Memorial Hermann Advantage PPO 2016 Summary of Benefits
|
|
- Erick Oswin Barton
- 5 years ago
- Views:
Transcription
1 Memorial Hermann Advantage PPO 2016 Summary of Benefits 16E1-APPO-SBC
2 Memorial Hermann Advantage PPO 2016 Summary of Benefits Standard and Supplemental plan benefits enclosed. January 1, December 31, 2016 H Y0110_PRE_PPO_SB_0815 CMS Accepted 9/16/15 16E1-APPO-SBC
3 THIS PAGE INTENTIONALLY LEFT BLANK.
4 SUMMARY OF BENEFITS January 1, December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." You have choices about how to get your Medicare benefits 1 One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. 1 Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Memorial Hermann Advantage (PPO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Memorial Hermann Advantage (PPO) covers and what you pay. 1 If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 1 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 Sections in this booklet 1 Things to Know About Memorial Hermann Advantage (PPO) 1 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services 1 Covered Medical and Hospital Benefits 1 Prescription Drug Benefits 1 Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (844) Este documento está disponible en otros formatos como Braille y en letra grande. Este documento puede estar disponible en un idioma diferente al inglés. Para información adicional, llámenos al (844) Things to Know About Memorial Hermann Advantage (PPO) Hours of Operation 1 From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m Central time. 1 From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Memorial Hermann Advantage (PPO) Phone Numbers and Website 1 If you are a member of this plan, call toll-free (844) If you are not a member of this plan, call toll-free (888) Page
5 SUMMARY OF BENEFITS 1 Our website: healthplan.memorialhermann.org/medicare Who can join? To join Memorial Hermann Advantage (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Texas: Fort Bend, Harris, and Montgomery. Which doctors, hospitals, and pharmacies can I use? Memorial Hermann Advantage (PPO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website (healthplan.memorialhermann.org/medicare). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. 1 Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. 1 Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. 1 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, healthplan.memorialhermann.org/medicare. 1 Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 4 Page
6 Summary of Benefits January 1, December 31, 2016 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? $0 per month. In addition, you must keep paying your Medicare Part B premium. $100 per year for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: 1 $6,700 for services you receive from in-network providers. 1 $7,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. Memorial Hermann Advantage PPO is a health plan with a Medicare contract. Enrollment in Memorial Hermann Advantage PPO depends on contract renewal. Memorial Hermann Health Solutions, Inc. is the parent company of Memorial Hermann Health Insurance Company and Memorial Hermann Health Plan, Inc., both of which are Medicare Advantage organizations. 5 Page
7 Covered Medical and Hospital Benefits Note: 1 Services with a 1 may require prior authorization. 1 Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture Not covered Ambulance 1 Chiropractic Care Dental Services 1 Diabetes Supplies and Services 1 In-network: $250 copay 1 Out-of-network: $250 copay Non-emergent transportation prior authorization required. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 1 In-network: $20 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 1 In-network: $75 copay In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Certain limitations or conditions may apply 6 Page
8 Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) 1 Diagnostic radiology services (such as MRIs, CT scans): 1 In-network: $300 copay Diagnostic tests and procedures: Lab services: Outpatient x-rays: 1 In-network: $15 copay Therapeutic radiology services (such as radiation treatment for cancer): 1 In-network: $35 copay Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 1 Primary care physician visit: Specialist visit: 1 In-network: $40 copay Cost share may apply for Part B injectable. 1 In-network: 20% of the cost $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 1 In-network: $40 copay Limitations may apply 7 Page
9 Hearing Services Exam to diagnose and treat hearing and balance issues: 1 In-network: $40 copay Routine hearing exam: 1 In-network: $0 copay Hearing aid: 1 In-network: $0 copay 1 Out-of-network: $0 copay Our plan pays up to $500 every two years for hearing aids from an in-network provider and an additional $500 every two years from an out-of-network provider. Home Health Care 1 Mental Health Care 1 Inpatient visit: The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $250 copay per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 40% of the cost per stay Outpatient group therapy visit: 1 In-network: $40 copay Outpatient individual therapy visit: 1 In-network: $40 copay 8 Page
10 Outpatient Rehabilitation 1 Outpatient Substance Abuse Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: 1 In-network: $35 copay Physical therapy and speech and language therapy visit: 1 In-network: $35 copay Other limitations may apply. Group therapy visit: 1 In-network: $40 copay Individual therapy visit: 1 In-network: $40 copay Ambulatory surgical center: 1 In-network: $225 copay Outpatient hospital: 1 In-network: $225 copay Not Covered Prosthetic devices: 1 In-network: 20% of the cost Related medical supplies: 1 In-network: 20% of the cost 1 In-network: $30 copay 1 Out-of-network: 20% of the cost 9 Page
