2015 Summary of Benefits. for

Transcription

1 2015 for Geisinger Gold Geisinger Gold

2 Introduction to 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 Geisinger Gold and ). Tips for comparing your Medicare choices This booklet gives you a summary of what Geisinger Gold Rx (PPO) and cover and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their 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 Geisinger Gold and Rx (PPO) 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 Braille and large print. This document may be available in a non-english language. For additional information, call us at (800) Things to Know About Geisinger Gold and 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 through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Geisinger Gold and Phone Numbers and Website If you are a member of this plan, call toll-free (800) If you are not a member of this plan, call toll-free (800) Our website: Who can join? To join Geisinger Gold or, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Pennsylvania: Berks, Carbon, Cumberland, Dauphin, Lancaster, Lebanon, Lehigh, Northampton, Perry, and York. H3924_14238_2 File and Use 8/31/14

3 Which doctors, hospitals, and pharmacies can I use? Geisinger Gold and have 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 must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug s? Our plan groups 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 stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan s benefits or s, please contact Geisinger Gold for details.

4 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly Please refer to the 2015 Monthly The monthly premium for premium? Premium Chart to determine the Geisinger Gold Preferred Geisinger Gold is $0 per Advantage premium for month. In addition, you must keep your county of residence. In addi paying your Medicare Part B tion, you must keep paying your premium. Medicare Part B premium. How much is the deductible? This plan does not have a This plan does not have a deductible. deductible. Is there any limit on how much I Yes. Like all Medicare health plans, Yes. Like all Medicare health plans, will pay for my covered services? our plan protects you by having our plan protects you by having yearyearly limits on your out-of-pocket ly limits on your out-of-pocket s s for medical and hospital care. for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $10,000 for services you receive from any provider. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $10,000 for services you receive from any provider. Your limit for services received Your limit for services received from from in-network providers will in-network providers will count tocount toward this limit. ward this limit. If you reach the limit on out-of If you reach the limit on out-of-pockpocket s, you keep getting cov et s, you keep getting covered ered hospital and medical services hospital and medical services and we and we will pay the full for the will pay the full for the rest of rest of the year. the year. Please note that you will still need Please note that you will still need Geisinger Gold Medicare Advan to pay your monthly premiums and to pay your monthly premiums and tage HMO, PPO, HMO POS, HMO -sharing for your Part D -sharing for your Part D SNP, and MSA plans are offered by prescription drugs. prescription drugs. Geisinger Health Plan/Geisinger Indemnity Insurance Company, health plans with a Medicare contract. Continued enrollment in Geisinger Gold depends on annual contract renewal.

5 COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and Other Not covered Not covered Alternative Therapies Ambulance In-network: $200 copay In-network: $190 copay Out-of-network: $200 copay Out-of-network: $190 copay If you are admitted to the hospital, If you are admitted to the hospital, you do not have to pay for the you do not have to pay for the ambulance services. ambulance services. Chiropractic Care Manipulation of the spine to correct Manipulation of the spine to correct a subluxation (when 1 or more of a subluxation (when 1 or more of the bones of your spine move out of the bones of your spine move out of position): position): In-network: $20 copay In-network: $20 copay Out-of-network: 45% of the Dental Services 1 Limited dental services (this does Limited dental services (this does not not include services in connection include services in connection with with care, treatment, filling, remov care, treatment, filling, removal, or al, or replacement of teeth): replacement of teeth): In-network: $35 copay In-network: $40 copay Out-of-network: 45% of the

6 Diabetes Supplies and Services 1 Diabetes monitoring supplies: Diabetes monitoring supplies: In-network: 0-20% of the, In-network: 0-20% of the, depending on the supply depending on the supply Out-of-network: 0-35% of the Out-of-network: 0-45% of the, depending on the supply, depending on the supply Diabetes self-management training: Diabetes self-management training: In-network: You pay nothing In-network: You pay nothing Out-of-network: You pay Out-of-network: You pay nothnothing ing Therapeutic shoes or inserts: Therapeutic shoes or inserts: In-network: 20% of the In-network: 20% of the Out-of-network: 0-35% of the Out-of-network: 0-45% of the, depending on the supply, depending on the supply Diagnostic Tests, Lab and Diagnostic radiology services (such Diagnostic radiology services (such Radiology Services, and X-Rays 1 as MRIs, CT scans): as MRIs, CT scans): In-network: 20% of the In-network: 20-30% of the, depending on the service Out-of-network: 45% of the Diagnostic tests and procedures: Diagnostic tests and procedures: In-network: $20 copay In-network: $25 copay Out-of-network: 45% of the Lab services: Lab services: In-network: $25 copay In-network: $20 copay Out-of-network: 45% of the Outpatient x-rays: In-network: $25 copay Outpatient x-rays: Out-of-network: 45% of the In-network: $20 copay Therapeutic radiology services (such as radiation treatment for cancer): In-network: 20% of the Therapeutic radiology services Out-of-network: 45% of the (such as radiation treatment for cancer): In-network: 20% of the Doctor s Office Visits Primary care physician visit: Primary care physician visit: In-network: $10 copay In-network: $10 copay Out-of-network: 45% of the Specialist visit: Specialist visit: In-network: $40 copay In-network: $35 copay Out-of-network: 45% of the

