2017 Summary of Benefits. Peach State Health Plan Medicare Advantage (HMO) Chattahoochee, Harris, and Muscogee Counties H7173, Plan 003

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1 2017 Summary of Benefits Peach State Health Plan Medicare Advantage (HMO) Chattahoochee, Harris, and Muscogee Counties H7173, Plan 003 H _2017_SB_Accepted_

2 Summary of Benefits January 1, 2017 December 31, 2017 This is a summary of drug and health services covered by Peach State Health Plan Medicare Advantage (HMO). Peach State Health Plan Medicare Advantage is contracted with Medicare for HMO and HMO SNP plans, and with the Georgia Medicaid program. Enrollment in Peach State Health Plan Medicare Advantage 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. Who can join? To join Peach State Health Plan Medicare Advantage (HMO), you must: have both Medicare A and Medicare Part B be a United States citizen or are lawfully present in the United States live in our service area Our service area includes the following counties in Georgia: Chattahoochee, Harris, and Muscogee Counties Which doctors, hospitals and pharmacies can I use? Peach State Health Plan Medicare Advantage (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You can view our provider & pharmacy directory on our website, This plan s phone numbers and website: If you are a member of this plan, call toll-free: (TTY users, please call 711.) If you are not a member of this plan, call toll-free: (TTY users, please call 711.) Our website:

3 Hours of Operation: From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. This document is available in other formats such as Braille, large print or audio. This information is not a complete description of benefits. Contact the plan for more information. Limitations, ments, and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. We don t discriminate based on race, ethnicity, national origin, color, religion, sex, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability, or geographic location. All organizations that provide Medicare Advantage plans, like our plan, must obey Federal laws against discrimination, including Title VI of the Civil Rights Act of 1964, the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, the Americans with Disabilities Act, Section 1557 of the Affordable Care Act, and all other laws that apply to organizations that get Federal funding, and any other laws and rules that apply for any other reason.

4 SUMMARY OF BENEFITS Premiums and Benefits Monthly Plan Premium Deductible Maximum Out-of- Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage January 1, 2017 December 31, 2017 Peach State Health Plan Medicare What you should Advantage (HMO) know $0 You must continue to pay your Medicare Part B premium. $0 per year for Part C benefits $280 per year for Part D prescription drugs Your yearly limit(s) in this plan: $5,900 for services you receive from in-network providers For each benefit period, you pay: $295 per day for days 1-6 You pay nothing for days 7-90 The Part D deductible applies to Tiers 2 5 drugs. Please note: You will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. Prior authorization (approval in advance) may be required. Please contact the plan for details. Doctor Visits o Primary o Specialists Preventive Care For more information on benefit periods and lifetime reserve days, please see the plan s Evidence of Coverage (EOC). $0 for primary care doctor visits $40 for specialist visits You pay nothing Please see the plan s Evidence of Coverage (EOC) for a full list of Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. A referral may be required for specialist visits. Please contact the plan for details. Any additional preventive services approved by Medicare during the contract year will be

5 Premiums and Benefits Preventive Care (cont.) Peach State Health Plan Medicare Advantage (HMO) preventive care services that the plan covers. What you should know covered. Emergency Care $75 per visit If you are admitted to the hospital within three days, you do not have to pay your share of the cost for emergency care. Urgently Needed Services $40 per visit Diagnostic Services/Labs/ Imaging Hearing Services Dental Services Diagnostic tests and procedures: $40 Lab services: $25 Diagnostic radiological services: $130 Therapeutic radiology services (such as radiation treatment for cancer): 20% of the total cost Outpatient x-ray services: $45 Routine hearing exam: You pay nothing for up to 1 every calendar year Hearing aid fitting/evaluation: You pay nothing for up to 1 every calendar year Hearing aid: You pay nothing for 1 hearing aid every calendar year Medicare-covered services: $40 Medicare-covered dental services: 20% of the total cost Preventive dental services: Prior authorization (approval in advance) may be required. Please contact the plan for details. This plan pays up to $750 for one hearing aid (for either the left or right ear). Medicare-covered services include an exam to diagnose and treat hearing and balance issues. Medicare-covered dental includes limited dental

6 Premiums and Benefits Dental Services (cont.) Vision Services Mental Health Services Peach State Health Plan Medicare Advantage (HMO) Oral exam (for up to 2 every calendar year): You pay nothing Cleaning (for up to 2 every calendar year): You pay nothing Dental x-ray (for up to 1 every calendar year): You pay nothing Routine eye exam (for up to 1 every calendar year): You pay nothing Contact lenses: You pay nothing Eyeglasses (frames and lenses): You pay nothing Medicare-covered services: You pay nothing For each benefit period, you pay: $265 per day for days 1-6 You pay nothing for days 7-90 For more information on benefit periods and lifetime reserve days, please see the plan s Evidence of Coverage (EOC). Outpatient group therapy visit: $40 Outpatient individual therapy visit: $40 What you should know services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth. Dental x-rays include bitewing series only. Medicare-covered services includes an exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) and eyeglasses or contact lenses after cataract surgery. The plan pays for up to $200 for contact lenses and/or eyeglasses (frames and lenses). Prior authorization (approval in advance) may be required. Please contact the plan for details. Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient

7 Premiums and Benefits Mental Health Services (cont.) Skilled Nursing Facility (SNF) Peach State Health Plan Medicare Advantage (HMO) For each benefit period, you pay: You pay nothing for days 1-20 $160 per day for days What you should know mental services in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. Prior authorization (approval in advance) may be required. Please contact the plan for details. Rehabilitation Services For more information on benefit periods and lifetime reserve days, please see the plan s Evidence of Coverage (EOC). Cardiac rehab services: $40 Occupational therapy visit: $10 Physical therapy and speech and language therapy visit: $10 Our plan covers up to 100 days in a SNF. Prior authorization (approval in advance) may be required. Please contact the plan for details. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) Ambulance $250 Prior authorization (approval in advance) is required for nonemergency ambulance services. Please contact the plan for details.

