2019 HMO Summary of Benefits
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1 2019 HMO Summary f Benefits Memrial Hermann Advantage HMO H7115, Plan 001 January 1, December 31, This Summary f Benefits dcuments prvides an utline f health and drug services cvered by Memrial Hermann Advantage HMO January 1, 2019 t December 31, Memrial Hermann Advantage HMO is prvided by Memrial Hermann Health Plan, Inc., a Medicare Advantage rganizatin with a Medicare cntract. Enrllment in this plan depends n cntract renewal. The benefit infrmatin prvided des nt list every service that we cver r list every limitatin r exclusin. T get a cmplete list f services we cver, please call us and request the Evidence f Cverage. T jin Memrial Hermann Advantage (HMO), yu must be entitled t Medicare Part A, be enrlled in Medicare Part B, and live in ur service area. Our service area includes the fllwing cunties in Texas: Frt Bend, Harris, and Mntgmery. Except in emergency situatins, if yu use the prviders that are nt in ur netwrk, we may nt pay fr these services. Fr cverage and csts f Original Medicare, lk in yur current Medicare & Yu handbk. View it nline at r get a cpy by calling MEDICARE ( ).TTY users shuld call This dcument is available in ther frmats such as Braille, large print, audi, r nn-english language. This infrmatin is nt a cmplete descriptin f benefits. Call (855) (TTY users shuld call 711), fr mre infrmatin r visit us at Hurs f peratin between Octber 1 st and March 31st are 8 a.m. t 8 p.m., 7 days a week; clsed Thanksgiving Day and Christmas Day, and pen n New Year s Day, Martin Luther King Jr. s Day, and President s Day. Hurs f peratin between April 1st and September 30 th are 8 a.m. t 8 p.m., Mnday thrugh Friday; clsed weekends and federal hlidays. H7115_PD_POST_SBCAHMO19_M CMS Accepted_09/13/2018
2 Premiums and Benefits Memrial Hermann Advantage HMO Mnthly Plan Premium Yu pay $0 Deductible Part D Deductible Maximum Out-f-Pcket Respnsibility (des nt include prescriptin drugs) Yu must cntinue t pay yur Medicare Part B premium. N deductible fr medical. $300 per year fr Tier 4 and Tier 5 Part D prescriptin drugs. Yu pay n mre than $3,900 annually Includes cpays and ther csts fr medical services fr the year. Inpatient Hspital Yu pay $300 per day fr days 1 thrugh 5 Yu pay nthing per day fr days 6 and beynd Prir Authrizatin rules may apply. Outpatient Hspital Yu pay $125 fr each Medicare-cvered ambulatry surgical service. Yu pay $300 fr each Medicare-cvered utpatient hspital service. Prir Authrizatin rules may apply. Dctr Visits Primary Specialists Preventive Care (e.g., flu vaccine, diabetic screenings) Emergency Care Yu pay nthing fr each primary care visit Yu pay $50 fr each specialist visit N referral fr specialist is needed. Yu pay nthing Other preventive services are available. There are sme cvered services that have a cst. Yu pay $90 per visit If yu are admitted t the hspital within 48 hurs, then yu d nt have t pay $90. Urgently Needed Services Yu pay $35 per visit
3 Premiums and Benefits Diagnstic Services/Labs/Imaging Diagnstic tests and prcedures Lab services MRI, CAT Scan X-Rays Memrial Hermann Advantage HMO Yu pay $75 per diagnstic test r prcedure Yu pay nthing fr lab services Yu pay $200 per test/service Yu pay $10 per x-ray Prir authrizatin is required fr sme services. Hearing Services Medicare-cvered hearing exam Rutine hearing exam Hearing aid Yu pay $50 when perfrmed by a physician r audilgist Yu pay $10 fr cmputer-administered hearing test (tgram) $400 annual ttal allwance fr hearing aid(s), bth ears cmbined. Dental Services Oral exam & Cleaning (Preventive) Medicare-cvered dental services (Cmprehensive) Visin Services Medicare-cvered eye exams Eyewear (cntact, glasses) Mental Health Services Outpatient grup therapy/ individual therapy visit Inpatient mental health care Nt cvered Yu pay $75 per visit fr each Medicare-cvered dental service Yu pay $50 $200 annual ttal allwance fr surgical and nn-surgical need fr eyewear r cntact lenses. Yu pay $40 per grup r individual visit Yu pay $300 per day fr days 1 thrugh 5 Yu pay nthing per day fr days 6 and beynd Skilled Nursing Facility Yu pay nthing fr days 1 thrugh 20 Yu pay $150 per day fr days 21 thrugh 100 Physical Therapy Ambulance Transprtatin Yu pay $25 per visit Yu pay $250 per ne-way trip Nt cvered
4 Medicare Part B Drugs 20% f the cst fr chemtherapy drugs 20% f the cst fr ther Part B drugs PRESCRIPTION DRUG BENEFITS (PART D) Deductible Phase During this stage, yu pay the full cst f yur Tier 4 and Tier 5 drugs. Yu stay in this stage until yu have paid $300 fr yur Tier 4 and Tier 5 drugs. Initial Cverage Phase During this stage, the plan pays its share f the cst f yur Tier 1, Tier 2, and Tier 3 drugs and yu pay yur share f the cst. After yu (r thers n yur behalf) have met yur Tier 4 and Tier 5 deductible, the plan pays its share f the csts f yur Tier 4 and Tier 5 drugs and yu pay yur share. Yu stay in this Initial Cverage Stage until yur ttal drug csts (ttal f all payments made fr yur cvered Part D drugs) fr the year reach $3820. Retail Cstsharing (In-Netwrk) (30-day supply) Retail Cstsharing (In-Netwrk) (90-day supply) Mail Order Cstsharing (90-day supply) Initial Cverage Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Nn-Preferred Drug Tier 5: Specialty Yu pay $2 Yu pay $15 Yu pay $45 Yu pay $99 Yu pay 27% Yu pay $4 Yu pay $30 Yu pay $90 Yu pay $198 Nt ffered Yu pay $0 Yu pay $30 Yu pay $90 Yu pay $198 Nt ffered Cst-Sharing may change depending n the pharmacy yu chse and when yu enter a new phase f the Part D benefit.
5 Cverage Gap - During this stage, yu pay 25% f the price fr brand name drugs (plus a prtin f the dispensing fee) and 37% f the price fr generic drugs. Yu stay in this stage until yur year-t-date ut-f-pcket csts (ttal f all payments made fr yur cvered Part D drugs) reach a ttal f $5100. This amunt and rules fr cunting csts tward this amunt have been set by Medicare. Nt everyne will enter the Cverage Gap. Catastrphic Cverage - Yu qualify fr the Catastrphic Cverage Stage when yur ut-f-pcket drug csts have reached the $5100 limit fr the calendar year. Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.40 fr a generic drug r a drug that is treated like a generic and $8.50 fr all ther drugs. Our plan pays the rest f the cst.
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