7 Durable Medical Equipment In-network: 20% of the In-network: 20% of the (wheelchairs, oxygen, etc.) 1 Out-of-network: 45% of the Emergency Care $65 copay $65 copay If you are admitted to the hospi If you are admitted to the hospital tal within 3 days, you do not have within 3 days, you do not have to pay to pay your share of the for your share of the for emergenemergency care. See the Inpatient cy care. See the Inpatient Hospital Hospital Care section of this book Care section of this booklet for let for other s. other s. Foot Care (podiatry services) Foot exams and treatment if you Foot exams and treatment if you have have diabetes-related nerve damage diabetes-related nerve damage and/or and/or meet certain conditions: meet certain conditions: In-network: $35 copay In-network: $40 copay Out-of-network: 45% of the Routine foot care (for up to 4 visit(s) Routine foot care (for up to 4 vis every year): it(s) every year): In-network: You pay nothing In-network: You pay nothing Out-of-network: 45% of the Hearing Services Exam to diagnose and treat hearing Exam to diagnose and treat hearing and balance issues: and balance issues: In-network: $35 copay In-network: $40 copay Out-of-network: 45% of the Home Health Care 1 In-network: You pay nothing In-network: You pay nothing Out-of-network: 45% of the

8 Mental Health Care 1 Inpatient visit: Our plan covers up Inpatient visit: Our plan covers up to to 190 days in a lifetime for inpa 190 days in a lifetime for inpatient tient mental health care in a psychi mental health care in a psychiatric atric hospital. The inpatient hospital hospital. The inpatient hospital care care limit does not apply to inpa limit does not apply to inpatient tient mental services provided in a mental services provided in a general general hospital. Our plan covers 90 hospital. Our plan covers 90 days days for an inpatient hospital stay. for an inpatient hospital stay. Our Our plan also covers 60 lifetime plan also covers 60 lifetime reserve reserve days. These are extra days. These are extra days that we days that we cover. If your hospital cover. If your hospital stay is longer stay is longer than 90 days, you can than 90 days, you can use these extra use these extra days. But once you days. But once you have used up have used up these extra 60 days, these extra 60 days, your inpatient your inpatient hospital coverage will hospital coverage will be limited to be limited to 90 days. 90 days. In-network: In-network: $218 copay per day $390 copay per stay for days 1 through 7. You pay noth Out-of-network: ing per day for days 8 through 90 35% of the per stay Out-of-network: 45% of the Outpatient group therapy visit: per stay In-network: $10 copay Outpatient group therapy visit: In-network: $10 copay Out-of-network: 45% of the Outpatient individual therapy visit: Outpatient individual therapy visit: In-network: $25 copay In-network: $25 copay Out-of-network: 45% of the Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions a maximum of 2 one-hour sessions per day for up to 36 sessions up to per day for up to 36 sessions up to weeks): weeks): In-network: $10 copay In-network: $10 copay Out-of-network: 45% of the Occupational therapy visit: Occupational therapy visit: In-network: $35 copay In-network: $40 copay Out-of-network: 45% of the Physical therapy and speech and Physical therapy and speech and language therapy visit: language therapy visit: In-network: $35 copay In-network: $40 copay Out-of-network: 45% of the

9 Outpatient Substance Abuse 1 Group therapy visit: Group therapy visit: In-network: $10 copay In-network: $10 copay Out-of-network: 45% of the Individual therapy visit: Individual therapy visit: In-network: $25 copay In-network: $25 copay Out-of-network: 45% of the Outpatient Surgery 1 Ambulatory surgical center: Ambulatory surgical center: In-network: 20% of the In-network: 30% of the Out-of-network: 45% of the Outpatient hospital: Outpatient hospital: In-network: 30% of the In-network: 20% of the Out-of-network: 45% of the Over-the-Counter Items Not Covered Not Covered Prosthetic Devices (braces, Prosthetic devices: Prosthetic devices: artificial limbs, etc.) 1 In-network: 20% of the In-network: 20% of the Out-of-network: 45% of the Related medical supplies: Related medical supplies: In-network: 20% of the In-network: 20% of the Out-of-network: 45% of the Renal Dialysis 1 In-network: 20% of the In-network: 20% of the Out-of-network: 45% of the Transportation Not covered Not covered Urgent Care $35 copay $40 copay If you are admitted to the hospital If you are admitted to the hospital within 3 days, you do not have to within 3 days, you do not have to pay pay your share of the for urgent your share of the for urgent care. care. See the Inpatient Hospital See the Inpatient Hospital Care Care section of this booklet for section of this booklet for other s. other s.