11 Transportation Urgently Needed Services Vision Services Not covered $40 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 1 In-network: $40 copay Routine eye exam: 1 In-network: $0-40 copay, depending on the service Contact lenses: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglasses (frames and lenses): 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglass frames: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglass lenses: 1 In-network: $0 copay 1 Out-of-network: $100 copay Eyeglasses or contact lenses after cataract surgery: 1 In-network: $0 copay Our plan pays up to $100 every two years for eyewear from an in-network provider and an additional $100 every two years from an out-of-network provider. 10 Page
12 Preventive Care Hospice Our plan covers many preventive services, including: 1 Abdominal aortic aneurysm screening 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy services 1 Obesity screening and counseling 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections screening and counseling 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive visit (one-time) 1 Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 11 Page
13 Inpatient Care Inpatient Hospital Care 1 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of days for an inpatient hospital stay. 1 In-network: 4 $250 copay per day for days 1 through 5 4 You pay nothing per day for days 6 through 90 4 You pay nothing per day for days 91 and beyond 1 Out-of-network: 4 40% of the cost per stay Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. 1 In-network: 4 You pay nothing per day for days 1 through 20 4 $150 copay per day for days 21 through 100 Prescription Drug Benefits How much do I pay? 1 Out-of-network: 4 40% of the cost per stay For Part B drugs such as chemotherapy drugs: 1 In-network: 20% of the cost Other Part B drugs: 1 In-network: 20% of the cost 12 Page
14 Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $3,310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) One-month supplytwo-month supply $0 $5 copay $47 copay $95 copay 30% of the cost $0 $10 copay $94 copay $190 copay 30% of the cost Three-month supply $0 $12.50 copay $ copay $ copay 30% of the cost Standard Mail Order Cost-Sharing Tier Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) Three-month supply $0 $10 copay $94 copay $190 copay 30% of the cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. 13 Page
15 Coverage Gap Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,310. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4,850, which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier Drugs Covered Tier 1 (Preferred Generic) All Tier 2 (Generic) All One-month supply $0 $5 copay Two-month supply $0 $10 copay Three-month supply $0 $12.50 copay Standard Mail Order Cost-Sharing Tier Drugs Covered Tier 1 (Preferred Generic) All Tier 2 (Generic) All Three-month supply $0 $10 copay Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay the greater of: 1 5% of the cost, or 1 $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs. Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Memorial Hermann Advantage Pack Benefits include: 1 Worldwide Emergency/Urgent Coverage 1 Chiropractic Services 1 Preventive Dental 1 Comprehensive Dental 1 Eyewear 1 Hearing Aids How much is the monthly premium? Additional $49.00 per month. You must keep paying your Medicare Part B premium and your $0 monthly plan premium. 14 Page
16 How much is the deductible? Is there a limit on how much the plan will pay? This package does not have a deductible. Our plan pays up to $2,225 every year. Our plan has additional coverage limits for certain benefits. ADDITIONAL INFORMATION ABOUT MEMORIAL HERMANN ADVANTAGE (PPO) Includes 24/7 Nursing Hotline, Fitness Program and Readmission Prevention Care. Nurse Line 1 24/7 Nurseline: 1 Our plan offers Nurse triage 24 hours, 7 days a week Fitness Center Membership 1 You may choose to purchase additional buy-up services. Contact your exercise center 1 The Silver&Fit Home Fitness program if you cannot get to a fitness facility or prefer to work out at home 1 Healthy Aging classes (online or DVD) 1 The Silver Slate newsletter 4 times a year 1 The Silver&Fit website 1 A toll-free telephone hotline to answer questions about the program Available contracted fitness club location must be utilized throughout service area. Specific class offerings will vary by location. Readmission Prevention Our plan offers a Home Health Aide service available to all members transitioning from an acute, skilled, or other inpatient setting to home. The goals are to safely transition to a home setting and to prevent readmission. These services are not duplicate to Medicare-covered benefits as no skilled need exists. Services will be initiated immediately (e.g. within 1 week) of a member's discharge and provided on a limited and specified period of time not to exceed 4 weeks per authorized period. Readmission Prevention Care is provided to members upon discharge from a facility or SNF. $10.00 copay per visit (in-a-home setting) with a maximum benefit of $ per year. (Services can not exceed 4 weeks per authorization period) 15 Page
17 healthplan.memorialhermann.org/medicare Copyright 2015 Memorial Hermann. All rights reserved.
