2018 Summary of Benefits HAP Senior Plus (PPO) H Option H Option H Option January 1, December 31, 2018

Transcription

1 2018 Summary of Benefits H Option H Option H Option January 1, December 31, 2018 H2322_PPO SB 2018 R1 CMS Accepted 10/30/2017

2 Summary of Benefits January 1, December 31, 2018 There is more than one plan listed in this Summary of Benefits booklet. The booklet gives you 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. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as HAP Senior Plus (PPO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as large print. This document may be available in a non-english language. For additional information, call us at (888) Things to Know About 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. Eastern time. From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time, Saturday from 8:00 a.m. to 12:00 p.m. Eastern time. 1

3 Phone Numbers and Website If you are a member of one of these plans, call toll-free (888) If you are not a member of one of these plans, call toll-free (800) Our website: Who can join? To join, 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 Michigan: Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Hillsdale, Huron, Ingham, Iosco, Jackson, Lapeer, Livingston, Macomb, Midland, Monroe, Oakland, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola, Washtenaw, and Wayne. Which doctors, hospitals, and pharmacies can I use? has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You can see our plan's provider directory at our website ( You can see our plan's pharmacy directory at our website ( Or, if you prefer a full paper directory, call us at the number listed above and we will send you a copy. 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, Or, if you prefer a paper formulary, call us at the number listed above and we will send you a copy. How will I determine my drug s? Our plans group each medication into one of five "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 benefit stage you have reached. Later in this document we discuss the benefit stages: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 2

4 Summary of Benefits January 1, December 31, 2018 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit How much is the monthly premium? Plan 011 Option 1 $15 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does has deductibles for hospital and medical services. $275 per year for some in-network and out-of-network services. This plan does not have a deductible for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? 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: $5,500 for services you receive from in-network providers. $7,000 for services you receive from any provider. Your for services received from in-network providers will count toward this limit. If you reach the on out-of-pocket 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. 2

5 Plan 008 Option 2 $118 per month. In addition, you must keep paying your Medicare Part B premium. Plan 004 Option 3 $190 per month. In addition, you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical services. This plan does not have a deductible for Medical or Part D Prescription drugs. $200 per year for some in-network and out-of-network services. This plan does not have a deductible for Part D prescription drugs. 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: $4,500 for services you receive from in-network providers. $6,500 for services you receive from any provider. Your s for services received from in-network providers will count toward this limit. If you reach the on out-of-pocket 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. 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: $4,000 for services you receive from in-network providers. $6,100 for services you receive from any provider. Your for services received from in-network providers will count toward this limit. If you reach the on out-of-pocket 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. 3

6 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Is there a limit on how much the plan will pay? Plan 011 Option 1 Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. 4

7 Plan 008 Option 2 Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. Plan 004 Option 3 Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. 5

8 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Inpatient Hospital Care 1 Benefit Plan 011 Option 1 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $250 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 There is no to you for additional hospital days not normally covered under Original Medicare. Out-of-network: 30% of the per stay Outpatient Hospital Services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. In-Network: $200 co-pay Out-of-Network: 30% co-pay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies Certain screenings and preventive services Certain drugs and biologicals You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at or by calling MEDICARE ( ). 6

9 Plan 008 Option 2 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $200 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 There is no to you for additional hospital days not normally covered under Original Medicare. Out-of-network: 25% of the per stay Plan 004 Option 3 Our plan covers an unlimited number of days for an inpatient hospital stay. In-network: $135 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 There is no to you for additional hospital days not normally covered under Original Medicare. Out-of-network: 20% of the per stay We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. In-Network: $150 co-pay Out-of-Network: 25% co-pay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies Certain screenings and preventive services Certain drugs and biologicals You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at or by calling MEDICARE ( ). We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. In-Network: $100 Out-of-Network: 20% co-pay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies Certain screenings and preventive services Certain drugs and biological You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at or by calling MEDICARE ( ). 7

