H5211. Essence (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Spirit Rx (HMO-POS) Spirit (HMO-POS) Y0117_MC C-09-17

Transcription

1 2018 H5211 Essence Essence Rx Esteem Rx Spirit Rx Spirit Y0117_MC C-09-17

2 January 1, 2018 December 31, 2018 This is a summary of health and prescription drug services covered by Security Health Plan s Essence, Essence Rx, Esteem Rx, Spirit and Spirit Rx Medicare Advantage plans. The benefit information provided is a summary of what each plan covers 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. To join Essence Rx or Essence, 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 Wisconsin: Adams, Ashland, Barron, Bayfield, Burnett, Buffalo, Chippewa, Clark, Douglas, Dunn, Eau Claire, Florence, Forest, Iron, Jackson, Juneau, Langlade, Lincoln, Marathon, Oneida, Pepin, Portage, Price, Rusk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waupaca, Waushara and Wood. To join Esteem Rx, 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 Wisconsin: Adams, Ashland, Barron, Bayfield, Burnett, Buffalo, Chippewa, Clark, Douglas, Dunn, Eau Claire, Florence, Forest, Iron, Jackson, Juneau, Langlade, Lincoln, Marathon, Oneida, Pepin, Portage, Price, Rusk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waupaca, Waushara and Wood. To join Spirit Rx or Spirit, 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 Wisconsin: Adams, Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Clark, Columbia, Dane, Douglas, Dunn, Eau Claire, Florence, Forest, Green, Green Lake, Iowa, Iron, Jackson, Jefferson, Juneau, Langlade, Lincoln, Marathon, Marquette, Oneida, Pepin, Portage, Price, Richland, Rusk, Sauk, Sawyer, Shawano, Taylor, Trempealeau, Vilas, Washburn, Waukesha, Waupaca, Waushara and Wood. 2

3 Security Health Plan has a network of doctors, hospitals, pharmacies and other providers. You can see our plans provider directory on our website at You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plans pharmacy directory on our website at Essence and Spirit cover Part B drugs including chemotherapy and some drugs administered by your provider. However, these plans do NOT cover Part D prescription drugs. Essence Rx, Esteem Rx and Spirit Rx cover Part D drugs. In addition, these plans cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see our complete formulary (list of Part D prescription drugs) and any restrictions on our website at Or you can call us and we will send you a printed copy of the provider directory, pharmacy directory and/or abridged formulary. For more information, call our Customer Service Department at If you are hearing or speech impaired, call TTY 711. You can call 7 days a week from 8 a.m. to 8 p.m. Or, visit us at For 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 users should call This Summary of Benefits is available in other formats such as large print. 3

4 January 1, 2018 December 31, 2018 Premiums and benefits Monthly plan premium Deductible Medical services Part D prescription drugs Maximum out-ofpocket responsibility (does not include prescription drugs, hearing aids or eyeglasses) Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know $76 $17 $0 $219 $162 You must continue to Medicare Part B premium. In-network: $0 $1,500 $300 for drugs in Tiers 3-5 only. In-network: $3,400 $3,500 In-network: $0 $1,500 Part D drugs are not covered In-network: $3,400 $3,500 In-network: $0 $0 $300 for drugs in Tiers 3-5 only. In-network: $6,500 In-network and out-of-network combined: $8,000 In-network: $0 $1,500 $0 In-network: $1,200 $3,500 In-network: $0 $1,500 Part D drugs are not covered In-network: $1,200 $3,500 These amounts are the most you will pay for copays and other costs for medical services for the year. For Essence and Spirit plans, out-ofnetwork costs apply toward the innetwork maximum out-of-pocket, but innetwork cost sharing does NOT apply toward the out-ofnetwork out-ofpocket maximum. 4

5 Premiums and benefits Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know Inpatient hospital coverage pay $300 per day, days 1-5. You pay nothing for days 6-discharge. pay $300 per day, days 1-5. You pay nothing for days 6-discharge. pay $395 per day, days 1-4. You pay $0 per day for days 5-discharge. pay $250 per stay. pay $250 per stay. Copayments will not start over if you transition to an inpatient rehabilitation or psychiatric unit within the same facility or to another hospital. Copayments will start over if you are readmitted following a discharge home or transition from a swing bed or skilled nursing facility. Outpatient hospital coverage pay $200 for Medicare-covered surgical services. pay $200 for Medicare-covered surgical services. cost for Medicarecovered surgical services. pay $100 for Medicare-covered surgical services. pay $100 for Medicare-covered surgical services. Doctor visits (primary care providers and specialists) pay $15 for primary care and $50 for specialty care. pay $15 for primary care and $50 for specialty care. pay $25 for primary care and $50 for specialty care. pay $0 for primary care and $25 for specialty care. pay $0 for primary care visits and $25 for specialty care. 5