10 Vision Services Exam to diagnose and treat diseases Exam to diagnose and treat diseases and conditions of the eye (including and conditions of the eye (including yearly glaucoma screening): yearly glaucoma screening): In-network: $0-35 copay, depending on the service Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing In-network: $0-40 copay, depending on the service Out-of-network: 45% of the Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing Out-of-network: 45% of the

11 Preventive Care In-network: You pay nothing. In-network: You pay nothing Out-of-network: 35% of the. Out-of-network: 45% of the Our plan covers many preventive Our plan covers many preventive services, including: services, including: Abdominal aortic aneurysm Abdominal aortic aneurysm screening screening Alcohol misuse counseling Alcohol misuse counseling Bone mass measurement Bone mass measurement Breast cancer screening (mammo Breast cancer screening (mammogram) gram) Cardiovascular disease (behavior Cardiovascular disease (behavioral al therapy) therapy) Cardiovascular screenings Cardiovascular screenings Cervical and vaginal cancer Cervical and vaginal cancer screenscreening ing Colonoscopy Colonoscopy Colorectal cancer screenings Colorectal cancer screenings Depression screening Depression screening Diabetes screenings Diabetes screenings Fecal occult blood test Fecal occult blood test Flexible sigmoidoscopy Flexible sigmoidoscopy HIV screening HIV screening Medical nutrition therapy Medical nutrition therapy services services Obesity screening and counseling Obesity screening and counseling Prostate cancer screenings (PSA) Prostate cancer screenings (PSA) Sexually transmitted infections Sexually transmitted infections screening and counseling screening and counseling Tobacco use cessation counseling Tobacco use cessation counseling (counseling for people with no (counseling for people with no sign of tobacco-related disease) sign of tobacco-related disease) Vaccines, including Flu shots, Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal Hepatitis B shots, Pneumococcal shots shots Welcome to Medicare preventive Welcome to Medicare preven visit (one-time) tive visit (one-time) Yearly Wellness visit Yearly Wellness visit Any additional preventive services Any additional preventive services approved by Medicare during the approved by Medicare during the contract year will be covered. contract year will be covered.

12 Hospice You pay nothing for hospice care You pay nothing for hospice care from a Medicare-certified hospice. from a Medicare-certified hospice. You may have to pay part of the You may have to pay part of the for drugs and respite care. for drugs and respite care. INPATIENT CARE Inpatient Hospital Care 1 Our plan covers an unlimited num Our plan covers an unlimited number ber of days for an inpatient hospital of days for an inpatient hospital stay. stay. In-network: In-network: $218 copay per day for days 1 $390 copay per stay through 7 You pay nothing per day for You pay nothing per day for days days 91 and beyond 8 through 90 Out-of-network: You pay nothing per day for days 35% of the per stay 91 and beyond Out-of-network: 45% of the per stay Inpatient Mental Health Care For inpatient mental health care, see For inpatient mental health care, see the Mental Health Care section of the Mental Health Care section of this booklet. this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a Our plan covers up to 100 days in a SNF. SNF. In-network: In-network: $0 copay per day for days 1 $0 copay per day for days 1 through 20 through 20 $156 copay per day for days $156 copay per day for days through 63 through 63 $0 copay per day for days 64 $0 copay per day for days 64 through 100 through 100 Out-of-network: Out-of-network: 35% of the per stay 45% of the per stay PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemother For Part B drugs such as chemotheraapy drugs 1 : py drugs 1 : In-network: 20% of the In-network: 20% of the Out-of-network: 45% of the Other Part B drugs 1 : Other Part B drugs 1 : In-network: 20% of the In-network: 20% of the Out-of-network: 45% of the

