2019 Allwell Medicare Premier (HMO) H9287: 001 Pima County, AZ

Transcription

1 2019 Allwell Medicare Premier (HMO) H9287: 001 Pima County, AZ H9287_19_7919SB_001_M_Accepted

2 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at allwell.azcompletehealth.com. You are eligible to enroll in Allwell Medicare Premier (HMO) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Allwell Medicare Premier (HMO) service area county). Our service area includes the following county in Arizona: Pima. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.) The Allwell Medicare Premier (HMO) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit allwell.azcompletehealth.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Medicare Premier (HMO) will be responsible for the costs.) This Allwell Medicare Premier (HMO) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2019 Benefits Allwell Medicare Premier (HMO) H Premiums / Copays / Coinsurance Monthly Plan Premium $0 You must continue to pay your Medicare Part B premium. Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage* Outpatient Hospital* Doctor Visits* Preventive Care (e.g. flu vaccine, diabetic screening) Emergency Care Urgently Needed Services Diagnostic Services/ Labs/Imaging* Hearing Services $0 deductible for medical services $0 deductible for Part D prescription drugs $3,400 annually This is the most you will pay in copays and coinsurance for medical services for the year. $210 copay per day, days 1 through 6 $0 copay per day, days 7 and beyond Outpatient Hospital (includes observation services):$200 copay per visit Ambulatory Surgical Center: $100 copay per visit Primary Care: $0 copay per visit Specialist: $30 copay per visit $0 copay Other preventive services are available. $120 copay per visit You do not have to pay the copay if admitted to the hospital immediately. $30 copay per visit Lab services: $0 - $25 copay Diagnostic tests and procedures: $0 copay X-ray services: $0 - $75 copay Hearing exam (Medicare-covered): $30 copay Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

4 Benefits Allwell Medicare Premier (HMO) H Premiums / Copays / Coinsurance Dental Services Dental services (Medicare-covered): $30 copay per visit Additional preventive and comprehensive dental benefits are available for an extra premium. See optional supplemental benefits section. Vision Services Vision exam (Medicare-covered): $0 copay per visit Routine eye exam: $0 copay Routine eyewear: up to $100 allowance for every calendar year Mental Health Services* Individual and group therapy: $30 copay per visit Skilled Nursing Facility* For each benefit period, you pay: $0 copay per day, days 1 through 20 $170 copay per day, days 21 through 100 Physical Therapy* Ambulance* Transportation Medicare Part B Drugs* $30 copay per visit $220 copay (per one-way trip) Not Covered Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

5 Deductible Phase Part D Prescription Drugs This plan does not have a Part D deductible. Initial Coverage Phase Preferred Retail (after you pay your Rx 30-day supply deductible, if applicable) Standard Retail Rx 30-day supply Tier 1: Preferred Generic $0 copay $5 copay $0 copay Mail-Order Rx 90-day supply Tier 2: Generic $7 copay $12 copay $18 copay Tier 3: Preferred Brand $37 copay $47 copay $101 copay Tier 4: Non-Preferred Drug $90 copay $100 copay $260 copay Tier 5: Specialty 33% coinsurance 33% coinsurance Not available Tier 6: Select Care Drugs $0 copay $0 copay $0 copay Important Info: Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail- Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at (TTY: 711).

6 Additional Covered Benefits Benefits Allwell Medicare Premier (HMO) H Premiums / Copays / Coinsurance Meals* $0 copay Plan covers home-delivered meals (up to 2 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility provided the meals are medically necessary and ordered by a physician or practitioner. Chiropractic Care* Medical Equipment/ Supplies* Foot Care* (Podiatry Services) Virtual Visit Wellness Programs Worldwide Emergency Care Routine Annual Exam Chiropractic services (Medicare-covered): $20 copay per visit Additional benefits are available for an extra premium. See optional supplemental benefits section. Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): $30 copay per visit Teladoc offers 24 hours a day/7days a week/365 days a year virtual visit access to board certified doctors to help address a wide variety of health concerns/questions. Fitness program: $0 copay 24-hour nurse advice line: $0 copay Supplemental smoking and tobacco use cessation (counseling to stop smoking or tobacco use): $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. $50,000 plan coverage limit for supplemental urgent/emergent services outside the U.S. and its territories every year. $0 Copay Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

7 Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Monthly Premium This additional monthly premium is in addition to your monthly plan premium and the monthly Medicare Part B premium. Gold Package 3 $45 per month Preventive/Comprehensive dental care You can see any licensed dentist to receive covered preventive and/or comprehensive services with minor restorative and non-surgical periodontics; however, you pay a little more to use providers who are out-of-network. Dental Care Benefits Annual deductible (applies to all dental services) Annual benefit maximum Preventive and diagnostic services: oral exams, cleanings (prophylaxis), fluoride treatment, dental x-rays, emergency exam Preventive & Comprehensive Dental PPO In-network Out-of-network $50 $100 $1,000 in- and out-of-network combined Covered at 100% You pay 20% General services: fillings, general anesthetics You pay 20% You pay 40% Major services: crowns, removable & fixed bridges, complete, & partial dentures, oral surgery, periodontics, endodontics Chiropractic and Acupuncture Services Chiropractic Acupuncture You pay 30% $15 copay per visit $15 copay per visit You pay 50% Annual visit limit - 24 visits per year (acupuncture and chiropractic visits combined)

8 Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Monthly Premium This additional monthly premium is in addition to your monthly plan premium and the monthly Medicare Part B premium. Gold Package 4 $21 per month Preventive/Comprehensive Dental Care You can see any licensed dentist to receive covered preventive and/or comprehensive services with minor restorative and non-surgical periodontics; however, you pay a little more to use providers who are out-of-network. Dental Care Benefits Annual deductible (deductible applies to all services) Annual benefit maximum Preventive services: oral exams, cleanings (prophylaxis), fluoride treatment, dental x-rays - 1 set of preventive x-rays (up to 4 bitewing x-rays) Preventive and Diagnostic Step-Up Dental PPO Services In-network Out-of-network $50 in- and out-of-network (applies to all dental services) $1,000 in-and out-of-network combined Covered at 100% You pay 20% General services: Fillings You pay 20% You pay 40% Major services: periodontal scaling & root planning, periodontal maintenance You pay 20% You pay 40%

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13 For more information, please contact: Allwell Medicare Premier (HMO) PO Box Van Nuys, CA allwell.azcompletehealth.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. 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 This information is not a complete description of benefits. Call (TTY: 711) for more information. Coinsurance is the percentage you pay of the total cost of certain medical services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. SBS020961EK00 (7/18)

14 2019 Part D Model LIS Premium Summary Table for Those Receiving Extra Help HEALTH NET COMMUNITY SOLUTIONS OF ARIZONA, INC./ Allwell Medicare Premier (HMO) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help. Your level of extra help Monthly Premium for Allwell Medicare Premier (HMO)* 100% $0 75% $0 50% $0 25% $0 *This does not include any Medicare Part B premium you may have to pay. Allwell Medicare Premier (HMO) s premium includes coverage for both medical services and prescription drug coverage. If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Member/Customer Services at , TTY: 711 from From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends and on federal holidays. Allwell Medicare Premier (HMO) is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell Medicare Premier (HMO) depends on contractrenewal.you must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. This information is not a complete description of benefits. Contact the plan for moreinformation. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. ALL_19_8963LTR_C_ H9287_001