spply Tier 1 Preferred Generic Drgs Tier 2 Non-Preferred Generic Drgs Tier 3 Preferred Brand Drgs Tier 4 Non-Preferred Brand Drgs Tier 5 Specialty Drgs CHARTER+Rx PEAK+Rx SOUND+Rx Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 Tier 1 Tier 2 Tier 3 Tier 4 Tier 5 $4 $20 $45 25% coinsrance 33% coinsrance $4 $20 $45 25% coinsrance 33% coinsrance $4 $20 $45 25% coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance $10 $50 $ % coinsrance 33% coinsrance $10 $50 $ % coinsrance 33% coinsrance $10 $50 $ % coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance $8 $40 $90 25% coinsrance 33% coinsrance YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 18

22 Additional Benefits These are inclded in all plans at no additional cost. Healthways SilverSneakers Fitness Program Exercise, edcation, and social activities are very important to yor health and wellbeing, which is why Sondpath offers Healthways SilverSneakers Fitness program at no additional cost! SilverSneakers incldes the following: What Yo Get A fitness membership with access to more than 11,000 locations nationwide (inclding women-only locations) where yo can se eqipment and take grop exercise classes SilverSneakers FLEX with classes inclding tai chi, yoga, dance, and walking grops offered in yor favorite neighborhood locations sch as parks, recreation centers and adlt-living commnities SilverSneakers Steps, which incldes a choice of for kits general fitness, strength, walking and yoga Sondpath members to se at home or when yo travel Fn social activities and events, pls health edcation seminars To find yor closest SilverSneakers location and FLEX classes, order a SilverSneakers Steps kit, or get additional information, visit silversneakers.com. Remember, when yo travel yo can se any SilverSneakers location in the nation! Get started today and be one step closer to a healthier lifestyle. Vision Care throgh Yor VSP Doctor Annal rotine eye exams are an important part of overall health care. With VSP vision coverage, yo ll get personalized care that focses on yor eyes and overall wellness. The coverage also provides great savings, is simple to se and offers the latest eyewear styles and brand names. What Yo Get No-cost annal rotine eye examination with VSP participating providers $120 hardware allowance toward prchase of vision hardware like eyeglass frames or contact lenses, with a low $25 copay With VSP s vision coverage, yor basic lenses are covered in fll. Additionally, any lens options, sch as progressives, are offered at a discont of 20-25% Additional pairs of glasses or snglasses prchased on the same day as yor eye exam, from the same doctor, are offered at a 30% discont 19 SOUNDPATH HEALTH DECISION MAKING GUIDE 2015

23 We can t be happier with the programs they offer yo. Yo have a dental program, yo have the gym, and that is jst tremendos. It s a mst; it will make yo feel at least 20 years yonger than what yo feel right now. They believe in preventive medicine. Frank & Joan B. Actal Sondpath Health Members

24 Vale Added Services As a Sondpath Health plan member, yo can take advantage of additional services for FREE or at disconted prices. What Yo Get Hearing Health Program from Hearing Care Soltions Do yo find it harder to hear the msic and TV shows yo love? Are words like hh? or what? taking over yor vocablary? Not to worry we ve got a Hearing Health Program jst for yo. Annal hearing exam at no charge Two-year spply of batteries at no charge and three-year comprehensive warranty, inclding loss and damage For levels of technology, priced from $675 to $1, day hearing aid evalation period Fixed, disconted pricing on hearing aids from major manfactrers No-interest, free financing for p to 12 months for qalified applicants * The prodcts and services described above are neither offered nor garanteed nder or contract with the Medicare program. In addition, they are not sbject to the Medicare appeals process. Any disptes regarding these prodcts and services may be sbject to the Sondpath Health grievance process. Mayo Clinic Books The Mayo Clinic offers reliable, comprehensive books on healthy living filled with information yo can se. Sondpath Health members enjoy 20% off on select Mayo Clinic books. Omron Sondpath Health is offering a special 10% discont on a variety of highqality Omron blood pressre monitoring prodcts sold throgh QickMedical, Medical Eqipment and Spplies. Ntrisystem Discont Program Ntrisystem has been helping millions of people lose weight and change their lives for the better. By providing real food yo know and love, gidelines yo can live by and balanced ntrition, the Ntrisystem program makes losing weight work for yo. Sondpath Health is offering a 10% discont exclsively to or members on Ntrisystem food prodcts, membership and services. 21 SOUNDPATH HEALTH DECISION MAKING GUIDE 2015

25 Other FREE Featres of or Plans Award-Winning Qarterly Health and Wellness Magazine for All Members, Partners in Health Member Advisory Committee Members meet qarterly with Sondpath Health team members to review positioning and commnications of plan services and benefits. Access to Online Wellness Tools and Resorces Members have access to over 400 online tools, qizzes, reference materials and videos. Online e-newsletter, Members Matter Providing yo pdates and tips on getting the most ot of yor plan benefits. Member Orientation Meetings Designed to help yo nderstand yor plan benefits, Sondpath Health services and more. Member Appreciation Events Or thanks to yo: social and interactive events in the conties we serve. YOUR GUIDE TO MAKING SOUND HEALTH CARE DECISIONS 22

26 NOTES

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28 It s easy to enroll with Sondpath Health By Phone Call Sondpath Health at: , TTY/TDD: 711 Sondpath Health is open Monday - Friday, 8:00 am - 8:00 pm; Monday - Snday, 8:00 am - 8:00 pm, between October 1 and Febrary 14. Beneficiaries may also enroll in Sondpath Health by calling MEDICARE, 24 hors a day, 7 days a week. In Person Come to an informative, no obligation event in yor commnity. See the meeting schedle at and click on the event tab, call to ask for an in-home personal appointment, or stop by one of or offices. Online Go to Medicare Beneficiaries may also enroll in Sondpath Health throgh the CMS Medicare Online Enrollment Center located at For additional information on Medicare or Medicare Advantage, visit or Medicare Academy at Sondpath Health is an HMO plan with a Medicare contract. Enrollment in Sondpath Health depends on contract renewal. The benefit information provided is a brief smmary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formlary, pharmacy network, provider network, premim and/or copayments/coinsrance may change on Janary 1 of each year. Yo mst contine to pay yor Medicare Part B premim. A sales person will be present with information and applications. For accommodation of persons with special needs at sales meetings call (TTY/TDD sers shold call 711). Medicare beneficiaries may also enroll in Sondpath Health throgh the CMS Medicare Online Enrollment Center located at