Memorial Hermann Advantage (PPO)
Memorial Hermann Advantage (PPO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
More informationMemorial Hermann Advantage (HMO)
Memorial Hermann Advantage (HMO) INTRODUCTION TO SUMMARY OF BENEFITS January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
More informationFRESENIUS TOTAL HEALTH (HMO SNP)
Summary of Benefits FRESENIUS TOTAL HEALTH (HMO SNP) (a Medicare Advantage Health Maintenance Organization (HMO) offered by FRESENIUS HEALTH PLANS OF NORTH CAROLINA, INC. with a Medicare contract) Available
More informationAnother choice is to get your Medicare benefits by joining a Medicare health plan (such as Senior Care Plus: Value Rx Plan (HMO)).
Summary of Benefits Report SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare
More informationSummary of BenefitS. Cigna-HealthSpring Preferred (Hmo) H Cigna H0354_15_19948 Accepted
Summary of BenefitS Coverage Cigna-HealthSpring Preferred (Hmo) H0354-001 2014 Cigna H0354_15_19948 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get your medicare
More informationAnother choice is to get your Medicare benefits by joining a Medicare health plan (such as Senior Care Plus: Freedom Rx Select Plan (PPO)).
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
More informationSCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits. Y0057_SCAN_9240_2015F File & Use Accepted
SCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits Y0057_SCAN_9240_2015F File & Use Accepted SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Healthy Heart (HMO) Los Angeles and Orange counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0179 CMS Accepted 09082015
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Kern (partial) County January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Contra Costa County (partial) January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every
More information2016 Summary of Benefits. Classic Rx (HMO)
2016 Summary of s Classic Rx (HMO) Summary Of s January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list
More informationbenefits Summary of BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida
2016 Summary of benefits BlueMedicare SM Regional PPO A Medicare Advantage Regional PPO Plan State of Florida Florida Blue is a trade name of Blue Cross and Blue Shield of Florida Inc., an Independent
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Gold Select (HMO) Riverside and San Bernardino counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0182 CMS Accepted 09092015
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Ruby Select (HMO) San Francisco County, CA Benefits effective January 1, 2015 H0562 Health Net of California, Inc. Material ID # H0562_2015_0280 CMS Accepted 09032014
More information2016 Summary of Benefits. Preferred Rx (PPO)
2016 Summary of s Preferred Rx (PPO) January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list every limitation
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Los Angeles County (partial) & Orange County January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn
More informationSummary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT
Summary of Benefits for Available in Hartford county, CT Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal.
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Ruby Select (HMO) Placer (partial county) and Sacramento counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0183 CMS Accepted
More informationSummary of Benefits. for Anthem MediBlue Select (HMO) Available in Hartford county, CT
Summary of Benefits for Available in Hartford county, CT Anthem Blue Cross and Blue Shield is an HMO plan with a Medicare contract. Enrollment in Anthem Blue Cross and Blue Shield depends on contract renewal.
