2017 Benefit Highlights

Transcription

1 2017 Benefit Highlights Bridgeway Health Solutions Medicare Advantage (HMO) Pinal County, AZ Plan benefits Copays/Coinsurance Monthly plan premium $35.10 Maximum out-of-pocket (MOOP) $6,700 Doctor office visits Primary care provider Specialist Lab services X-rays Complex diagnostic imaging (MRI, MRA, CT, PET, etc.) and radiation therapy Diabetic supplies Inpatient hospital care The amounts for each benefit period are: $1,288 deductible for days 1 through 60 $322 copay per day for days 61 through 90 $644 copay per day for 60 lifetime reserve days These amounts may change for 2017 Skilled nursing facility The amounts for each benefit period are: per day, days 1 through 20 $161 copay per day, days 21 through 100 These amounts may change for 2017 Outpatient services surgery (hospital and ambulatory care) Physical/Speech/Language therapy Pulmonary rehabilitation Ambulance services Y0020_2017_0025 CMS Approved

2 Plan benefits Copays/Coinsurance Emergency care, up to $75 Worldwide emergency/urgent coverage annual limit of $50,000 Urgently needed services, up to $65 Hearing aids (1 pair every 3 years) 1 Routine vision exam 2 Routine eyewear 3 Dental HMO preventive and comprehensive (Dental services are covered In-network only with contracted providers.) /$1,000 benefit maximum for 2 hearing aids (for both ears combined) every 3 years $10 copay Plan pays up to $100 allowance every 2 years. Comprehensive dental benefits have a $1,500 maximum allowance every year. Prescription drug coverage Value Formulary With Medicare only, you pay 30-day retail cost sharing Annual Part D deductible 4 $400 Tier 1: Preferred generic drugs Tier 2: Generic drugs Tier 3: Preferred brand drugs 5 Tier 4: Non-preferred brand drugs 6 Tier 5: Specialty tier Tier 6: Select Care drugs Initial coverage limit (ICL) $3,700 The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Once the ICL has been met, you move into the Coverage Gap phase. During the Coverage Gap, you pay 40% of the price for covered brand-name drugs and 51% of the price for covered generic drugs until your costs total $4,950, which is the end of the Coverage Gap. Both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the Coverage Gap. Not everyone will enter the Coverage Gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you will then pay the greater of $3.30 copay or 5% coinsurance for generic drugs and $8.25 copay or 5% coinsurance for all other drugs. 2

3 1 Benefit allowance once every 3 years. Multi-year benefit may not be available in subsequent years. 2 Benefit allowance once every year. 3 Benefit allowance once every 2 years. Multi-year benefit may not be available in subsequent years. 4 Deductible applies to all tiers. 5 This tier includes preferred brand drugs and may include some generic drugs. Brand drugs in this tier are not eligible for exceptions for payment at a lower tier. 6 This tier includes non-preferred brand drugs and may include some generic drugs. This information is not a complete description of benefits. Contact the plan for more information. You must continue to pay your Medicare Part B premium. Limitations, copayments and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. The actual complete terms and conditions of the health plan are set forth in the applicable Evidence of Coverage document. This information is available for free in other languages. Please contact our Member Services at for additional information (TTY: 711). From October 1 through February 14, our office hours are 8:00 a.m. to 8:00 p.m., 7 days a week, excluding certain holidays. However, after February 14, our office hours are 8:00 a.m. to 8:00 p.m., Monday through Friday. On weekends and certain holidays, your call will be handled by our automated phone system. English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al Navajo: Díí baa akó nínízin: Díí saad bee yániłti go Diné Bizaad, saad bee áká ánída áwo dę ę, t áá jiik eh, éí ná hólǫ, kojį hódíílnih Chinese: (TTY: 711) Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711). 3

4 Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa Korean: (TTY: 711) French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS :711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Japanese: (TTY: 711) Farsi: توجه: اگر به زبان فارسی گفتگو می کنيد تسھيالت باشد. با (711 (TTY: تماس بگيريد. زبانی بصورت رايگان برای شما فراھم می Assyrian: ܢ ܚ ܠܡ ܬ ܐ ܢ ܕܩ ܒܠܝ ܬܘ ܝ ܐ ܡ ܨܝ ܬܘ ܐ ܐ ܬܘܪ ܢ ܠ ܫ ܢ ܢ ܟ ܐ ܗ ܡܙ ܡܝ ܬܘ sܙܘ ܗ ܪ ܐ: ܐ ܢ ܐ ܚܬܘ ܢ ܥ ܠ ܡ ܢܝ ܢ ܐ ܐ ܡ ܓ ܢ ܐܝ ܬ. ܩܪܘ ܕܗ ܝ ܪܬ ܐ ܒܠ ܫ ܢ (TTY: 711) Serbo-Croatian: OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). Thai: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร 4

5 Health Net complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: Provides free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: Qualified interpreters and information written in other languages If you need these services, contact Health Net's Customer Contact Center at (TTY: 711), 8:00 a.m. to 8:00 p.m. Mountain time, seven days a week. If you believe that Health Net has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number above and telling them you need help filing a grievance; Health Net's Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD): Complaint forms are available at Health Net Community Solutions of Arizona, Inc. has a contract with Medicare to offer HMO and HMO SNP coordinated care plans. Enrollment in a Health Net Medicare Advantage plan depends on contract renewal. Health Net Community Solutions of Arizona, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. FLY008654EP00 5