PLAN CHOICES. What You Need to Know. Pennsylvania Service Areas. This is a summary of drug and health services for January 1, 2017 December 31, 2017
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1 PLAN CHOICES What You Need to Know This is a summary of drug and health services for January 1, 2017 December 31, 2017 The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limit or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. Pennsylvania Service Areas Bucks Delaware Philadelphia <Y0097_XXX Accepted> Y0097_840 Accepted 6
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3 PLAN CHOICES CONTINUED... How to Contact Gateway GATEWAY ( ) (TTY 711) How to Find a Provider or Pharmacy Hours of Operation From October 1 to February 14, From February 15 to September 30, you can call us 7 days a week from you can call us Monday through Friday 8:00 a.m. to 8:00 p.m. Eastern time. from 8:00 a.m. to 8:00 p.m. Eastern time. More About Original Medicare If you want to know more about the 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
4 Dual Eligible (D-SNP) Plans Highlights Medicare Assured Diamond SM (HMO SNP) Monthly Plan Premium $0 Doctor Office Visits $0 PCP Generic Prescriptions as low as $0 Additional Benefits SilverSneakers Dental Preventive, Comprehensive, Dentures Vision Eye Exam and Glasses/Contacts Hearing Exam and up to $750 for Hearing Aids Personal Emergency Response System Over-The-Counter Care $120 Allowance Every 3 Months with Quarterly Rollover Medicare Assured Ruby SM (HMO SNP) Monthly Plan Premium as low as $39.40 * Doctor Office Visits $0 PCP Generic Prescriptions as low as $0 Additional Benefits SilverSneakers Dental Preventive Vision Eye Exam and Glasses/Contacts Hearing Exam and up to $750 for Hearing Aids Over-The-Counter Care $60 Allowance Every 3 Months with Quarterly Rollover 9
5 Benefits Chart Benefit Gateway Health Medicare Assured Diamond SM (HMO SNP) Gateway Health Medicare Assured Ruby SM (HMO SNP) Premium $0 monthly plan premium $39.40* monthly plan premium Deductible $0 Deductible $0 Deductible Maximum Out-Of-Pocket Expense $3,400 out-of-pocket limit for Medicare-covered services Hospitalization $0 copay per day for days 1-90 $6,700 out-of-pocket limit for Medicare-covered services $0 or $275** copay per day for days 1-5; $0 copay per day for days 6-90 Doctor Visits $0 PCP / $0 Specialist copay $0 PCP / $0 or $35** Specialist copay Preventive Care $0 copay $0 copay Emergency Room $0 copay $0 or $75** copay Urgent Care $0 copay $0 or $45** copay Diagnostic Services/ Labs/Imaging $0 copay $0 copay Routine Hearing (Applies to both ears combined) $0 copay $0 copay Preventive Dental Eyeglasses or Contact Lenses $0 copay for each preventive dental visit. 1 oral exam every six months and 1 cleaning every six months 1 pair of contact lenses per year/ 1 pair of eyeglasses (lenses and frames) per year/ $100 maximum benefit amount every year. $0 copay for each preventive dental visit. 1 oral exam every six months and 1 cleaning every six months 1 pair of contact lenses per year/ 1 pair of eyeglasses (lenses and frames) per year/ $100 maximum benefit amount every year. Mental Health Services $0 copay $0 or $35** copay Skilled Nursing Facility $0 copay per day for days $0 copay per day for days 1-20; $0 or $164.50** copay per day for days Rehabilitation Services $0 copay $0 or $35** copay Ambulance $0 copay $0 or $200** copay Transportation to Plan Approved Locations for up to 36 one-way trips to plan-approved locations every year for up to 24 one-way trips to plan-approved locations every year Routine Podiatry $0 copay $0 or $35** copay Medical Equipment/Supplies $0 copay 0% or 20%** of the cost Fitness covered covered Part D Deductible: $0 Part D Deductible: $0 or $82* Prescriptions Initial Coverage (up to 30-day retail supply) Tier 1: $0.00, $1.20 or $3.30 copay All other Drugs: $0.00, $3.70 or $8.25 copay Tier 1: $0.00, $1.20 or $3.30 copay; or 15% of the cost All other Drugs: $0.00, $3.70 or $8.25 copay; or 15% of the cost *Could be waived based on LIS status **Depending on your level of Medicaid assistance 10
6 Medicare Advantage Prescription Drug Plan (MAPD) Highlights Medicare Assured Select SM (HMO SNP) Monthly Plan Premium $0 Doctor Office Visits $0 PCP Generic Prescriptions as low as $0 Additional Benefits SilverSneakers Dental Preventive and Dentures 11
7 Benefits Chart Benefit Premium Deductible Maximum Out-Of-Pocket Expense Hospitalization Doctor Visits Preventive Care Emergency Room Urgent Care Diagnostic Services/ Labs/Imaging Hearing Exam (Applies to both ears combined) Preventive Dental Eyeglasses or Contact Lenses Mental Health Services Skilled Nursing Facility Rehabilitation Services Ambulance Transportation to Plan Approved Locations Podiatry Medical Equipment/Supplies Fitness Prescriptions Initial Coverage (up to 30-day retail or mail-order supply) Gateway Health Medicare Assured Select SM (HMO SNP) $0 monthly plan premium $0 Deductible $6,700 $300 copay per day for days 1-6; $0 copay per day for days 7-90 $0 PCP / $50 Specialist copay $0 copay $75 copay $40 copay $0 copay $50 copay $0 copay for each preventive dental visit. 1 oral exam every six months and 1 cleaning every six months not covered $40 copay $0 copay per day for days 1-20; $ copay per day for days $40 copay $175 copay not covered $50 copay 20% of the cost covered Part D Deductible: $400 Tier 1: $0 Copay Tier 2: $15 Copay Tier 3: $47 Copay Tier 4: $100 Copay Tier 5: 25% of the cost 12
8 Gateway Health SM offers HMO plans with a Medicare Contract. Some Gateway Health plans have a contract with Medicaid in the states where they are offered. Enrollment in these plans 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 pay your Medicare Part B premium The State pays the Part B premium for full dual members. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Medicare Assured Select SM (HMO) plans have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network the plan may not pay for these services. You must be entitled to Medicare Part A, enrolled in Medicare Part B and live in the service area to enroll in this plan. Gateway Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
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