Benefit Highlights. CALIFORNIA Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Joaquin, Santa Clara 01/01/ /31/2016
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1 2016 Benefit Highlights CALIFORNIA Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Joaquin, Santa Clara 01/01/ /31/2016
2 TO ENROLL OR LEARN MORE: CALL (TTY ) 8 a.m. to 8 p.m., Monday-Friday. Ask to speak with a licensed insurance agent who can explain your options in detail and help you find the coverage that s right for you. Visit You can compare our plans offered in your area, request more information or enroll online.
3 THE VALUE OF EASY CHOICE If you re facing a decision about your Medicare coverage, it s important to understand your options. Easy Choice is dedicated to helping you get the most from all we offer. Our focus on serving people in government-sponsored healthcare programs allows us to design Medicare Advantage plans that deliver benefits like these: Limits on out-of-pocket expenses To help give you peace of mind, we offer maximum out-of-pocket (MOOP) limits on all plans. After you reach the yearly limit, you ll be 100 percent covered for in-network Medicare-covered services. This protects you from catastrophic medical bills. Dental, vision and hearing Many Easy Choice plans offer these important coverages. Prescription drug (Part D) coverage Many plans cover prescription medications with low or no co-pays for preferred generic drugs. Save more money by using one of our network pharmacies (retail and mail-service) that offers preferred cost-sharing. These are just some of the benefits you ll find in an Easy Choice Medicare Advantage plan. Plan benefits vary by region. If you re new to Medicare, let us help you get the healthcare you deserve. Call us today.
4 2016 BENEFIT HIGHLIGHTS Easy Choice Plus Plan (HMO) 002 Service Area Other Eligibility Requirements Must reside in Alameda, Orange, Riverside, San Bernardino, San Diego, San Joaquin, Santa Clara Must be entitled to Medicare Part A, and enrolled in Medicare Part B Maximum Out of Pocket $6,700 Plan Premium *Part D Monthly Premium may vary based on the level of Extra Help that you receive. $12.00 *For some people, this may be paid in part or in full by Medicaid or a third party. Primary Care Office Visits $0 Specialist Office Visits Lab Work $0 X-Rays $0 Complex Diagnostics (MRI, CT Scan) Diabetic Monitoring Supplies $0 Durable Medical Equipment Renal Dialysis Outpatient Mental Health (Individual Therapy Visit) Outpatient Mental Health (Group Therapy Visit) Outpatient Surgery (Hospital) Outpatient Surgery (Ambulatory Surgical Center) Inpatient Mental Health Inpatient Hospitalization Skilled Nursing Facility Days 1-3: $494/Days 4-90: $0 Days 1-3: $500/Days 4-90: $0 Days 1-20: $0/Days : $160 Home Health $0 Transportation to Plan-Approved Locations $0 (Up to 24 one-way trips per year) Annual Membership at 24 Hour Fitness $0 Urgent Care Annual Maximum for Worldwide Emergency Care Emergency Room Visit may be paid in part or in full by Medicaid or a third party.) 20% cost for Urgent Care is waived if admitted into the hospital within 24-hours. $25,000 per year may be paid in part or in full by Medicaid or a third party.) 20% cost for Emergency Room is waived if admitted into the hospital within 24-hours.