6 Premiums and benefits Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know Preventive care Medicare-covered preventive services are covered at 100%. Medicare-covered preventive services are covered at 100%. Medicare-covered preventive services are covered at 100%. Medicare-covered preventive services are covered at 100%. Medicare-covered preventive services are covered at 100%. Additional preventive services approved by Medicare during the contract year will be covered. Any office visit copay associated with a Medicarecovered preventive service will be waived. Medicare does not cover all preventive services. For a list of covered preventive services, go to coverage/preventiveand-screeningservices.html Emergency care You pay $100 per visit. You pay $100 per visit. You pay $80 per visit. You pay $100 per visit. You pay $100 per visit. You pay $0 if you are admitted to hospital within 24 hours for the same condition. Emergency care is covered worldwide. Urgently needed services You pay $15 for primary care and $50 for specialist care. You pay $15 for primary care and $50 for specialist care. You pay $25 for primary care and $50 for specialist care. You pay $0 for primary care and $25 for specialist care. You pay $0 for primary care and $25 for specialist care. Urgently needed services are covered worldwide. 6

7 Premiums and benefits Diagnostic services/ labs/imaging (X-rays/radiation therapy) High end imaging (MRI tests, CT and PET scans, ultrasounds, echocardiograms, nuclear medicine stress tests) Essence Rx pay $200. Essence pay $200. Esteem Rx Spirit Rx pay $150. Spirit pay $150. What you should know You are responsible for obtaining prior authorization for radiation therapy if out of network and for genetic testing in or out of network. You are responsible for obtaining prior authorization for high-end imaging if out of network. Hearing services Diagnostic and annual routine visits pay $50. pay $50. pay $15. pay $25. pay $25. Hearing aids You pay $500 for each hearing aid up to 2 hearing aids per year. You pay $500 for each hearing aid up to 2 hearing aids per year. You pay $500 for each hearing aid up to 2 hearing aids per year. You pay $500 for each hearing aid up to 2 hearing aids per year. You pay $500 for each hearing aid up to 2 hearing aids per year. Hearing aid costs do not count toward your out-of-pocket maximum. You must use an in-network provider for hearing aids and will be limited to select hearing aid brands/ types as specified by each provider. 7

8 Premiums and benefits Dental services Medicarecovered One preventive exam per calendar year (includes a preventive cleaning and either a full mouth X-ray, panoramic X-ray or up to four bitewing X-rays) Vision services Diagnostic and routine exams Eyeglasses or contact lenses after cataract surgery Essence Rx Not covered In or out-ofnetwork: You pay $0 for one exam per calendar year. For additional exams: pay $50. Out-ofnetwork: You pay 20% of the cost after you Essence Not covered In or out-ofnetwork: You pay $0 for one exam per calendar year. For additional exams: pay $50. Out-ofnetwork: You pay 20% of the cost after you Esteem Rx You Not covered pay $0 for one exam per calendar year. You pay $50 for additional exams. the cost for each exam. Spirit Rx Not covered In or out-ofnetwork: You pay $0 for one exam per calendar year. For additional exams: pay $25. Out-ofnetwork: You pay 20% of the cost after you Spirit Not covered In or out-ofnetwork: You pay $0 for one exam per calendar year. For additional exams: pay $25. Out-ofnetwork: You pay 20% of the cost after you What you should know Limited dental services do not include services associated with care, treatment, filling, removal or replacement of teeth. You must use a Liberty Network dentist for preventive dental services. Refraction will only be covered at 100% if provided by an innetwork provider. If provided by an outof-network provider, the cost of the refraction will be subject to out-ofnetwork cost sharing. 8