10 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Outpatient Hospital Services (cont'd) Plan 011 Option 1 TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Doctor's Office Visits Primary care physician visit: In-network: $35 copay Out-of-network: 30% of the Specialist visit: In-network: $50 copay Out-of-network: 30% of the Preventive Care In-network: You pay nothing Out-of-network: 30% of the 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) 8

11 Plan 008 Option 2 TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Plan 004 Option 3 TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Primary care physician visit: In-network: $20 copay Out-of-network: 25% of the Specialist visit: In-network: $40 copay Out-of-network: 25% of the In-network: You pay nothing Out-of-network: 25% of the 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) Primary care physician visit: In-network: $15 copay Out-of-network: 20% of the Specialist visit: In-network: $30 copay Out-of-network: 20% of the In-network: You pay nothing Out-of-network: 20% of the 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) 9

12 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Plan 011 Option 1 Preventive Care (cont'd) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care $80 copay 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. Worldwide coverage. $80 for each covered emergency room visit outside the United States. Urgently Needed Services $50 copay Worldwide coverage. $50 for each covered urgent care visit outside the United States. Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service.) 1 Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): In-network: $200 copay Out-of-network: 30% of the Diagnostic tests and procedures: In-network: $200 copay 10

13 Plan 008 Option 2 Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Plan 004 Option 3 Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. $80 copay 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. Worldwide coverage. $80 for each covered emergency room visit outside the United States. $80 copay 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. Worldwide coverage. $80 for each covered emergency room visit outside the United States. $40 copay Worldwide coverage. $40 for each covered urgent care visit outside the United States. $30 copay Worldwide coverage. $30 for each covered urgent care visit outside the United States. Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): In-network: $150 copay Out-of-network: 25% of the Diagnostic tests and procedures: In-network: $150 copay Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): In-network: $100 copay Out-of-network: 20% of the Diagnostic tests and procedures: In-network: $100 copay 11

14 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service.) 1 (cont'd) Plan 011 Option 1 Out-of-network: 30% of the Lab services: In-network: $20 copay (excludes genetic labs) Out-of-network: 30% of the Outpatient x-rays: In-network: $35 copay for standard routine x-rays Out-of-network: 30% of the Therapeutic radiology services (such as radiation treatment for cancer): In-network: $50 copay Out-of-network: 30% of the A separate physician/professional services sharing may apply if other services that have a sharing amount are received at the same visit. Hearing Services Exam to diagnose and treat hearing and balance issues: In-network: $35 - $50 copay, depending on the service Out-of-network: 30% of the Routine hearing exam: In-network: $35 - $50 copay, depending on the service Out-of-network: 30% of the Dental Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $35-50 copay, depending on the service 12

15 Plan 008 Option 2 Out-of-network: 25% of the Lab services: In-network: $10 copay (excludes genetic labs) Out-of-network: 25% of the Outpatient x-rays: In-network: $35 copay for standard routine x-rays Out-of-network: 25% of the Therapeutic radiology services (such as radiation treatment for cancer): In-network: $40 copay Out-of-network: 25% of the A separate physician/professional services sharing may apply if other services that have a sharing amount are received at the same visit. Plan 004 Option 3 Out-of-network: 20% of the Lab services: In-network: $10 copay (excludes genetic labs) Out-of-network: 20% of the Outpatient x-rays: In-network: $0 copay for standard routine x-rays Out-of-network: 20% of the Therapeutic radiology services (such as radiation treatment for cancer): In-network: $30 copay Out-of-network: 20% of the A separate physician/professional services sharing may apply if other services that have a sharing amount are received at the same visit. Exam to diagnose and treat hearing and balance issues: In-network: $20-40 copay, depending on the service Out-of-network: 25% of the Routine hearing exam: In-network: $20-40 copay, depending on the service Out-of-network: 25% of the Exam to diagnose and treat hearing and balance issues: In-network: $15-30 copay, depending on the service Out-of-network: 20% of the Routine hearing exam: In-network: $15-30 copay, depending on the service Out-of-network: 20% of the Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $20-40 copay, depending on the service Out-of-network: 25% of the Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $15-30 copay, depending on the service Out-of-network: 20% of the 13

