2019 Benefit Highlights
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- Bartholomew Harrington
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1 Los Angeles and Orange Counties 2019 Benefit Highlights VillageHealth (HMO-POS SNP) Medicare Advantage Plan
2 Plan Details Monthly Plan Premium $0 $34.80 $34.80 Annual Plan Deductible $0 deductible deductible Comprehensive Care Primary Care Office Visits $0 $0 20% Specialist Office Visits $0 0% 20% 0% 20% Outpatient Mental Health (individual/group) Diabetic Supplies (lancets, test strips, monitor) $0 $0 20% $0 $0 $0 Diabetic Self-Management Training $0 $0 $0 Lab Services $0 $0 $0 X-rays $0 $0 20% Diagnostic Radiology (e.g. MRI, CT) $0 $0 20% Dialysis Treatment $0 20% N/A Durable Medical Equipment $0 20% N/A Hospital and Emergency Care Inpatient Hospital Care $0 costs costs Skilled Nursing Facility $0 costs Outpatient Surgery $0 20% 20% N/A Emergency Care $0 (U.S. only) 20% (U.S. only) $0 (if admitted immediately) 20% (U.S. only) $0 (if admitted immediately) Urgent Care Services $0 (U.S. only) $0 (U.S. only) 20% (U.S. only) Ambulance Services $0 20% 20% Maximum Out-of-Pocket Annual Maximum Out-of-Pocket (MOOP) $6,700 $6,700 $6,700
3 Prescription Drug Coverage Pharmacy Network Preferred Standard Preferred Standard Part D Deductible $0 $0 $415 $415 Initial Coverage Stage - SCAN Contracted Retail Pharmacy (1-month/30-day supply) TIER 1: Preferred Generic $0 TIER 2: Generic TIER 3: Preferred Brand TIER 4: Non-Preferred Drug TIER 5: Specialty Tier $0 or $1.25 or $3.40 Generic drugs (including drugs treated like a generic): $0 or $1.25 or $3.40 All other drugs: $0 or $3.80 or $8.50 $0 $3 25% of the total drug cost Your copay/coinsurance may change when you enter another phase of the Part D benefit. If you qualify for Extra Help with your prescription drug costs, the Extra Help program will pay all or part of your monthly plan premium and your prescription drug deductibles and copay/coinsurance. VillageHealth is a Medicare Advantage HMO with a Point-of-Service (POS) option, which means you can use providers outside the plan s network. There are no referrals or prior authorizations needed for most covered services.
4 Additional Benefits and Services (In-Network only) (In-Network only) Access to a Personal VillageHealth Nurse Dental Services (routine) $0 $0 In addition to your preventive dental benefits, your plan covers services such as: crowns, dentures, fillings, etc. See the Delta Dental fee schedule. Dental exams $0 $0 Dental cleanings $0 (2 every 12 months) $0 (2 every 12 months) Dental X-rays $0 (1 every 6 months) $0 (1 every 6 months) Vision Services (routine) Eye exam $0 (1 per year) $0 (1 per year) Glasses or contact lenses $0 (every 2 years) $0 (every 2 years) Coverage for frames or contacts $240 (every 2 years) $240 (every 2 years) Transportation (routine) $0 $0 (up to 80 one-way trips per year) (up to 80 one-way trips per year) Podiatry Services (routine) $0 (6 visits per year) $0 (6 visits per year) Health Club Membership $0 $0 Home Delivered Meals $0 (criteria & limitations apply) $0 (criteria & limitations apply) 75-mile limit will apply to each one-way trip
5 VillageHealth (HMO-POS SNP) A Special Needs Plan for those diagnosed with End-Stage Renal Disease, including pre- and post-transplant patients. VillageHealth is designed to meet the specialized needs of people who have End-Stage Renal Disease or are post-transplant. VillageHealth offers benefits beyond Medicare coverage such as transportation, dental and vision coverage. As a VillageHealth member, you ll be assigned your own VillageHealth Nurse to work with you, your family and your doctors to coordinate and manage your healthcare needs.
6 Contact an authorized VillageHealth representative today Or visit: TTY users: a.m. to 8 p.m., Monday through Friday, Pacific Time 8 a.m. to 8 p.m., 7 days a week, Pacific Time (From October 1 through March 31) VillageHealth (HMO-POS SNP) is an HMO Plan and is a Point of Service (POS) plan with a Medicare contract. Enrollment in VillageHealth depends on contract renewal. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Call (TTY: 711) for more information. Calling the agent number will direct you to a licensed insurance agent. SCAN Health Plan complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 ( 聽障專線 :711) Y0057_SCAN_10870_2018F_M_ R559 08/18 19C-BHLVH2
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2018 Summary of Benefits
2018 Summary of Benefits January 1 December 31, 2018 Generations State of Oklahoma Group Retirees (HMO) GlobalHealth is an HMO plan with a Medicare contract. Enrollment in GlobalHealth depends on contract