9 Premiums and benefits Vision services (continued) Eyeglasses for members with routine vision correction needs Mental health services Inpatient visit Outpatient group/individual therapy visit Essence Rx $175 allowance each calendar year toward purchase. pay $300 per day, days 1-5. You pay $0, days pay $40. Essence $175 allowance each calendar year toward purchase. pay $300 per day, days 1-5. You pay $0, days pay $40. Esteem Rx $200 allowance each calendar year toward purchase. pay $395 per day, days 1-4. You pay $0 days pay $40. Spirit Rx $175 allowance each calendar year toward purchase. pay $250 per stay. pay $25. Spirit $175 allowance each calendar year toward purchase. pay $250 per stay. pay $25. What you should know You must use an innetwork provider. Additional costs you pay for eyeglasses do not count toward your out-of-pocket maximum. There is a 190-day lifetime limit for inpatient services in a psychiatric hospital. Copayments will not start over if you transition to an inpatient rehabilitation or psychiatric unit within the same facility or to another hospital. Copayments will start over if you are readmitted following a discharge home or transition from a swing bed or skilled nursing facility. 9

10 Premiums and benefits Skilled nursing facility Physical therapy, occupational therapy, speech and language pathology Essence Rx pay $0 each day, days 1-6. You pay $20 each day, days You pay $0 each day, days pay $20 per day - can include all types. Essence pay $0 each day, days 1-6. You pay $20 each day, days You pay $0 each day, days pay $20 per day - can include all types. Esteem Rx pay $0 each day, days You pay $160 each day, days You pay $0 each day, days pay $40 per day - can include all types. Spirit Rx pay $0 each day, days 1-6. You pay $20 each day, days You pay $0 each day, days pay $20 per day - can include all types. Spirit pay $0 each day, days 1-6. You pay $20 each day, days You pay $0 each day, days pay $20 per day - can include all types. What you should know Evaluation by a physician is required prior to entering a skilled nursing facility. You are responsible for obtaining prior authorization for skilled nursing care if out of network. Custodial care is not covered. You are responsible for obtaining prior authorization for therapy services if out of network. Ambulance You pay $200. You pay $200. You pay $275. You pay $150. You pay $150. We cover Medicarecovered ambulance benefits worldwide. The ambulance benefit is a transport benefit. If there is no transport, it is not covered by Medicare and you are liable for payment. Transportation Not covered Not covered Not covered Not covered Not covered 10

11 Premiums and benefits Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know Medicare Part B drugs Part B-covered drugs and biologicals, including chemotherapy drugs The coinsurance applies to Part B- covered drugs that are injected or infused while you are getting physician, hospital outpatient or ambulatory surgical center services, including diagnostic tests. You are responsible for obtaining prior authorization if Part B drugs are received out of network. Foot care (podiatry services) Foot exams pay $50. pay $50. pay $50. pay $25. pay $25. We cover medicallynecessary treatment of injuries and diseases of the feet, as covered by Medicare. Routine foot care Not covered Not covered Not covered Not covered Not covered You pay 100% for routine foot care unless Medicare coverage criteria are met. 11

12 Premiums and benefits Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know Durable medical equipment and supplies Durable medical equipment (e.g. wheelchairs, oxygen) and prosthetic devices and related supplies (e.g. braces, artificial limbs) You are responsible for obtaining prior authorization for durable medical equipment and prosthetic devices and related supplies. See your Provider Directory for a list of suppliers. In-network only: Ostomy, wound care and urological supplies are covered at 100%. Wellness programs (e.g. fitness) You pay $0 for health and wellness support from Security Health Plan health coaches and nurse care managers. You pay $0 for health and wellness support from Security Health Plan health coaches and nurse care managers. You pay $0 for health and wellness support from Security Health Plan health coaches and nurse care managers. You pay $0 for health and wellness support from Security Health Plan health coaches and nurse care managers. You pay $0 for health and wellness support from Security Health Plan health coaches and nurse care managers. Fitness programs through outside organizations (e.g. YMCA) are not covered. Chiropractic services Manipulation of the spine to correct a subluxation (when one or more of the bones of your spine move out of position) pay $20. pay $20. pay $20. pay $20. pay $20. Routine chiropractic visit pay $20. pay $20. pay $20. pay $20. pay $20. Routine chiropractic benefits do not include maintenance 12

13 Premiums and benefits Essence Rx Essence Esteem Rx Spirit Rx Spirit What you should know Chiropractic services (continued) care. You pay 100% of charges for maintenance care visits. Additional benefits include medical office visits, X-rays, subluxations other than to the spine, and therapies. Diabetes selfmonitoring training, supplies and services Home health care You You You You You You must use Accu- Chek or OneTouch brands for selfmonitoring systems and supplies. You are responsible for obtaining prior authorization for home health care services if out of network. 13