16 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Plan 011 Option 1 Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $35-50 copay, depending on the service Out-of-network: 30% of the Routine eye exam: In-network: $35-50 copay, depending on the service Out-of-network: 30% of the Contact lenses (for up to 1 every two years): In-network: You pay nothing Eyeglass frames (for up to 1 every two years): In-network: You pay nothing Eyeglass lenses (for up to 1 every two years): In-network: You pay nothing Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. Mental Health Care 1 Inpatient visit: 14 Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to

17 Plan 008 Option 2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $20-40 copay, depending on the service Out-of-network: 25% of the Routine eye exam: In-network: $20-40 copay, depending on the service Out-of-network: 25% of the Contact lenses (for up to 1 every two years): In-network: You pay nothing Eyeglass frames (for up to 1 every two years): In-network: You pay nothing Eyeglass lenses (for up to 1 every two years): In-network: You pay nothing Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. Plan 004 Option 3 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $15-30 copay, depending on the service Out-of-network: 20% of the Routine eye exam: In-network: $15-30 copay, depending on the service Out-of-network: 20% of the Contact lenses (for up to 1 every two years): In-network: You pay nothing Eyeglass frames (for up to 1 every two years): In-network: You pay nothing Eyeglass lenses (for up to 1 every two years): In-network: You pay nothing Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. Inpatient visit: Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to Inpatient visit: Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to 15

18 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Plan 011 Option 1 Mental Health Care 1 (cont'd) inpatient mental health services provided in a general hospital. Our plan also covers 190 "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 the "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. In-network: $250 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Out-of-network: 30% of the per stay Outpatient group therapy visit: In-network: $35 copay Outpatient individual therapy visit: In-network: $35 copay You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. In-network: $0 copay per day for days 1 through 20 $ copay per day for days 21 through

19 Plan 008 Option 2 inpatient mental health services provided in a general hospital. Our plan also covers 190 "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 the "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. In-network: $200 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Out-of-network: 25% of the per stay Outpatient group therapy visit: In-network: $20 copay Outpatient individual therapy visit: In-network: $20 copay You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. Plan 004 Option 3 inpatient mental health services provided in a general hospital. Our plan also covers 190 "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 the "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. In-network: $135 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Out-of-network: 20% of the per stay Outpatient group therapy visit: In-network: $15 copay Outpatient individual therapy visit: In-network: $15 copay You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. Our plan covers up to 100 days in a SNF. In-network: $0 copay per day for days 1 through 20 $ copay per day for days 21 through 100 Our plan covers up to 100 days in a SNF. In-network: $0 copay per day for days 1 through 20 $ copay per day for days 21 through

20 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Skilled Nursing Facility (SNF) 1 (cont'd) Plan 011 Option 1 Out-of-network: 30% of the per stay Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Outpatient Rehabilitation 1 Cardiac (heart) rehab services: In-network: $40 copay Out-of-network: 30% of the Occupational therapy visit: In-network: $40 copay Out-of-network: 30% of the Physical therapy and speech and language therapy visit: In-network: $40 copay Out-of-network: 30% of the Ambulance 1 In-network: $200 copay Out-of-network: 30% of the Transportation Not covered Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $50 copay Out-of-network: 30% of the Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 In-network: 20% of the 18 1