More informationSummary of Benefits. for CareMore Touch (HMO SNP) Available in Los Angeles and Orange Counties (partial)
Summary of Benefits for CareMore Touch (HMO SNP) Available in Los Angeles and Orange Counties (partial) SBLAOCTCH15 Y0017_15_081476A CHP CMS Accepted (09082014) Section I: Introduction to Summary of Benefits
More informationBENEFITS 2015 EmblemHealth Essential (HMO), EmblemHealth VIP (HMO) and EmblemHealth VIP High Option (HMO). Nassau January 1, December 31, 2015
SUMMARY OF S 2015 EmblemHealth Essential (HMO), EmblemHealth and EmblemHealth VIP High Option (HMO). Nassau January 1, 2015 - December 31, 2015 H3330_124613 Accepted 09/09/2014 SECTION I - INTRODUCTION
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Los Angeles County (partial) & Orange County January 1, 2015 to December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn
More information2016 Forever Blue Medicare PPO
2016 Forever Blue Medicare PPO H5526 Summary of Benefits FOREVER BLUE MEDICARE PPO VALUE (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare
More informationSummary of BenefitS. Cigna-HealthSpring Preferred (Hmo) H Cigna H0150_15_19876 Accepted
Summary of BenefitS Coverage Cigna-HealthSpring Preferred (Hmo) H0150-024 - 2 2014 Cigna H0150_15_19876 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get your medicare
More informationSummary of Benefits. for CareMore ESRD (HMO SNP) Available in San Bernardino County (partial) SBSBESRD16 Y0114_16_081547A CHP CMS Accepted ( )
Summary of Benefits for CareMore ESRD (HMO SNP) Available in San Bernardino County (partial) SBSBESRD16 Y0114_16_081547A CHP CMS Accepted (08222015) Summary of Benefits January 1, 2016 - December 31, 2016
More informationSummary of Benefits. Section I - Introduction to Summary of Benefits
summary of benefits 2015, and. Bronx, Kings, New York, Queens and Richmond January 1, 2015 - December 31, 2015 H3330_124612 Accepted 9/8/14 Section I - Introduction to Summary of s You have choices about
More informationHNE Medicare Value (HMO)
2016 Medicare Advantage Summary of Benefits January 1, 2016 - December 31, 2016 H8578_2016_453 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have
More information2016 Senior Blue HMO H3384. Summary of Benefits
2016 Senior Blue HMO H3384 Summary of Benefits BLUECROSS BLUESHIELD SENIOR BLUE HMO 601 (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare
More informationSummary of Benefits Community Advantage (HMO)
Summary of Benefits Community Advantage (HMO) January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Seniority Plus Sapphire (HMO) Kern, Los Angeles, Orange, Riverside, San Bernardino and San Diego counties, CA Benefits effective January 1, 2015 H0562 Health Net of
More informationCentral Health Medicare Plan (HMO)
Central Health Medicare Plan (HMO) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how
More informationFIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct HMO Plus (HMO)
FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct HMO Plus (HMO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties P age 1 SECTION I - INTRODUCTION TO SUMMARY
More information2015 Summary of Benefits
2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how
More informationSummary of Benefits. BlueMedicare SM HMO A Medicare Advantage HMO Plan. Miami-Dade County. Y0011_ CMS Accepted
2015 Summary of Benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Miami-Dade County Y0011_32459 0814 CMS Accepted (HMO) Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives
More informationSummary of Benefits Boone County
Summary of Benefits 2017 Boone County Y0027_16-093_EN CMS Accepted 08/30/2016 Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It
More informationSummary of Benefits. for Anthem Senior Advantage Basic (HMO)
Summary of Benefits for Anthem Senior Advantage Basic (HMO) Available in Ashland, Clermont, Cuyahoga, Darke, Fairfield, Franklin, Fulton, Geauga, Lake, Licking, Lorain, Madison, Medina, Ottawa, and Warren
More informationBlueCHiP for Medicare Group Preferred (HMO-POS) Summary of Benefits. January 1, December 31, 2015
BlueCHiP for Medicare Group Preferred Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
More information2015 BlueCHiP for Medicare Group Preferred Unlimited 2 (HMO-POS) Summary of Benefits. January 1, December 31, 2015