13 Initial Coverage You pay the following until your You pay the following until your total yearly drug s reach $2,960. total yearly drug s reach Total yearly drug s are the to- $2,960. tal drug s paid by both you and Total yearly drug s are the total our Part D plan. drug s paid by both you and You may get your drugs at net- our Part D plan. work retail pharmacies and mail You may get your drugs at network order pharmacies. retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Standard Retail Cost-Sharing One-month Tier One-month supply Tier supply Tier 1 (Preferred $3 copay Tier 1 (Preferred $6 Generic) Generic) copay Tier 2 (Non-Pre- $18 copay Tier 2 (Non-Pre- $20 ferred Generic) ferred Generic) copay Tier 3 (Preferred $39 copay Tier 3 (Preferred $39 Brand) Brand) copay Tier 4 (Non-Pre- $85 copay Tier 4 (Non-Pre- $85 ferred Brand) ferred Brand) copay Tier 5 (Specialty 33% of the Tier 5 Tier) 33% of the (Specialty Tier) Standard Mail Order Standard Mail Order Cost-Sharing Cost-Sharing Tier Three-month Three-month Tier supply supply Tier 1 (Preferred Tier 1 (Preferred $9 copay Generic) Generic) $18 copay Tier 2 (Non-Pre- Tier 2 (Non-Pre- $54 copay ferred Generic) ferred Generic) $60 copay Tier 3 (Preferred Tier 3 (Preferred $117 copay Brand) Brand) $117 copay Tier 4 (Non-Pre- Tier 4 (Non- $255 copay ferred Brand) Preferred Brand) $255 copay If you reside in a long-term care fa- cility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-net- work pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.

14 Coverage Gap Most Medicare drug plans have a Most Medicare drug plans have a coverage gap (also called the donut coverage gap (also called the dohole ). This means that there s a nut hole ). This means that there s a temporary change in what you will temporary change in what you will pay for your drugs. The coverage pay for your drugs. The coverage gap gap begins after the total yearly begins after the total yearly drug drug (including what our plan (including what our plan has paid and has paid and what you have paid) what you have paid) reaches $2,960. reaches $2,960. After you enter the coverage gap, After you enter the coverage gap, you pay 45% of the plan s for you pay 45% of the plan s covered brand name drugs and 65% for covered brand name drugs and of the plan s for covered generic 65% of the plan s for covered drugs until your s total $4,700, generic drugs until your s total which is the end of the coverage gap. $4,700, which is the end of the cov Not everyone will enter the coverage erage gap. Not everyone will enter gap. the coverage gap. Under this plan, you may pay even Under this plan, you may pay less for the brand and generic drugs even less for the brand and generic on the formulary. Your varies by drugs on the formulary. Your tier. You will need to use your forvaries by tier. You will need to use mulary to locate your drug s tier. See your formulary to locate your drug s the chart that follows to find out how tier. See the chart that follows to much it will you. find out how much it will you. Standard Retail Cost-Sharing Drugs Tier Covered Tier 1 (Preferred All Generic) Standard Mail Order Cost-Sharing Standard Retail Cost-Sharing Drugs Tier Covered Tier 1 (Preferred All Generic) Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Drugs Covered All Tier Tier 1 (Preferred Generic) Drugs Covered All

15 Catastrophic Coverage After your yearly out-of-pocket After your yearly out-of-pocket drug s (including drugs pur drug s (including drugs purchased through your retail pharma chased through your retail pharmacy and through mail order) reach cy and through mail order) reach $4,700, you pay the greater of: $4,700, you pay the greater of: 5% of the, or $2.65 copay for 5% of the, or $2.65 copay for generic (including brand drugs treat generic (including brand drugs treated as generic) and a $6.60 copay ed as generic) and a $6.60 copayment ment for all other drugs. for all other drugs. Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Benefits include: Benefits include: Geisinger Gold Health+ Eligible Supplemental Benefits Eligible Supplemental Benefits Preventive Dental Preventive Dental Eye Exams Eye Exams Eyewear Eyewear Hearing Exams Hearing Exams Hearing Aids Hearing Aids How much is the monthly Additional $ per month. Additional $ per month. premium? You must keep paying your Medi You must keep paying your Medicare Part B premium and the care Part B premium and your Geisinger Gold Preferred Geisinger Gold Preferred Advantage monthly plan Complete $0 monthly premium according to your county plan premium. of residence (See Chart). How much is the deductible? This package does not have a This package does not have a deductible. deductible. Is there a limit on how much the Our plan has a coverage limit for Our plan has a coverage limit for plan will pay? certain benefits. certain benefits.

16 2015 Monthly Premiums by County of Residence County Please locate your county in the list below for plan availability and monthly premium. Berks $75 $0 Carbon $75 $0 Cumberland $70 $0 Dauphin $70 $0 Lancaster $70 $0 Lebanon $70 $0 Lehigh $75 $0 Northampton $75 $0 Perry $70 $0 York $70 $0