8 Premiums and Benefits Transportation Foot Care (podiatry services) Medical Equipment/Supplies Wellness Programs (e.g., fitness) Peach State Health Plan Medicare Advantage (HMO) You pay nothing for 12 one-way trips per calendar year Medicare-covered podiatry services: $40 Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen): 20% of the total cost Prosthetics (e.g., braces, artificial limbs): 20% of the total cost Medical supplies: 20% of the total cost Diabetes monitoring supplies: 20% of the total cost Therapeutic shoes or inserts: 20% of the total cost Fitness program: You pay nothing 24-hour nurse advice line: You pay nothing What you should know You must: Use this plan s contracted transportation providers Go to and from this plan s network providers and facilities within the service area Schedule your trip 48 hours in advance Medicare-covered podiatry services include foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions. Prior authorization (approval in advance) may be required. Please contact the plan for details. The plan covers a basic fitness membership at participating fitness facilities. Members can also request an

9 Premiums and Benefits Wellness Programs (e.g., fitness) (cont.) Medicare Part B Drugs Over-the-Counter (OTC) Items Peach State Health Plan Medicare Advantage (HMO) Chemotherapy drugs: 20% of the total cost Other Part B drugs: 20% of the total cost You pay nothing What you should know in-home fitness program. You can call the nursing hotline 24 hours a day, 365 days a year with questions about your health. Prior authorization (approval in advance) may be required. Please contact the plan for details. The plan covers $25 per month for items available via mail order. Any unused plan benefit amounts do not carry forward into the next month. Please visit the plan s website to see the list of covered over-thecounter items.

10 Deductible Phase Initial Coverage Phase (After you pay your deductible, if applicable) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Outpatient Prescription Drugs The plan s deductible is: $280 per year. You begin in this payment phase when you fill your first prescription of the calendar year. During this phase, you pay the full cost of your Tiers 2 5 drugs. You generally stay in this phase until you have paid $280 for your Tiers 2-5 drugs. Once you have paid your deductible, you move to the next phase (Initial Coverage). During this phase, the plan pays its share of the cost of your Part D drugs and you pay your share of the cost. After you (or others on your behalf) have met your Part D deductible, the plan pays its share of the costs of your Part D drugs and you pay your share. You generally stay in this phase until your year-to-date total drug costs (your payments plus any payments by the plan) reach $3,700. Once your total drug costs reach $3,700 you move to the next phase (Coverage Gap). Retail and Mail-Order Cost Sharing You may get drugs from an out-ofnetwork pharmacy at the same cost as an in-network pharmacy. One-month supply including Mail Order Tier 1 (Preferred Generic): $0 Two-month supply including Mail Order Tier 1 (Preferred Generic): $0 Three-month including Mail Order Tier 1 (Preferred Generic): $0 Tier 2 (Generic): $16 Tier 2 (Generic): $32 Tier 2 (Generic): $48 Tier 3 (Preferred Brand): $42 Tier 3 (Preferred Brand): $84 Tier 3 (Preferred Brand): $126 Tier 4 (Non- Preferred Brand): $86 Tier 4 (Non- Preferred Brand): $172 Tier 4 (Non- Preferred Brand): $258 Tier 5 (Specialty): 25% of the total cost Tier 5 (Specialty): 25% of the total cost Tier 5 (Specialty): 25% of the total cost Tier 6 (Select Care): $0 Tier 6 (Select Care): $0 Tier 6 (Select Care): $0

11 You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at For certain kinds of drugs, you can use the plan s network mail order services. Generally, the drugs provided through mail order are drugs that you take on a regular basis, for a chronic or long-term medical condition. The drugs available through our plan s mail order service are marked as MO drugs in our Drug List. Coverage Gap Phase Catastrophic Phase During this phase, for Tier 6 (Select Care drugs), you continue to pay $0. For Tier 1 (Preferred Generic drugs), you pay your ment or coinsurance. For generic drugs on all other tiers, you pay 51% of the price. For brand name drugs on all other tiers, you pay 40% of the price (plus a portion of the dispensing fee). You generally stay in this phase until your year-to-date out-of-pocket costs reaches $4,950. Once your outof-pocket costs reach $4,950, you move to the next phase (Catastrophic Coverage). During this phase, the plan pays most of the cost for your covered drugs. For each prescription, you pay the greater of: 5% of the cost OR $3.30 for a generic drug (or a drug that is treated like a generic) $8.25 for all other drugs.

12 Multi-language Interpreter Services English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese Mandarin: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Chinese Cantonese: 注意 : 如果您說英文, 您可獲得免費的語言協助服務 請致電 ( 聽障專線 :711) Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Y0020_MLI17_R2_Accepted_

13 Arabic: ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم:.)711 Hindi: ध य न द : यदद आप ब लत ह त आपक ललए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: 711) पर क ल कर Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください Navajo:

14 Peach State 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. Peach State Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Peach State Health Plan: 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 Peach State Health Plan s Member Services at (TTY: 711). If you believe that Peach State Health Plan 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; Peach State Health Plan s Member Services 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

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16 Peach State Health Plan Medicare Advantage (HMO) Peach State Health Plan 1100 Circle 75 Parkway, Suite 1100 Atlanta, GA Current members should call (TTY: 711) Prospective members should call (TTY: 711) From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. You can see our plan s provider and pharmacy directory at 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 BKT008712EK00