2015 BlueCHiP for Medicare Group Preferred Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that
More informationBlue Shield 65 Plus Choice Plan (HMO) Blue Shield 65 Plus (HMO) summary of benefits
summary of benefits Los Angeles (partial) & Orange Counties January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we
More informationBooklet Contents. Senior Blue (HMO) (H3384) Summary of Benefits. Forever Blue Medicare (PPO) (H5526) Summary of Benefits
MEDICARE ADVANTAGE 2017 Booklet Contents Senior Blue (HMO) (H3384) Summary of Benefits Forever Blue Medicare (PPO) (H5526) Summary of Benefits Optional Supplemental Dental Benefits Summary of Benefits
More informationbenefits Summary of BlueMedicare SM HMO A Medicare Advantage HMO Plan Broward County
2016 Summary of benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Broward County Florida Blue HMO is the trade name of Health Options, an HMO affiliate of Florida Blue. These companies are Independent
More informationBlue Shield 65 Plus (HMO) summary of benefits
summary of benefits San Bernardino (partial) & Riverside (partial) Counties January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every
More informationSummary of Benefits. Prime (HMO-POS), Value Plus (HMO), and Value (HMO) January 1, 2016 December 31, 2016 G ENERATIONS A DVANTAGE
Summary of s Prime (HMO-POS), Value Plus (HMO), and Value (HMO) January 1, 2016 December 31, 2016 G ENERATIONS A DVANTAGE For more information about benefits or enrollment, call us or visit our website
More informationSUMMARY OF BENEFITS. Cigna-HealthSpring Achieve (HMO SNP) H January 1, December 31, Cigna H2108_16_32734 Accepted
SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Achieve (HMO SNP) H2108-030 2015 Cigna H2108_16_32734 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives
More informationExplorer Rx 7 (PPO) Summary of Benefits
Explorer Rx 7 (PPO) Summary of Benefits Coos and Curry Counties, Oregon January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service
More informationCDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO)
Introduction to the Summary of Benefits Report for CDPHP BASIC RX (HMO) CDPHP VALUE RX (HMO) CDPHP CHOICE (HMO) CDPHP CHOICE RX (HMO) January 1, 2015 December 31, 2015 CAPITAL REGION OF NEW YORK STATE
More informationbenefits Summary of BlueMedicare SM HMO A Medicare Advantage HMO Plan Palm Beach County
2016 Summary of benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Palm Beach County Florida Blue HMO is the trade name of Health Options, an HMO affiliate of Florida Blue. These companies are
More informationSummary of Benefits January 1, 2015 December 31, 2015
BLUECROSS BLUESHIELD SENIOR BLUE 601, BLUECROSS BLUESHIELD SENIOR BLUE HMO SELECT AND BLUECROSS BLUESHIELD SENIOR BLUE HMO 651 PARTD (a Medicare Advantage Health Maintenance Organization offered by HEALTHNOW
More informationMyCare Rx 23 (HMO) Summary of Benefits
MyCare Rx 23 (HMO) Summary of Benefits Southwestern Idaho January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Group Medicare Advantage-Prescription Drug Plan for CalPERS retirees January 1, 2015 to December 31, 2015 Blue Shield of California is a HMO plan with a Medicare
More informationSummary of Benefits. Y0027_16-092_EN CMS Accepted 08/30/2016
Summary of Benefits 2017 Y0027_16-092_EN CMS Accepted 08/30/2016 Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t list
More informationSummary of Benefits: Essentials Rx 26 (HMO) Coos County Curry County Lane County
Summary of Benefits: Essentials Rx 26 (HMO) Coos County Curry County Lane County January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare Essentials
More informationSummary of Benefits for CareMore Value Plus (HMO) and CareMore StartSmart Plus (HMO)
Summary of Benefits for and CareMore StartSmart Plus (HMO) Available in Clark County (partial) SBCLARKCVPSS15 Y0017_15_081489A CHP CMS Accepted (09082014) Section I: Introduction to Summary of Benefits
More informationSummary of Benefits: MyCare Rx 29 (HMO) Yellowstone County
Summary of Benefits: MyCare Rx 29 (HMO) Yellowstone County January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare MyCare Rx 29 (HMO). The benefit
More informationGuide PPO Rx (PPO) Summary of Benefits
Guide PPO Rx (PPO) Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-877-933-8454 8 a.m. to 8 p.m. daily October 1 to February 15 and 8 a.m. to 8 p.m. weekdays the rest of the year.
