OPERATIONS BULLETIN. Date: February 13, 2015 Geisinger Gold Participating Providers Re: Geisinger Gold 2015

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1 OPERATIONS BULLETIN Date: February 13, 2015 To: Geisinger Gold Participating Providers Re: Geisinger Gold 2015 Geisinger Gold 2015 Product Line Geisinger Gold serves more than 79,000 members in 40 counties throughout Pennsylvania. A physician-led organization focused on keeping members healthy and delivering the best value in health care coverage, Geisinger Gold currently contracts with more than 90 area hospitals, 29,000 providers, and 3,000 pharmacies. NCQA s Medicare Health Insurance Plan Rankings for named Geisinger Gold the #1 ranked Medicare Advantage plan in Pennsylvania and among the top 10 in the nation. Geisinger Health Plan is nationally recognized for its disease management programs. Our Geisinger Gold HMO and PPO plans carry a 4.5 and 4.0 CMS Star rating respectively. Plans for 2015 include: Classic Advantage (HMO) Classic Advantage Rx (HMO) Classic Complete Rx (HMO)* Preferred Advantage Rx (PPO)* Preferred Complete Rx (PPO)* Preferred Essential Rx (PPO)* Preferred Select Rx (PPO)* Secure Rx (HMO SNP) Reserve (MSA)* Medicare Part D Rx Drug Coverage All plans except Classic Advantage and Reserve are offered with Deductible prescription drug coverage. This benefit includes fixed, predictable copays in the initial coverage level and cost sharing up to the coverage gap. Members will receive coverage through the gap for tier 1 generic drugs at $3 or $6 copays, 55% discount on drugs and 35% discount on generic drugs (for all generics not covered on tier 1), as well as the Geisinger Gold contracted rates (discount from retail) on prescriptions while in the coverage gap. Supplemental Benefits Classic Advantage, Classic Advantage Rx, and Secure Rx plans feature built-in supplemental benefit coverage for the following: preventive dental routine vision exams eyewear hearing exams and hearing aids foot care 24 hour nurse line Fitness reimbursement (up to $90 allowance per quarter). *Geisinger Gold Health+ Optional supplemental benefits can be purchased for these plans through Geisinger Gold Health+. Geisinger Gold Health+ benefits include: Routine dental Routine vision (1 routine exam per year $20 copay; $100 hardware allowance per year) Routine hearing (1 routine exam per year $20 copay; $250 hearing aid & fitting allowance per year) Fitness Reimbursement (up to $90 allowance per quarter) Please note: The Geisinger Gold Health + package is indicated on the back of the member identification card with a dummy rider that ends in R. Members who don t elect the Health + package will have a dummy rider on the back of the card indicating an X. 1

2 Medicare Covered Preventive Services The following Medicare covered preventive services are available at no cost to Gold members (except Reserve; Reserve members must meet annual deductible first): Abdominal Aortic Aneurysm Screening Annual Wellness Visit Bone Mass Measurement Cancer Screenings Cardiovascular Disease Screening Cardiovascular Disease Behavioral Therapy Depression Screening Diabetes Screenings Diabetes Self-Management Training Glaucoma Screening HIV Screening Immunizations Medical Nutritional Therapy Welcome to Medicare Exam Screening & Counseling Alcohol Misuse Screening for Sexually Transmitted Infections Tobacco Use Cessation Counseling Obesity Screening & Counseling Sample ID Card: HPPNM17 Warehouse/Gold_PA_and_NJ_bulletins_091514/GOL D_2015_provider _bulletin_pa_1214_rev0215.doc Dev. 12/14 2

3 Plan Name Check table below to see where Geisinger Gold 2015 products are offered. Central Region Northeast Region South Region Southeast Region West Region Classic Advantage Yes Yes Yes Yes Yes Classic Advantage Rx Yes Yes Yes Yes Yes Classic Complete Rx Yes Yes Yes Yes Yes Secure Rx Yes Yes Yes Yes Yes Preferred Advantage Rx Not Available Not Available Yes Yes Not Available Preferred Complete Rx Not Available Not Available Yes Yes Not Available Preferred Select Rx Yes Yes Not Available Not Available Not Available Preferred Essential Rx* Not Available Not Available Not Available Yes Not Available *Preferred Essential Rx is available in Carbon, Lehigh and Northampton counties only. Reserve MSA is available in all PA counties (see page 14 of this bulletin). 3