21 Plan 008 Option 2 Plan 004 Option 3 Out-of-network: Out-of-network: 25% of the per stay 20% of the per stay Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Cardiac (heart) rehab services: In-network: $20 copay Out-of-network: 25% of the Occupational therapy visit: In-network: $20 copay Out-of-network: 25% of the Physical therapy and speech and language therapy visit: In-network: $20 copay Out-of-network: 25% of the In-network: $150 copay Out-of-network: 25% of the Cardiac (heart) rehab services: In-network: $15 copay Out-of-network: 20% of the Occupational therapy visit: In-network: $15 copay Out-of-network: 20% of the Physical therapy and speech and language therapy visit: In-network: $15 copay Out-of-network: 20% of the In-network: $100 copay Out-of-network: 20% of the Not covered Not covered Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $40 copay Out-of-network: 25% of the In-network: 20% of the Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: In-network: $30 copay Out-of-network: 20% of the In-network: 20% of the 19

22 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: Plan 011 Option 1 In-network: 20% of the Related medical supplies: In-network: 20% of the Diabetes Supplies and Services 1 Diabetes monitoring supplies: In-network: $0 copay Out-of-network:30% of the Diabetes self-management training: In-network: $0 copay Out-of-network: 30% of the Therapeutic shoes or inserts: In-network: $0 copay Out-of-network: 30% of the Wellness Programs (e.g., fitness) Silver&Fit Program through American Specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $25 per year at first fitness center visit. Nutritional counseling with a registered dietitian. Select doctor-supervised weight loss programs when specific criteria are met. 20

23 Prosthetic devices: Plan 008 Option 2 In-network: 20% of the Related medical supplies: In-network: 20% of the Prosthetic devices: Plan 004 Option 3 In-network: 20% of the Related medical supplies: In-network: 20% of the Diabetes monitoring supplies: In-network: $0 copay Out-of-network: 25% of the Diabetes self-management training: In-network: $0 copay Out-of-network: 25% of the Therapeutic shoes or inserts: In-network: $0 copay Out-of-network: 25% of the Diabetes monitoring supplies: In-network: $0 copay Out-of-network: 20% of the Diabetes self-management training: In-network: $0 copay Out-of-network: 20% of the Therapeutic shoes or inserts: In-network: $0 copay Out-of-network: 20% of the Silver&Fit Program through American specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $25 per year at first fitness center visit. Nutritional counseling with registered dietitian. Select doctor-supervised weight loss programs when specific criteria are met. Silver&Fit Program through American Specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $50 per year at first fitness center visit. Nutritional counseling with a registered dietitian. Select doctor-supervised weight loss programs when specific criteria are met. 21

24 PRESCRIPTION DRUG BENEFITS Benefit Plan 011 Option 1 How much do I pay? For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the depending on the drug Out-of-network: 30% of the Other Part B drugs 1 : In-network: 20% of the depending on the drug Out-of-network: 30% of the 1 May require prior authorization. Initial Coverage You pay the following until your total yearly drug s reach $3,750. 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. 22

25 Plan 008 Option 2 Plan 004 Option 3 For Part B drugs such as chemotherapy drugs 1 : For Part B drugs such as chemotherapy drugs 1 : In-network: 20% of the depending on the drug In-network: 20% of the depending on the drug Out-of-network: 25% of the Out-of-network: 20% of the Other Part B drugs 1 : Other Part B drugs 1 : In-network: 20% of the depending on the drug Out-of-network: 25% of the 1 May require prior authorization. In-network: 20% of the depending on the drug Out-of-network: 20% of the 1 May require prior authorization. You pay the following until your total yearly drug s reach $3,750. 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 pay the following until your total yearly drug s reach $3,750. 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. 23

26 PRESCRIPTION DRUG BENEFITS Benefit Plan 011 Option 1 Initial Coverage (cont'd) Standard Retail Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred Generic) Tier 2 25% of the 25% of the 25% of the 25% of the 25% of the 25% of the (Generic) Tier 3 25% of the 25% of the 25% of the (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) 25% of the 33% of the 25% of the 33% of the 25% of the 33% of the Standard Mail Order Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred Generic) Tier 2 25% of the 25% of the 25% of the 25% of the 25% of the 25% of the (Generic) Tier 3 25% of the 25% of the 25% of the (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) 25% of the 33% of the 25% of the 33% of the 25% of the 33% of the If you reside in a long-term care facility, you pay the same as at a retail pharmacy. 24