14 There are four stages of cost-sharing in the Part D benefit deductible, initial coverage, coverage gap and catastrophic coverage. Cost-sharing changes when you enter each stage of the Part D benefit. Essence Rx Esteem Rx Spirit Rx What you should know Deductible stage You must pay a $300 deductible for drugs in tiers 3-5 only Initial coverage stage Tier 1: Preferred generic Tier 2: Generic Tier 3: Preferred brand drugs Tier 4: Nonpreferred drugs Tier 5: Specialty drugs Tier 6: Vaccines Standard retail, mail-order and long-term care costsharing (30-day supply / 90-day supply) You pay $5 / $15 You pay $14 / $42 You pay $45 / $135 You pay $100 / $300 You pay 25% / 90-day supply not available You pay $0 / 90-day supply not available You must pay a $300 deductible for drugs in tiers 3-5 only Standard retail, mail-order and long-term care costsharing (30-day supply / 90-day supply) You pay $5 / $15 You pay $20 / $60 You pay $45 / $135 You pay $100 / $300 You pay 25% / 90-day supply not available You pay $0 / 90-day supply not available There is no deductible for the Spirit Rx plan. Standard retail, mail-order and long-term care costsharing (30-day supply / 90-day supply) You pay $9 / $27 You pay $20 / $60 You pay $47 / $141 You pay $100 / $300 You pay 33% / 90-day supply not available You pay $0 / 90-day supply not available For plans with a deductible, you must pay the full cost of your tier 3-5 drugs until you reach the plan s deductible amount. For all other drugs, you start immediately in the initial coverage stage. For more information on the coverage gap and catastrophic coverage stages of the benefit, please call us or review our Evidence of Coverage online at We cover drugs filled at an out-of-network pharmacy only when you are not able to use a network pharmacy. If the cost of your drug is less than the listed copay, you will pay only the lower amount. The Zostavax shingles vaccine and tetanusdiphtheria-pertussis (Tdap) vaccine given as routine vaccinations are covered for members with Part D coverage. 14

15 A primary care office visit includes general/family practice, internal medicine, obstetrics/gynecology, pediatrics and a visit with a nurse practitioner or physician s assistant. A specialty care office visit covers all other physician specialties. We employ doctors, nurses and other staff to review certain services to ensure that members receive the right care at the right place and time. Called Utilization Management (UM), this process helps control member costs for health care services. Learn about our UM procedures at If you would like a printed copy, please call Care management, health coaching and other services are also offered free to help our members stay healthy. Learn more at We take the confidentiality of our member s health information seriously. View our Notice of Privacy Practices online at Call for a paper copy at A comprehensive medication review is one of many Medication Therapy Management (MTM) services we provide free to members with Part D coverage. Offered to members who have multiple chronic conditions, MTM services ensure you get the best results from your medications and keep your out-of-pocket costs down. To learn more, call our Pharmacy Services Department:

16 Security Health Plan of Wisconsin, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Security Health Plan of Wisconsin, Inc. does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Security Health Plan of Wisconsin, Inc.: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service. If you believe that Security Health Plan of Wisconsin, Inc. has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with Security Health Plan, Attn: Grievances, 1515 North Saint Joseph Avenue, Marshfield, WI Phone: (TTY: 711). Fax: shp.appeals.grievance@securityhealth.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Security Health Plan can help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC Phone: or (TDD). Complaint forms are available at ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Hmoob (Hmong) LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). 繁體中文 (Chinese) 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711). 16

17 Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم والبكم: 117(. (Arabic) ال عرب )رقم هاتف الصم ية Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Deitsch (Pennsylvania Dutch) Wann du Deitsch schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: (TTY: 711). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ह द (Hindi) ध य न द : यदद आप ह द ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Shqip (Albanian) KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: 711). Tagalog (Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 17

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20 1515 North Saint Joseph Avenue PO Box 8000 Marshfield, WI TTY: 711 Fax a.m. 8 p.m., 7 days a week Security Health Plan is an HMO-POS, MSA and D-SNP plan with a Medicare contract. Enrollment in Security 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 copayments/coinsurance may change on January 1 of each year. You must continue to Part B premium. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. About Security Health Plan Security Health Plan of Wisconsin, Inc., part of the Marshfield Clinic Health System, is helping its 220,000 members in Wisconsin and beyond reach their best health. Accredited by the National Committee for Quality Assurance (NCQA), Security Health Plan offers health insurance coverage for employees of large and small businesses, individuals and families. Security Administrative Services, a wholly-owned subsidiary of Security Health Plan, provides full service third party administration for self-funded employers in Wisconsin, Indiana, and Michigan. HP (09/17) 2017 Security Health Plan of Wisconsin, Inc.