2018 CareOregon Advantage Star (HMO) Summary of Benefits

Transcription

1 2018 Summary of Benefits For Oregon counties: Clackamas, Columbia, Multnomah and Washington H5859_1099_CO_3018v3 CMS ACCEPTED

2 CAREOREGON ADVANTAGE STAR (HMO) (A Medicare Advantage Health Maintenance Organization (HMO) offered by HEALTH PLAN OF CAREOREGON, INC. with a Medicare contract) SUMMARY OF BENEFITS January 1, December 31, 2018 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and and live in our service area. Our service area includes the following counties in Oregon: Clackamas, Columbia, Multnomah and Washington. 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 has a network of doctors, hospitals, pharmacies, and other providers. You can see our plan s provider directory at our website (careoregonadvantage.org/providersearch). You can see our plan s pharmacy directory at our website (careoregonadvantage.org/pharmacy). You can see our plan s formulary (list of Part D prescription drugs) and any restrictions on our website, (careoregonadvantage.org/druglist). Or, call us and we will send you a copy of the provider and pharmacy directories or formulary. This document is available in other formats such as Braille or large print. This document may be available in a non-english language. 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., Pacific time. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m., Pacific time. Phone Numbers and Website: If you are a member of this plan, call or toll-free at TTY/TDD users can call 711. If you are not a member of this plan, call or toll-free at TTY/TDD users can call 711. Our website: careoregonadvantage.org CareOregon Advantage Star is an HMO plan with a Medicare contract. Enrollment in CareOregon Advantage Star depends on contract renewal. Rev 5/18/2018 H5859_1099_CO_3018v3 CMS Accepted

3 Discrimination is Against the Law CareOregon Advantage complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. CareOregon Advantage does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. CareOregon Advantage: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters 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: Qualified interpreters Information written in other languages If you need these services, contact CareOregon Advantage Customer Service. If you believe that CareOregon Advantage 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: Grievance Coordinator 315 SW Fifth Ave Portland, OR Toll-free: Fax: TTY/TDD: MedicareEnrollmentServices@careoregon.org You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Customer Service 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, D.C , (TDD) Complaint forms are available at 2

4 Premiums and Benefits Monthly premium Deductible Maximum Out-of- Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Care Outpatient Hospital Services You pay $34.60 per month In addition, you must keep paying your Medicare Part B premium. You pay $150 per year Applies to Inpatient Acute Hospital Care and Inpatient Psychiatric Care. You pay $6,700 per year You will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. After you pay your $150 annual deductible, you pay: Days 1-3: $315 per day Days 4-90: $0 per day 20% of the cost for: Medicare-covered ambulatory surgical center visit Medicare-covered outpatient hospital facility visit Primary care physician: You pay $5 copay per visit Doctor s Office Visits Preventive Services Emergency Care Urgently Needed Services Diagnostic Services, Labs and Imaging Hearing Services Dental Services Specialists: You pay $30 copay per visit Specialist services may require a referral from your primary care physician and prior authorization. You pay nothing $75 per visit $40 per visit You pay 20% of the cost for Diagnostic radiology services (such as MRIs, CT scans) Outpatient X-rays Therapeutic radiology services (such as radiation treatment for cancer) Diagnostic tests and procedures Lab services Some services may require a referral from your doctor. You pay a $20 copay for diagnostic exams only You pay 20% of the cost Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth) 3

5 Premiums and Benefits Vision Services Mental Health Care Skilled Nursing Facility (SNF) Outpatient Rehabilitation Standard You pay nothing for: - Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk. - one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery Supplemental - $15 copay for up to 1 supplemental eye exam every year. - $0 copay for up to 1 pair of eyeglass frames or contact lenses every year. ($175 plan coverage limit for frames/$100 limit for contacts) You pay nothing for: - up to 1 pair of basic eyeglass lenses per year (including standard progressive lenses) After you pay your $150 annual deductible, you pay: Days 1-3: $300 per day Days 4-90: $0 per day You pay $30 per visit for: Outpatient group therapy Outpatient individual therapy You pay nothing for days 1-20 You pay $160 copay per day for days You pay nothing for Cardiac (heart) rehab services You pay $30 copay per visit for: Occupational therapy visits Physical therapy and speech and language therapy visits Ambulance Transportation Medicare Part B Drugs You pay $275 copay per one-way trip Not covered You pay 20% of the cost for: Part B drugs such as chemotherapy drugs Other Part B drugs May require prior authorization. 4

6 Premiums and Benefits Foot Care (podiatry services) Diabetes Supplies and Services Health and Wellness Education Programs You pay $30 copay for: Foot exams and treatment Routine foot care (limited to 1 per year, unless you have a certain medical condition affecting your lower limbs) May require a referral from your doctor. You pay nothing for: Diabetes monitoring supplies Diabetes self-management training You pay 20% of the cost for therapeutic shoes or inserts There is no cost for this service Nurse Advice Line: Available 24 hours a day, 7 days a week. Outpatient Prescription Drugs Standard Retail and Mail Order Cost-Sharing Deductible Stage $405 yearly deductible for drugs in tiers 3-6 Initial Coverage Stage 30-day supply 60-day supply 90-day supply -Tier 1 (Preferred $4 copay $8 copay $12 copay Generic) - Tier 2 (Generic) $20 copay $40 copay $60 copay - Tier 3 (Preferred Brand) $47 copay $94 copay $141 copay - Tier 4 (Non-Preferred $100 copay $200 copay $300 copay Brand) - Tier 5 (Injectable Drugs) $100 copay $200 copay $300 copay - Tier 6 (Specialty Tier) 25% of the cost 25% of the cost 25% of the cost Coverage Gap Stage Catastrophic Coverage Stage You pay 35% of the plan s cost for covered brand name drugs and no more than 44% of the plan s cost for covered generic drugs until your costs total $5,000 You pay the greater of: 5% of the cost, or $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copay for all other drugs You may get drugs from an out-of-network pharmacy at the same cost as an innetwork pharmacy. You stay in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches $3,750. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. After your yearly out-ofpocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000 5

7 CareOregon Advantage Customer Service CALL: or toll-free TTY/TDD: 711 HOURS OF OPERATION: every day, 8 a.m. to 8 p.m. WEBSITE: careoregonadvantage.org facebook.com/careoregon twitter.com/careoregon COA STAR