4 Classic Advantage & Classic Complete Rx Classic Advantage Classic Complete Rx Deductible Out of Pocket Max $3,400 $6,700 PCP $5 $10 Physician Specialist $20 Inpatient Hospital - Acute $125/day (days 1-5) $190/day (days 1-7) /day (days 6-90) /day (days 8-90) Inpatient Psychiatric Hospital $125/day (days 1-5) $190/day (days 1-7) /day (days 6-90) /day (days 8-90) SNF (no prior hospital stay required) $40/day (days 1-20) $75/day (days 21-54) /day (days ) /day (days 1-20) $156/day (days 21-63) /day (days ) Cardiac/Pulmonary Rehab $10 per day $10 per day (72 day limit) (72 day limit) Emergency Care Urgent Care Worldwide Coverage $20 Waived if $25,000 worldwide Waived if $25,000 worldwide Home Health Services (includes related medical supplies) Chiropractic Services (Original Medicare Benefit) $20 $20 Podiatry (Original Medicare Benefits) $20 Podiatry - Routine Nail Trimming /4 per year /4 per year Occupational Therapy $10 Physical & Speech Therapy $10 per day per day Outpatient All Other Diagnostic Procedures/Tests $5 $5 Outpatient Lab $5 $5 Outpatient X-Rays $25 $30 Outpatient MRI, CT, PET Scans $100 20% Outpatient Radiation Therapy, Nuclear Medicine $25 20% Outpatient All Other Therapeutic Radiology $60 20% Ultrasound Diagnostic $25 20% Other Diagnostic/General Imaging $100 20% Outpatient Hospital/ASC Services 20% 20% Outpatient Mental Health $10 group/$25 individual $10 group/$25 individual Ambulance $100 $175 Part B Drugs 20% 20% Durable Medical Equipment (DME) 20% 20% Prosthetics and Related Supplies 20% 20% 4

5 Classic Advantage & Classic Complete Rx Classic Advantage Classic Complete Rx Diabetes Supplies - Preferred Brand Glucometer Preferred Brand Glucometer every Preferred Brand Glucometer every 0% preferred test strips; 0% lancets & lancet devices (any ); 20% test strips, lancets & nonpreferred Diabetes Supplies - All Other glucometer (prior 20% non-preferred test strips, lancets & glucometers (prior auth auth required for non-preferred required for non-preferred meters & strips meters & strips Diabetes - Therapeutic Shoes or Inserts 20% 20% Acupuncture & Other Alternative Therapies - Non-Medicare Covered Not Covered Not Covered Supplemental Preventive Health Svc Annual Routine Physical Exams $5 $10 Supp Education/Health Mgmt Progs Health Club $90/quarter Supp Education/Health Mgmt Progs Nursing Hotline Dental Services (Preventive): Oral Exam with or without cleaning $20; every 6 months Dental Services (Preventive): Dental X- $20 bitewing only; $30 panoramic & Rays all other types, limit 1 per year Comprehensive Dental (Original Medicare-Covered Benefit only) Comprehensive Dental (Non-Medicare Covered) Vision Exam (Medical): for glaucoma screen - office visit copay may apply $20 Vision Exam (Routine) $20; 1 per year Original Medicare-Covered Eyewear (Post-Cataract Surgery) Eyewear: Routine Eyewear, Non- Medicare Covered. Contact Lenses, Eyeglasses, Lenses and Frames Only Medicare-covered (Basic frames and lenses) $200 benefit max every Hearing Exams - Diagnostic Only $20 Only Medicare-covered (Basic frames and lenses) Routine Hearing Exams $20; 1 per year Hearing Aids/Fitting for Hearing Aids $800 Maximum Benefit; every 3 years (fitting/eval. falls under this limit) Part D Deductible Tier 1 Preferred Generics (30 day) $3 $6 Tier 2 Non-preferred Generics (30 day) $18 $20 Tier 3 Preferred Brand (30 day) $39 $39 Tier 4 Non-preferred Brand (30 day) $85 $85 Tier 5 Specialty (30 day) 33% 33% Gap Coverage - Tier 1 Generic $3 $6 5