More informationYou have choices about how to get your Medicare benefits
SECTION 1 Introduction to the Summary of Soundpath Health Charter + Rx (HMO), Soundpath Health Sound + Rx (HMO), Soundpath Health Peak + Rx (HMO) Summary of January 1, 2016 - December 31, 2016 This booklet
More informationSummary of Benefits. for CareMore Breathe (HMO SNP), CareMore Heart (HMO SNP) and CareMore Diabetes (HMO SNP) Available in Stanislaus County
Summary of Benefits for, CareMore Heart (HMO and Available in Stanislaus County SBSTANBRTHRTDBT15 Y0017_15_081488A CHP CMS Accepted (09082014) Section I: Introduction to Summary of Benefits You have choices
More informationSummary of Benefits. CareMore Care Access (HMO) - Medicare Only. Available in Pima County. SB_CM_AZ_CA Y0114_18_32747_U_028 CMS Accepted ( )
Summary of Benefits Available in Pima County SB_CM_AZ_CA Y0114_18_32747_U_028 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered by from January 1, 2018 - December
More informationHMO Summary of Benefits Memorial Hermann Advantage HMO H
2017 HMO Summary of Benefits HMO H7115-001 This Summary of Benefits document provides an outline of health and drug services covered by HMO plan January 1, 2017 December 31, 2017. HMO is provided by Memorial
More informationSummary of Benefits: MyCare Rx 32 (HMO) Southwestern Idaho
Summary of Benefits: MyCare Rx 32 (HMO) Southwestern Idaho January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare MyCare Rx 32 (HMO). The benefit
More informationMAPD HMO Summary of Benefits
MAPD HMO Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-877-795-6131 8 a.m. to 8 p.m. daily TTY/TDD 711 HealthAllianceRetiree.org/SOI ste-statemedsob-0914 SECTION I INTRODUCTION
More informationPPO Summary of Benefits Memorial Hermann Advantage PPO H
2017 Summary of Benefits H2968-001 This Summary of Benefits document provides an outline of health and drug services covered by plan January 1, 2017 December 31, 2017. is provided by Memorial Hermann Health
More information2016 SUMMARY OF BENEFITS
2016 SUMMARY OF BENEFITS Clover Health Classic (PPO) (Atlantic, Bergen, Essex, Mercer, Monmouth, Passaic, Somerset, and Union Counties) Clover Health is a Preferred Provider Organization (PPO) plan with
More informationExplorer 6 (PPO) Summary of Benefits
Explorer 6 (PPO) Summary of Benefits Southwestern Idaho January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover
More informationSummary of Benefits: Explorer Rx 11 (PPO) Northern Idaho
Summary of Benefits: Explorer Rx 11 (PPO) Northern Idaho January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare Explorer Rx 11 (PPO). The benefit
More information2018 Summary of Benefits Advantage Silver NY, Plan 019. H2m _ QHPNY0984 Accepted
2018 Summary of Benefits Advantage Silver NY, Plan 019 H2m _ QHPNY0984 Accepted IMPORTANT INFORMATION Proposed Effective Date Your Primary Care Provider (PCP) Name Address Phone Number Important Numbers:
More informationEssentials Choice Rx 24 (HMO-POS) Summary of Benefits
Essentials Choice Rx 24 (HMO-POS) Summary of Benefits Southwestern Idaho January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service
More informationSummary of Benefits: Explorer Rx 9 (PPO) Eastern Idaho
Summary of Benefits: Explorer Rx 9 (PPO) Eastern Idaho January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare Explorer Rx 9 (PPO). The benefit