27 Plan 008 Option 2 Standard Retail Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $2 copay $4 copay $5 copay Generic) Tier 2 (Generic) $15 copay $30 copay $37.50 copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $45 copay $90 copay Standard Mail Order Cost-Sharing $ copay $100 copay $200 copay $250 copay 33% of the 33% of the 33% of the One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $2 copay $4 copay $5 copay Generic) Tier 2 (Generic) $15 copay $30 copay $37.50 copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $45 copay $90 copay $ copay $100 copay $200 copay $250 copay 33% of the 33% of the 33% of the If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Plan 004 Option 3 Standard Retail Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $4 copay $8 copay $10 copay Generic) Tier 2 (Generic) $10 copay $20 copay $25 copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $45 copay $90 copay Standard Mail Order Cost-Sharing $ copay $100 copay $200 copay $250 copay 33% of the 33% of the 33% of the One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $4 copay $8 copay $10 copay Generic) Tier 2 (Generic) $10 copay $20 copay $25 copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $45 copay $90 copay $ copay $100 copay $200 copay $250 copay 33% of the 33% of the 33% of the If you reside in a long-term care facility, you pay the same as at a retail pharmacy. 25

28 PRESCRIPTION DRUG BENEFITS Benefit Plan 011 Option 1 Initial Coverage (cont'd) Under limited circumstances, you may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Coverage Gap The coverage gap begins after the yearly drug (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the plan s for covered brand-name drugs and 44% of the plan s for covered generic drugs until your s total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For more information about your s in this stage, look at Chapter 6, Section 6, in the Evidence of Coverage online at (hap.org/medicare/member-resources.) 26

29 Plan 008 Option 2 Under limited circumstances, you may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Plan 004 Option 3 Under limited circumstances, you may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. The coverage gap begins after the yearly drug (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the plan s for covered brand-name drugs and 44% of the plan s for covered generic drugs until your s total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For more information about your s in this stage, look at Chapter 6, Section 6, in the Evidence of Coverage online at (hap.org/medicare/ member-resources.) The coverage gap begins after the yearly drug (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the plan s for covered brand-name drugs and the lower of 44% of the plan s for covered generic drugs, or the Tier 1 or Tier 2 copayments, until your s total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For more information about your s in this stage, look at Chapter 6, Section 6, in the Evidence of Coverage online at (hap.org/medicare/ member-resources.) These charts show your copays for generic drugs when you are in the Coverage Gap. Standard Retail Cost-Sharing One- Two- Three- Drugs month month month Tier Covered supply supply supply Tier 1 (Preferred All $4 copay $8 copay $10 copay Generic) Tier 2 (Generic) All $10 copay $20 copay $25 copay Standard Mail Order Cost-Sharing One- Two- Three- Drugs month month month Tier Covered supply supply supply Tier 1 (Preferred All $4 copay $8 copay $10 copay Generic) Tier 2 (Generic) All $10 copay $20 copay $25 copay 27

30 PRESCRIPTION DRUG BENEFITS Benefit Plan 011 Option 1 Catastrophic Coverage After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the, or $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs. 28

31 Plan 008 Option 2 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the, or $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs. Plan 004 Option 3 After your yearly out-of-pocket drug s (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the, or $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs. 29

32 ADDITIONAL COVERED MEDICAL AND HOSPITAL BENEFITS Benefit Plan 011 Option 1 Acupuncture Not covered Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Out-of-network: 30% of the Home Health Care In-network: You pay nothing Out-of-network: 30% of the Outpatient Substance Abuse 1 Group therapy visit: In-network: $35 copay Individual therapy visit: In-network: $35 copay Outpatient Surgery 1 Ambulatory surgical center: In-network: $100 copay, depending on the service Out-of-network: 30% of the Outpatient hospital: In-network: $200 copay, depending on the service Out-of-network: 30% of the Over-the-Counter Items Not Covered Renal Dialysis 1 In-network: 20% coinsurance, depending on the service Out-of-network: 30% of the $30 copay for Self Dialysis. 30% coinsurance covers dialysis treatment in a network facility. 30