5 2016 BENEFIT HIGHLIGHTS (cont.) Easy Choice Plus Plan (HMO) 002 (cont.) Ambulance Services Routine Podiatry $0 (1 visit every 6 months) Routine Hearing Exam $0 Hearing Aids Allowance You receive $350 per year towards the cost of a hearing aid Routine Eye Exam $0 Eyewear Allowance Acupuncture Drugs Covered under Medicare Part B $100 per year $0 (Up to 6 visits per year) Part D Deductible $360 on tier 2 to 5; (If you receive Extra Help: $0 or $74 on tier 2 to 5) Part D Drug Initial Coverage Limit $3,310 Tier 1 Drugs Preferred Generic 30 Day Supply Tier 2 Drugs Non-Preferred Generic 30 Day Supply Tier 3 Drugs Preferred Brand 30 Day Supply Tier 4 Drugs Non-Preferred Brand 30 Day Supply Tier 5 Drugs Specialty 30 Day Supply If you receive Extra Help, you will pay Part D Drugs Covered in the GAP Part D Drug Catastrophic Coverage Over-the-Counter (OTC) Medication Allowance $0 $20 $47 $99 25% Generics: $0, $1.20, $2.95, or 15% Brand: $0, $3.60, $7.40, or 15% 58% for Generic and 45% for Brand drugs (If have low income subsidy, will pay low income subsidy level co-pays) After yearly out of pocket costs reach $4,850, pay the greater of 5% of the cost, or $2.95 for generic and $7.40 for all other drugs $7 per month Nurse Advice Line $0 Dental Services (Preventive & Comprehensive) $1,500 benefit max per year (Refer to Freedom/Plus Dental Fee Schedule)
6 2016 BENEFIT HIGHLIGHTS Easy Choice Plus Plan (HMO) 017 Service Area Other Eligibility Requirements *Part D Monthly Premium may vary based on the level of Extra Help that you receive. Must reside in Los Angeles, CA Must be entitled to Medicare Part A, and enrolled in Medicare Part B Maximum Out of Pocket $6,700 Plan Premium $12.00 *For some people, this may be paid in part or in full by Medicaid or a third party. Primary Care Office Visits $0 Specialist Office Visits $0 Lab Work $0 X-Rays $0 Complex Diagnostics (MRI, CT Scan) Diabetic Monitoring Supplies $0 Durable Medical Equipment Renal Dialysis Outpatient Mental Health (Individual Therapy Visit) $0 Outpatient Mental Health (Group Therapy Visit) $0 Outpatient Surgery (Hospital) Outpatient Surgery (Ambulatory Surgical Center) $0 Inpatient Mental Health Inpatient Hospitalization Skilled Nursing Facility Days 1-3: $300/Days 4-90: $0 Days 1-3: $300/Days 4-90: $0 Days 1-20: $0/Days : $160 Home Health $0 Transportation to Plan-Approved Locations $0 (Up to 48 one-way trips per year) Annual Membership at 24 Hour Fitness $0 Urgent Care Annual Maximum for Worldwide Emergency Care Emergency Room Visit may be paid in part or in full by Medicaid or a third party.) 20% cost for Urgent Care is waived if admitted into the hospital within 24-hours. $25,000 per year may be paid in part or in full by Medicaid or a third party.) 20% cost for Emergency Room is waived if admitted into the hospital within 24-hours.
7 2016 BENEFIT HIGHLIGHTS (cont.) Easy Choice Plus Plan (HMO) 017 (cont.) Ambulance Services Routine Podiatry $0 (1 visit every 6 months) Routine Hearing Exam $0 Hearing Aids Allowance You receive $350 per year towards the cost of a hearing aid Routine Eye Exam $0 Eyewear Allowance Acupuncture Drugs Covered under Medicare Part B $300 per year $0 (Up to 12 visits per year) Part D Deductible $360 on tier 2 to 5; (If you receive Extra Help: $0 or $74 on tier 2 to 5) Part D Drug Initial Coverage Limit $3,310 Tier 1 Drugs Preferred Generic 30 Day Supply Tier 2 Drugs Non-Preferred Generic 30 Day Supply Tier 3 Drugs Preferred Brand 30 Day Supply Tier 4 Drugs Non-Preferred Brand 30 Day Supply Tier 5 Drugs Specialty 30 Day Supply If you receive Extra Help, you will pay Part D Drugs Covered in the GAP Part D Drug Catastrophic Coverage Over-the-Counter (OTC) Medication Allowance $0 $20 $47 $99 25% Generics: $0, $1.20, $2.95, or 15% Brand: $0, $3.60, $7.40, or 15% 58% for Generic and 45% for Brand drugs (If have low income subsidy, will pay low income subsidy level co-pays) After yearly out of pocket costs reach $4,850, pay the greater of 5% of the cost, or $2.95 for generic and $7.40 for all other drugs $25 per month Nurse Advice Line $0 Dental Services (Preventive & Comprehensive) $1,500 benefit max per year (Refer to Freedom/Plus Dental Fee Schedule)
8 For More Information TTY a.m. 8 p.m., Monday Friday Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment in Easy Choice (HMO) depends on contract renewal. A more complete description of benefits is included in the Summary of Benefits document. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co-payments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Easy Choice uses a formulary. Individuals must have Part A and Part B to enroll in the plan. You must continue to pay your Medicare Part B premium. Please contact Easy Choice for details. H5087_CA031085_WCM_BOV_ENG CMS Accepted WellCare NA6V01BOV69736E_0915
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