6 Preferred Advantage Rx & Preferred Complete Rx Preferred Advantage Rx Preferred Complete Rx Deductible in-network out-of-network in-network out-of-network Out of Pocket Max $6,700 $10,000 $6,700 $10,000 PCP $10 35% $10 Physician Specialist 35% $40 Inpatient Hospital - Acute $390 per stay 35% $218/day (days 1-7) /day (days 8-90) Inpatient Psychiatric Hospital $390 per stay 35% $218/day (days 1-7) /day (days 8-90) /day (days 1-20) /day (days 1-20) SNF (no prior hospital stay $156/day (days 21-63) 35% $156/day (days 21-63) required) /day (days ) /day (days ) Cardiac/Pulmonary Rehab Emergency Care Urgent Care Worldwide Coverage Home Health Services (includes related medical supplies) Chiropractic Services (Original Medicare Benefit) Podiatry (Original Medicare Benefits) $10 per day (72 day limit) Waived if $25,000 worldwide 35% Waived if $25,000 worldwide $10 per day (72 day limit) $40 Waived if $25,000 worldwide 35% $20 35% $20 35% $40 Podiatry - Routine Nail Trimming /up to 4 visits /up to 4 visits 35% per year per year Occupational Therapy per day 35% $40 per day Physical & Speech Therapy per day 35% $40 per day Outpatient All Other Diagnostic $20 35% $25 Procedures/Tests Outpatient Lab $20 35% $25 Outpatient X-Rays $20 35% $25 Outpatient MRI, CT, PET Scans 20% 35% 30% Outpatient Radiation Therapy, Nuclear Medicine 20% 35% 20% Outpatient All Other Therapeutic Radiology 20% 35% 20% Ultrasound Diagnostic 20% 35% 20% Other Diagnostic/General Imaging 20% 35% 20% Outpatient Hospital Surgery/ASC 20% 35% 30% $40 Waived if $25,000 worldwide 6

7 Preferred Advantage Rx & Preferred Complete Rx Outpatient Mental Health Ambulance Preferred Advantage Rx Preferred Complete Rx in-network out-of-network in-network out-of-network $10 group/$25 $10 group/$25 35% individual individual $ $190 $190 Part B Drugs 20% 35% 20% Durable Medical Equipment (DME) 20% 35% 20% Prosthetics and Related Supplies 20% 35% 20% Preferred Preferred Brand Brand Preferred Brand Diabetes Supplies - Preferred Glucometer every Glucometer Glucometer every Brand Glucometer every Diabetes Supplies - All Other Diabetes - Therapeutic Shoes or Inserts Acupuncture & Other Alternative Therapies (Non- Medicare Covered) Supplemental Preventive Health Svc - Annual Routine Physical Exams Supp Education/Health Mgmt Progs - Health Club Supp Education/Health Mgmt Progs - Nursing Hotline Dental Services (Preventive): Oral Exam with or without cleaning Dental Services (Preventive): Dental X-Rays Comprehensive Dental (Original Medicare-Covered Benefit only) Vision Exam (Medical): for glaucoma screen - office visit copay may apply Vision Exam (Routine) 20% test strips, lancets & nonpreferred glucometer (prior auth required for nonpreferred meters & strips) 35% 20% test strips, lancets & nonpreferred glucometer (prior auth required for nonpreferred meters & strips) Preferred Brand Glucometer every 20% 35% 20% Not Covered Not Covered Not Covered Not Covered $10 35% $10 0% 0% 35% $40 35% $40 7

8 Preferred Advantage Rx & Preferred Complete Rx Preferred Advantage Rx Original Medicare-Covered Eyewear (Post-Cataract Surgery) Eyewear: Routine Eyewear, Non-Medicare Covered. Contact Lenses, Eyeglasses, Lenses and Frames Preferred Complete Rx in-network out-of-network in-network out-of-network Only Medicarecovered Only Medicare- 35% covered (Basic frames & (Basic frames & lenses) lenses) Hearing Exams - Diagnostic Only 35% $40 Routine Hearing Exams Hearing Aids/Fitting for Hearing Aids Part D Deductible Tier 1 Preferred Generics (30 day) $3 $6 Tier 2 Non-preferred Generics (30 day) $18 $20 Tier 3 Preferred Brand (30 day) $39 $39 Tier 4 Non-preferred Brand (30 day) $85 $85 Tier 5 Specialty (30 day) 33% 33% Gap Coverage - Tier 1 Generic $3 $6 8