More informationSummary of Benefits. for CareMore Breathe (HMO SNP), CareMore Heart (HMO SNP) and CareMore Reliance (HMO SNP)
Summary of Benefits for CareMore Breathe (HMO, CareMore Heart (HMO and Available in Los Angeles and Orange Counties (partial) SBLAOCBRTHRTREL15 Y0017_15_081478A CHP CMS Accepted (09082014) Section I: Introduction
More informationSummary of Benefits. CareMore Care to You (HMO SNP) Available in Pima County. SB_CM_AZ_CTY Y0114_18_32747_U_023 CMS Accepted ( )
Summary of Benefits Available in Pima County SB_CM_AZ_CTY Y0114_18_32747_U_023 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered by from January 1, 2018 - December
More informationSummary Of Benefits. Optima Medicare. January 1, December 31, Optima Medicare Basic HMO Optima Medicare Enhanced HMO
Summary Of Benefits January 1, 2015 - December 31, 2015 Optima Medicare Optima Medicare Basic HMO Optima Medicare Enhanced HMO www.optimahealth.com/medicare Table of Contents 4 Letter from Michael Dudley,
More information2017 SUMMARY OF BENEFITS MEDICARE ADVANTAGE PLANS
2017 SUMMARY OF BENEFITS MEDICARE ADVANTAGE PLANS Florida Hernando, Hillsborough, Miami-Dade, Pasco, Pinellas H1032 January 1, 2017 - December 31, 2017 WellCare Essential (HMO-POS) Plan 174 H1032_FL034473_WCM_SOB_ENG
More informationSummary of Benefits: Explorer 6 (PPO) Southwestern Idaho
Summary of Benefits: Explorer 6 (PPO) Southwestern Idaho January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by PacificSource Medicare Explorer 6 (PPO). The benefit
More informationGuide HMO Rx (HMO) / Guide HMO Plus Rx (HMO) Summary of Benefits
Guide HMO Rx (HMO) / Guide HMO Plus Rx (HMO) Summary of Benefits January 1, 2016 December 31, 2016 The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice
More information2016 Summary of Benefits. Preferred Advantage Rx (PPO) Preferred Complete Rx (PPO)
2016 Summary Of Benefits January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover, or list every limitation or
More information2016 Summary of Benefits
Freedom Blue PPO 2016 Summary of Benefits Western Pennsylvania H3916_15_0266 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what
More informationSummary of Benefits: Essentials Choice Rx 14 (HMO-POS) Central Oregon, Eastern Oregon, and Mid-Columbia Gorge
Summary of Benefits: Essentials Choice Rx 14 (HMO-POS) Central Oregon, Eastern Oregon, and Mid-Columbia Gorge January 1, 2018 December 31, 2018 This is a summary of drug and health services covered by
More information2016 Summary of Benefits
Freedom Blue PPO 2016 Summary of Benefits West Virginia H5106_15_0269 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 This booklet gives you a summary of what we cover and what you pay.
More informationSummary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES INTRODUCTION TO THE SUMMARY OF BENEFITS FOR
INTRODUCTION TO THE SUMMARY OF S FOR January 1, 2016 - December 31, 2016 Blount, Jefferson, Shelby, St. Clair, Talladega, and Walker Counties SECTION I INTRODUCTION TO THE SUMMARY OF S This booklet gives
More informationYou have choices about how to get your Medicare benefits
Summary of Benefits: MyCare Rx 28 (HMO) MyCare Rx 31 (HMO) Portland Metro Clackamas, Clark, Multnomah, and Washington County January 1, 2018 December 31, 2018 This is a summary of drug and health services
More information2018 Summary of Benefits MEMORIAL HERMANN ADVANTAGE HMO AND PPO.
