SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO H4093, PLAN 003
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1 SUMMARY OF BENEFITS PROVIDER PARTNERS HEALTH PLAN OF PENNSYLVANIA HMO H4093, PLAN 003 This is a summary of drug and health services covered by Provider Partners Health Plan of Pennsylvania (PPHP-PA) HMO. January 1, 2017 December 31, 2017 PPHP-PA HMO, offered by Provider Partners Health Plan of Pennsylvania is a Medicare Advantage Prescription Drug HMO Plan with a Medicare contract. Enrollment in PPHP-PA HMO depends on contract renewal. Benefits, premiums and/or copayments/co-insurance may change on January 1 of each year. Limitations, copayments, and restrictions may apply. This information is not a complete description of benefits. To get a complete list of services we cover, please request the Evidence of Coverage. Contact the plan for more information. To join PPHP-PA, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. You must continue to pay your Medicare Part B Premium. Our service area includes the following county in Pennsylvania: Westmoreland. H4093_003_B2017_SB Accepted
2 PREMIUMS/ BENEFITS PPHP-PA HEALTHPLAN WHAT YOU SHOULD KNOW Monthly Plan Premium You pay $35.40 Deductible You pay $147 You must continue to pay your Medicare Part B premium. These are 2016 amounts that may change for Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $6,700 annually The most you pay per year for copays, coinsurance and other costs for medical services. Inpatient Hospital Coverage (Days 1 60) $1,288 deductible (Days 61 90) $322 copay per day (Days 91+) $644 copay per day Our plan covers 90 days for inpatient hospital stays and 60 lifetime reserve days. These are 2016 amounts that may change for Doctor Visits You pay 20% per visit for both primary care and specialists Preventive Care You pay nothing Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care the visit up to $75 Emergency care is covered within the United States and not worldwide. Urgently Needed Services the visit up to $65 Urgent care is covered within the United States and not worldwide. Diagnostic Services/Labs/ Imaging Prior authorization is required for some services by your doctor or other network provider. Please contact the plan for more information.
3 PREMIUMS/ BENEFITS Hearing Services PPHP-PA HEALTHPLAN WHAT YOU SHOULD KNOW PPHP pays up to $100 per year for routine hearing exams. PPHP pays up to $500 per year for hearing aids. Dental Services PPHP pays up to $100 per year for preventive dental services Vision Services PPHP pays up to $50 per year for routine eye exams. PPHP pays up to $100 per year for eyeglasses. Mental Health Services Inpatient Visit Outpatient Individual/ Group Therapy (Days 1 60) $1,288 deductible (Days 61 90) $322 copay per day (Days 91+) $644 copay per day You pay 20% of the cost for outpatient group or individual therapy visits PPHP covers up to 190 days in a lifetime for inpatient services in a psychiatric hospital. These are 2016 amounts that may change for Skilled Nursing Facility You pay nothing for days You pay $161 per day for days You pay all costs for each day after 100 PPHP covers up to 100 days in a SNF. Rehabilitation Services Ambulance
4 PREMIUMS/ BENEFITS Transportation PPHP-PA HEALTHPLAN Non-emergency transportation is not covered by Medicare WHAT YOU SHOULD KNOW PPHP covers up to 36 oneway trips for non-emergency transportation Foot Care (podiatry services) Medical Equipment/ Supplies Additional items may be covered when medically necessary. Please call PPHP for more information. Wellness Programs (e.g., fitness) Not covered Annual Medicare Wellness Exam is covered by PPHP. Medicare Part B Drugs * Authorization may be required. Call PPHP for more information. OUTPATIENT PRESCRIPTION DRUGS PREFERRED RETAIL RX 30-DAY SUPPLY NON-PREFERRED RETAIL RX 30-DAY SUPPLY MAIL ORDER 90-DAY SUPPLY Phase: Initial Coverage (After you pay your deductible, if applicable) Tier 1: All RX 25% 25% 25% Cost sharing may change when entering another phase of the Part D benefit. Please call PPHP for more information at or access the Evidence of Coverage online 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
5 For more information, please call us toll-free at , TTY users should call 711 or visit us at PPHP has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, PPHP may not pay for these services. You can see our plan s provider directory, pharmacy directory, and the complete plan formulary (list of Part D prescription drugs) at our website at The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern. Discrimination is Against the Law PPHP complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PPHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PPHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: w Qualified sign language interpreters w Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: w Qualified interpreters w Information written in other languages If you need these services, contact Raquel Chapman. If you believe that PPHP 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 with: Raquel Chapman, Corporate Compliance Director, Provider Partners Health Plan, 1922 Greenspring Drive, Suite 6, Timonium, MD 21903, , (TTY-711), Fax , rchapman@ tributehealthplans.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Raquel Chapman, Corporate Compliance Director 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 ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at hhs.gov/ocr/office/file/index.html.
6 MULTI-LANGUAGE INTERPRETIVE SERVICE English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Español (Spanish) ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Français (French) ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). Tiếng Việt (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). ພາສາລາວ (Lao) ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລ ການຊ ວຍເຫ ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ (TTY: 711). 繁體中文 (Chinese) 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). Tagalog (Tagalog Filipino) PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. 日本語 (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 Italiano (Italian) ATTENZIONE: In caso la lingua parlata sia l italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). (Arabic) ةيبرعل ةدعاسملا تامدخ نإف ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم مقرب لصتا.ناجملاب كل رفاوتت ةيوغللا.(711 :مكبلاو مصلا فتاه مقر) 4649 Kajin Ṃajōḷ (Marshallese) LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk (TTY: 711). Polski (Polish) UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Igbo asusu (Ibo) Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call (TTY: 711).
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