9 Preferred Select Rx & Preferred Essential Rx Preferred Select Rx Preferred Essential Rx Deductible $1,000 $1,000 in-network out-of-network in-network out-of-network Out of Pocket Max $6,700 $10,000 $6,700 $10,000 PCP $10 $15 Physician Specialist Inpatient Hospital - Acute Deductible $218/day (days 1-7) 0 per stay /day (days 8-90) Inpatient Psychiatric Hospital Deductible $218/day (days 1-7) 0 per stay /day (days 8-90) Deductible Deductible SNF /day (days 1-20) /day (days 1-20) $156/day (days 21-57) $156/day (days 21-57) /day (days ) /day (days ) Cardiac/Pulmonary Rehab Emergency Care Urgent Care Worldwide Coverage Home Health Services (includes related medical supplies) Chiropractic Services (Original Medicare Benefit) Podiatry (Original Medicare Benefits) Podiatry - Routine Nail Trimming $10 per day (72 day limit) (Waive if Waived if $25,000 worldwide Deductible $20 Deductible /up to 4 visits per year Occupational Therapy Deductible Physical & Speech Therapy Deductible Outpatient All Other Diagnostic Procedures/Tests Deductible $20 Outpatient Lab Deductible $20 Outpatient X-Rays Deductible $20 (Waive if Waived if $25,000 worldwide $10 per day (72 day limit) $25 $ Waived if $25,000 worldwide Deductible $20 /up to 4 visits per year $25 $25 $45 $25 Waived if $25,000 worldwide Deductible 35%/ 4 per year 9

10 Preferred Select Rx & Preferred Essential Rx Preferred Select Rx Preferred Essential Rx in-network out-of-network in-network out-of-network Outpatient MRI, CT, PET Scans Deductible 20% Deductible 20% Outpatient Radiation Therapy, Deductible 20% Deductible 20% Nuclear Medicine Outpatient All Other Therapeutic Deductible 20% Deductible 20% Radiology Ultrasound Diagnostic Deductible 20% Deductible 20% Other Diagnostic/General Deductible 20% Deductible 20% Imaging Outpatient Hospital Surgery/ASC Deductible $295 Deductible 20% Outpatient Mental Health Deductible $10 group/$25 individual Ambulance Deductible $200 Part B Drugs 20% Durable Medical Equipment (DME) 20% Prosthetics and Related Supplies 20% Diabetes Supplies - Preferred Brand Glucometer Diabetes Supplies - All Other Diabetes - Therapeutic Shoes or Inserts Acupuncture & Other Alternative Therapies (Non- Medicare Covered) Supplemental Preventive Health Svc - Annual Routine Physical Exams Supp Education/Health Mgmt Progs - Health Club Preferred Brand Glucometer every 20% test strips, lancets & nonpreferred glucometer (prior auth required for nonpreferred meters & strips) 20% Deductible $200 Deductible Preferred Brand Glucometer every $10 group/$25 individual Deductible $150 20% 20% 20% Preferred Brand Glucometer every 20% test strips, lancets & nonpreferred glucometer (prior auth required for nonpreferred meters & strips) 20% Preferred Brand Glucometer every Not Covered Not Covered Not Covered Not Covered 20% $10 $20 10

11 Preferred Select Rx & Preferred Essential Rx Supp Education/Health Mgmt Progs - Nursing Hotline Dental Services (Preventive): Oral Exam with or without cleaning Dental Services (Preventive): Dental X-Rays Comprehensive Dental (Original Medicare-Covered Benefit only) Vision Exam (Medical): for glaucoma screen - office visit copay may apply Vision Exam (Routine) Original Medicare-Covered Eyewear (Post-Cataract Surgery) Eyewear: Routine Eyewear, Non-Medicare Covered. Contact Lenses, Eyeglasses, Lenses and Frames Preferred Select Rx Preferred Essential Rx in-network out-of-network in-network out-of-network 0% Deductible Deductible Deductible Hearing Exams - Diagnostic Only Deductible Only Medicarecovered (Basic frames & lenses) Routine Hearing Exams Hearing Aids/Fitting for Hearing Aids Part D Deductible Tier 1 Preferred Generics (30 day) $3 $6 Tier 2 Non-preferred Generics (30 day) $18 $20 Tier 3 Preferred Brand (30 day) $39 $39 Tier 4 Non-preferred Brand (30 day) $85 $85 Tier 5 Specialty (30 day) 33% 33% Gap Coverage - Tier 1 Generic $3 $6 Deductible 11