33 Plan 008 Option 2 Plan 004 Option 3 Not covered Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Out-of-network: 25% of the In-network: You pay nothing Out-of-network: 25% of the Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: $20 copay Out-of-network: 20% of the In-network: You pay nothing Out-of-network: 20% of the Group therapy visit: In-network: $20 copay Individual therapy visit: In-network: $20 copay Group therapy visit: In-network: $15 copay Individual therapy visit: In-network: $15 copay Ambulatory surgical center: In-network: $75 copay, depending on the service Out-of-network: 25% of the Outpatient hospital: In-network: $150 copay, depending on the service Out-of-network: 25% of the Ambulatory surgical center: In-network: $50 copay, depending on the service Out-of-network: 20% of the Outpatient hospital: In-network: $100 copay, depending on the service Out-of-network: 20% of the Not Covered Not Covered In-network: 20% coinsurance, depending on the service Out-of-network: 25% of the $0 copay for Self Dialysis. 25% coinsurance covers dialysis treatment in a network facility. In-network: $25 coinsurance, depending on the service Out-of-network: 20% of the $0 copay for Self Dialysis. 20% coinsurance covers dialysis treatment in a network facility. 31

34 ADDITIONAL COVERED MEDICAL AND HOSPITAL BENEFITS Benefit Plan 011 Option 1 Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. 32

35 Plan 008 Option 2 You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Plan 004 Option 3 You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 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. 33

36 OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) Benefit Package 1: Delta Dental Plan 1 Benefits include: Plan 011 Option 1 Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $25.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. How much is the deductible? This package does not have a deductible. Is there a limit on how much the plan will pay? Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 34

37 Benefits include: Plan 008 Option 2 Preventive Dental Comprehensive Dental Benefits include: Plan 004 Option 3 Preventive Dental Comprehensive Dental Additional $25.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. Additional $25.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. This package does not have a deductible. This package does not have a deductible. Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 35

38 OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) Benefit Package 2: Delta Dental Plan 2 Benefits include: Plan 011 Option 1 Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $50.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. How much is the deductible? This package does not have a deductible. Is there a limit on how much the plan will pay? Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services: 100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 36

39 Benefits include: Plan 008 Option 2 Preventive Dental Comprehensive Dental Benefits include: Plan 004 Option 3 Preventive Dental Comprehensive Dental Additional $50.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. Additional $50.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. This package does not have a deductible. This package does not have a deductible. Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services: 100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services:100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 37

40 ADDITIONAL INFORMATION ABOUT About is offered by Alliance Health and Life Insurance Company (Alliance). Alliance is a wholly owned subsidiary of Health Alliance Plan (HAP), a non-profit Michigan-based company. Freedom of choice As an member, you choose: Doctors and hospitals who participate in our approved network, or Any Medicare-participating doctor or hospital in the U.S. covers your care whether it is in-or out-of-network. Your s may be higher when using out-of-network providers. You have coverage anywhere in the world for emergency and urgent care at the copay amount. You can go to any network pharmacy with nationwide locations for your prescription drugs. Pharmacy/Provider Network and Formulary The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary. Out-of-Network/Contracted Provider Services Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the -sharing that applies to out-of-network services. Health Education At no to you, you have access to many health education programs on the HAP web site at including: HAP 5K Challenge Health Risk assessment to build an improvement plan and track progress Healthy Recipes/Eating healthy 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 January 1 of each year. is a plan with a Medicare contract. Enrollment in the plan depends on contract renewal. 38

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44 hap.org/medicare 2850 W. Grand Boulevard Detroit, MI Health Alliane Plan of Michigan. A Nonprofit Company