2018 SUMMARY OF BENEFITS

Transcription

1 2018 INFORMATION 2018 SUMMARY OF BENEFITS Benefits effective January 1, 2018 Plus and Enhanced Medicare Advantage HMO Plans Washoe County Y0109_WSHSB18_ CMS Accepted

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3 2018 SUMMARY of BENEFITS Washoe County PROMINENCE HEALTH PLAN PLUS HMO H5945, PLAN 002 AND PROMINENCE HEALTH PLAN ENHANCED HMO H5945, PLAN 005 THIS IS A SUMMARY OF DRUG AND HEALTH SERVICES COVERED BY PROMINENCE PLUS AND PROMINENCE ENHANCED HEALTH PLANS FOR JANUARY 1, 2018 THROUGH DECEMBER 31, Plus and Enhanced are Medicare Advantage HMO plans with a Medicare contract. Enrollment in the plans depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage booklet by calling You can also view and download the Evidence of Coverage booklet at Medicare.com. To join Plus or Enhanced, 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 county in Nevada: Washoe. Plus and Enhanced plans have a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. You can view it online at or request a copy by calling MEDICARE ( ). This document is available in other formats such as Braille, large print or audio. For more information, please call us at (TTY users should calll 711), 8 am to 8 pm seven days a week from October 1 through February 14 and Monday through Friday from February 15 through September 30, or visit us at Medicare.com. 3

4 Premiums and Benefits Plus Plan Enhanced Plan What you should know Monthly Plan Premium* You pay $0 You pay $37 You must continue to pay your Medicare Part B premium. Deductible You pay nothing You pay nothing These plans do not have a deductible. Maximum Out-of- Pocket Responsibility (does not include prescription drugs) $4,500 annually $3,400 annually The most you pay for copays, coinsurance and other costs for medical services for the year. Inpatient Hospital Coverage $300 copay per day for days 1 through 5 $0 copay days 6 through 90 $250 copay per day for days 1 through 6 $0 copay days 7 through 90 Our plans cover an unlimited number of days for an inpatient hospital stay. Authorization is required. Please contact the plan for more information. Outpatient Hospital Coverage Outpatient surgery in outpatient hospital or ambulatory surgery center $275 copay $250 copay required for outpatient surgery. Please contact the plan for more information. Observation care $300 copay $250 copay Doctor Visits Primary care Specialists $15 copay per visit $45 copay per visit $40 copay per visit Referrals are required for specialist visits. 4

5 Premiums and Benefits Plus Plan Enhanced Plan What you should know Preventive Care You pay nothing You pay nothing Any additional Abdominal aortic aneurysm screening; Alcohol misuse counseling; Annual physical exam; Bone mass measurement; Breast cancer screening (mammogram); Cardiovascular disease (behavioral therapy); Cardiovascular screenings; Cervical and vaginal cancer screening; Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy); Depression screening; Diabetes screenings; HIV screening; Lung cancer screening; Medical nutrition therapy services; Obesity screening and counseling; Prostate cancer screenings (PSA); Sexually transmitted infections screening and counseling; Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease); Vaccines, including Flu, Hepatitis B, & Pneumococcal shots; Welcome to Medicare preventive visit (one-time); Yearly Wellness visit. preventive services approved by Medicare during the contract year will be covered. There are some covered services that have a cost. Emergency Care $80 copay per visit $100 copay per visit The emergency care copay is waived if you are admitted to the hospital for the same diagnosis within 3 days of the emergency care visit. Urgently Needed Services $35 copay per visit $35 copay per visit The urgent care copay is waived if you are admitted to the hospital for the same diagnosis within 3 days of the urgent care visit. 5

6 Premiums and Benefits Plus Plan Enhanced Plan What you should know Diagnostic Services/ Labs/Imaging Diagnostic radiology services (e.g., CT, MRI) Lab services Diagnostic tests and procedures Outpatient x-rays $175 copay per visit $45 copay per visit $150 copay per visit $40 copay per visit Prior authorization is required for some services. Please contact the plan for more information. Hearing Services Routine hearing exam Medicare-covered hearing exam 20% coinsurance 20% coinsurance One routine hearing exam allowed annually Hearing aids Not covered $380 annual allowance Hearing aid allowance is a combined annual allowance, not per ear. Dental Services Oral exam cleaning and x-rays Medicare-covered dental Preventive dental visits are not covered $45 copay per visit $0 for preventive services (2 exams, 2 cleanings and 1 set of 2 bitewing x-rays) $500 maximum $45 copay per visit Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). required for Medicarecovered dental services. Please contact the plan for more information. Vision Services Medicare-covered eye exam $20 copay per visit $20 copay per visit Non-Medicare eye exams for glasses and eyewear are not covered. Mental Health Services Inpatient visit Outpatient therapy visit $300 copay per day for days 1 through 5. You pay nothing per day for days 6 through 90. $40 copay per visit $250 copay per day for days 1 through 6. You pay nothing per day for days 7 through 90. $40 copay per visit required for inpatient hospital stays and partial hospitalization. Please contact the plan for more information. Partial hospitalization $55 copay per day $55 copay per day Skilled Nursing Facility (SNF) (Per benefit period) $0 per day/days 1-20 $150 per day/ days $0 per day/days 1-20 $150 per day/ days Prior authorization is required. Please contact the plan for more information. 6