12 Secure Rx None to member Deductible Medicare FFS Part A deductible billed to Medicaid No deductible on Part B Out of Pocket Max $6,700 PCP copay for PCP not billed to Medicaid Physician Specialist 20% Medicare FFS billed to Medicaid for Specialist Inpatient Hospital - Acute Medicare FFS Part A deductible and Part A cost-sharing billed to Medicaid Inpatient Psychiatric Hospital Medicare FFS Part A deductible and Part A cost-sharing billed to Medicaid SNF Medicare FFS Part A deductible and Part A cost-sharing billed to Medicaid Cardiac/Pulmonary Rehab 20% Medicare FFS billed to Medicaid for Specialist Emergency Care copay billed to Medicaid Urgent Care Worldwide Coverage Home Health Services (includes related medical supplies) Chiropractic Services (Original Medicare Benefit) Podiatry (Original Medicare Benefits) Podiatry - Routine Nail Trimming Occupational Therapy Physical & Speech Therapy Outpatient All Other Diagnostic Procedures/ Tests Outpatient Lab Outpatient X-Rays Outpatient MRI, CT, PET Scans Outpatient Radiation Therapy, Nuclear Medicine Outpatient All Other Therapeutic Radiology Ultrasound Diagnostic Other Diagnostic/General Imaging 12

13 Secure Rx Outpatient Hospital/ASC Services Outpatient Mental Health Ambulance Part B Drugs Durable Medical Equipment (DME) Prosthetics and Related Supplies Diabetes Supplies - Preferred Brand Glucometer Diabetes Supplies - All Other Diabetes - Therapeutic Shoes or Inserts Acupuncture & Other Alternative Therapies - Non-Medicare Covered Supplemental Preventive Health Svc - Annual Routine Physical Exams Supp Education/Health Mgmt Progs Health Club Supp Education/Health Mgmt Progs - Nursing Hotline Dental Services (Preventive): Oral Exam with or without cleaning/x- Rays/Dentures Comprehensive Dental (Original Medicare-Covered Benefit only) Comprehensive Dental (Non-Medicare Covered) Vision Exam (Medical): for glaucoma screen - office visit copay may apply Vision Exam (Routine) Original Medicare-Covered Eyewear (Post-Cataract Surgery) Eyewear: Routine Eyewear, Non- Medicare Covered. Contact Lenses, Eyeglasses, Lenses and Frames Hearing Exams - Diagnostic Only Routine Hearing Exams Hearing Aids/Fitting for Hearing Aids Part D Over-the-Counter-Drugs Preferred Brand Glucometer every 20% strips, lancets & non-preferred meters (prior auth required on non-preferred strips & meters) Not Covered $90 per quarter every 6 months; maximum $2,000 per year combined for all non-medicare dental; incl. simple fillings & extractions; $400 denture allowance incl. in $2,000 max Not Covered ; 1 per year $200 maximum benefit every ; 1 per year $600 maximum benefit every 3 years Part D drugs covered with appropriate LIS cost-sharing & premium subsidies $50 allowance per quarter 13

14 Reserve MSA premium $1,020 deposit $3,600 deductible what member pays after deductible Reserve MSA is a Medicare Advantage Plan that combines a high-deductible health plan with a personal medical savings account. The plan deposits $1,020 from Medicare into the Member s MSA Plan savings account at the beginning of each year. The Reserve (MSA) Plan has an annual deductible of $3,600, but no monthly premium. Members can go to any doctor or hospital that accepts Medicare. No referrals are necessary. Providers should bill Geisinger Gold. Once the annual deductible is met, the plan pays for Medicare-covered medical expenses in full. (Please note: Medicare does not allow MSA plans to provide first-dollar coverage for any benefit. All covered benefits are subject to the $3,600 annual deductible.) Members may use funds from their MSA account to pay for any IRS qualified medical expense, but only expenses incurred for Medicare-covered services count toward the annual deductible. Any money remaining in the MSA bank account at the end of the year will roll over for use toward qualified medical expenses next year. This plan does not include prescription drug coverage. Members may join a separate Medicare Part D Prescription Drug plan from the carrier of their choosing for additional cost. 14