2018 Summary of Benefits MEMORIAL HERMANN ADVANTAGE HMO AND PPO. 2018 Summary of Benefits Memorial Hermann Advantage HMO H7115-001 This Summary of Benefits document provides an outline of health and drug
More informationBlue Shield 65 Plus (HMO) summary of benefits
Blue Shield 65 Plus (HMO) summary of benefits Group Medicare Advantage-Prescription Drug Plan for Santa Ana Unified School District retirees July 1, 2016 to June 30, 2017 Blue Shield of California is a
More informationSummary of Benefits: Essentials Rx 6 (HMO)
Summary of Benefits: Essentials Rx 6 (HMO) Essentials Rx 27 (HMO) Central Oregon, Eastern Oregon, and Mid-Columbia Gorge January 1, 2018 December 31, 2018 This is a summary of drug and health services
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) H2001-816 Group Name (Plan Sponsor): CalPERS with Dental and Vision Look inside to learn more about the plan
More informationbenefits BlueMedicare SM HMO A Medicare Advantage HMO Plan
2016 Summary of benefits BlueMedicare SM HMO A Medicare Advantage HMO Plan Alachua, Bay, Brevard, Charlotte, Citrus, Clay, Collier, Columbia, Duval, Escambia, Highlands, Indian River, Lake, Lee, Manatee,
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) H2001-816 Group Name (Plan Sponsor): Illinois Department of Central Management Services State Employees Group
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) H2001-816 Group Name (Plan Sponsor): Illinois Department of Central Management Services Teachers Retirement
More informationThe Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
/ Summary of Benefits January 1, 2016 December 31, 2016 The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. s pharmacy network offers
More information2018 Summary of Benefits HAP Senior Plus (PPO) H Option H Option H Option January 1, December 31, 2018
2018 Summary of Benefits H2322 - Option 1 011 H2322 - Option 2 008 H2322 - Option 3 004 January 1, 2018 - December 31, 2018 H2322_PPO SB 2018 R1 CMS Accepted 10/30/2017 Summary of Benefits January 1, 2018
More informationOur service area includes these counties in: Nevada: Clark, Nye.
2018 SUMMARY OF BENEFITS Overview of your plan Senior Dimensions Southern Nevada (HMO) H2931-002 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSummary of Benefits. January 1, 2016 to December 31, 2016
Summary of Benefits Summary of Benefits January 1, 2016 to December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every
More informationGENESIS PRIME - CONSTELLATION HEALTH (HMO SNP) 2016
GENESIS PRIME - CONSTELLATION HEALTH (HMO SNP) 2016 Constellation Health is an HMO plan with a Medicare contract and a contract with the Puerto Rico Medicaid program. Enrollment in Constellation Health
More information2015 Summary of Benefits. for
2015 for Geisinger Gold Geisinger Gold Introduction to You have choices about how to get your Medicare benefits. One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) H2001-816 Group Name (Plan Sponsor): Public Education Employees Health Insurance Plan Group Number: 15500
More informationOur service area includes the 50 United States, the District of Columbia and all US territories.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) Group Name (Plan Sponsor): HP PPO Plus Plan Group Number: 13603 H2001-828 Look inside to learn more about
More informationOur service area includes the 50 United States, the District of Columbia and all US territories.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) Group Name (Plan Sponsor): University of Arkansas System Group Number: 13555 H2001-816 Look inside to learn
More informationOur service area includes these counties in: Florida: Charlotte, Collier, Lee, Manatee, Sarasota.
2018 SUMMARY OF BENEFITS Overview of your plan AARP MedicareComplete Plan 2 (HMO) H1045-034 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer Service
More informationHAP Senior Plus (HMO)
2017 Summary of Benefits HAP Senior Plus (HMO) H2354 - Option 015 H2354 - Option 019 H2354 - Option 018 January 1, 2017 - December 31, 2017 Y0076_HMO SB 2017 II CMS ACCEPTED HAP Senior Plus (HMO) Summary
More information2016 Retired Employees Health Program (REHP)
2016 Retired Employees Health Program (REHP) PEBTF_2016 Cover Photo: Ron Chapple Stock/Ron Chapple Studios/Thinkstock Summary Of Benefits January 1, 2016 - December 31, 2016 This booklet gives you a summary
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (HMO) Group Name (Plan Sponsor): THE ARIZONA STATE RETIREMENT SYSTEM Group Number: 900009 H0609-808 Look inside
More information