7 Premiums and Benefits Plus Plan Enhanced Plan What you should know Physical Therapy Occupational therapy visit Physical therapy & speech language pathology visits $30 copay per visit $30 copay per visit $25 copay per visit $25 copay per visit 10 occupational, 10 physical and 10 speechlanguage therapy visits are allowed annually without prior authorization. required for all visits over 10. Please contact the plan for more information. Ambulance $275 copay per segment Waived if admitted to the hospital. $250 copay per segment Waived if admitted to the hospital. Non-emergency transport requires prior authorization. Please contact the plan for more information. Transportation Not covered Not covered Medicare Part B Drugs 20% of the cost for chemotherapy and other Part B drugs 20% of the cost for chemotherapy and other Part B drugs required for all Part B drugs with a cost greater than $100. Please contact the plan for more information. Annual Comprehensive Physical Exam $0 copay $0 copay You pay the plan cost-sharing amount for screening exams and/or diagnostic tests received in preparation for this visit or ordered as a result of this visit. Medical Equipment/ Supplies Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies 20% coinsurance 20% coinsurance 0% coinsurance 20% coinsurance 20% coinsurance 0% coinsurance required for all DME, prosthetics and medical supply items with a purchase price greater than $500 or $38.50 per month if rented. Please contact the plan for more information. Abbott Laboratories is a preferred vendor for diabetic testing supplies. 7

8 Premiums and Benefits Plus Plan Enhanced Plan What you should know Foot Care (podiatry services) Foot exams and treatment $50 copay per visit $40 copay per visit Routine foot care Not covered Not covered Acupuncture $20 copay per visit $20 copay per visit 10 acupuncture visits allowed annually without prior authorization. required for all visits over 10 annually. Chiropractic Care Medicare-covered chiropractic visit (Manipulation of the spine to correct a subluxation) $20 copay per visit $20 copay per visit required for all visits over 10 annually. Please contact the plan for more information. Wellness Programs (Gym membership) You pay nothing for Silver&Fit membership** You pay nothing for Silver&Fit membership** The Silver&Fit Exercise & Healthy Aging Program provides access to fitness centers or in-home exercise kits. Over-the-Counter Items Please visit our website for a list of covered over-the-counter items. $0 copay $25 monthly allowance $0 copay $25 monthly allowance Any unused portion of the monthly allowance may not be carried over from one month to the next. Items ordered through this program are delivered to you for free. Worldwide Emergency Care Not covered $100 copay per visit 8

9 IN-NETWORK RETAIL PHARMACY OUTPATIENT PRESCRIPTION DRUGS Plus Plan Enhanced Plan Retail Rx 30-day Supply* Prescription Drug Deductible No deductible No deductible Phase 1: Initial Coverage Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Drugs Tier 5: Specialty Drugs Tier 6: Selected Drugs Phase 2: Coverage Gap You pay $3 You pay $12 You pay $45 You pay $100 You pay 33% You pay $0 Tiers, 1, 2 and 6 are covered in the gap You pay $2 You pay $10 You pay $40 You pay $100 You pay 33% You pay $0 Tiers, 1, 2 and 6 are covered in the gap MAIL ORDER OUTPATIENT PRESCRIPTION DRUGS Plus Plan Enhanced Plan Mail Order 90-day Supply Prescription Drug Deductible No deductible No deductible Phase 1: Initial Coverage Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Drugs Tier 5: Specialty Drugs Tier 6: Selected Drugs Phase 2: Coverage Gap You pay $6 You pay $24 You pay $135 You pay $300 Not available You pay $0 Tiers, 1, 2 and 6 are covered in the gap You pay $4 You pay $20 You pay $120 You pay $300 Not available You pay $0 Tiers, 1, 2 and 6 are covered in the gap Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more specific information on the phases of the benefit, please call us or access our Evidence of Coverage online at Medicare.com *Prescription drugs may be up to a 90-day supply 9

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11 If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. You can view it online at or request a copy by calling MEDICARE ( ), 24 hours a day, seven days a week. TTY/TDD users should call Health Plan is an HMO plan with a Medicare contract. Enrollment in Health Plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary. *You must continue to pay your Part B premiums. ** The Silver&Fit program is provided by American Specialty Health Fitness, Inc. (ASH Fitness), a subsidiary of American Specialty Health Incorporated (ASH). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/TDD: 711). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY/TDD: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY/TDD: 711). 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. Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Sumusunod ang Health Plan sa mga naaangkop na Pederal na batas sa karapatang sibil at hindi nandidiskrimina batay sa lahi, kulay, bansang pinagmulan, edad, kapansanan o kasarian. Health Plan tuân thủ luật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính. For more information call (TTY: 711) 8 am to 8 pm, seven days a week from October 1 - February 14 and Monday through Friday from February 15 September 30. View our Provider and Pharmacy Directory on our website at: Medicare.com You can see the complete plan Formulary (list of Part D prescription drugs) and any restrictions on our website at Medicare.com. 11

12 To learn more about our plans or to enroll, call TOLL FREE TTY/TDD 711 Hours: October 1 to February 14 7 days a week, 8 am 8 pm February 15 to September 30 Monday through Friday 8 am 8 pm Medicare.com 1510 Meadow Wood Lane Reno, NV Health Plan is an HMO plan with a Medicare contract. Enrollment depends on contract renewal _WASHOE_9/17