from Dean Health Plan 2019 Plan Guide Inside this Guide you will find valuable coverage and benefit information for offered by Dean Health Plan Plans Essential Assurance Balance Complete H9096_473824 _ M p360_mapd_18_473824_m_plan_guide.indd 1
Discover Thank you for your interest in, offered by Dean Health Plan. from Dean Health Plan offers a strong network of providers with a history of exceptional care. Original Medicare, Prescription Drug Coverage and Additional Benefits Combined into a Single Plan. removes the hassle of enrolling in three different policies Original Medicare, a stand-alone prescription drug (Part D) plan and a supplemental plan to reduce out-of-pocket costs all while providing the coverage you need. Original Medicare You are responsible for Part A and Part B medical deductibles. Your Part A and Part B medical deductibles are covered. You must cover 20% of Part B medical services with no annual or lifetime limit on your out-of-pocket costs. You have a maximum out-of-pocket limit that protects you from large, catastrophic health care expenses. You pay 100% of the cost of your prescription drugs. Your prescription drugs are covered with manageable cost sharing according to the drug formulary. You pay 100% of the cost of hearing aids and eye wear. Most plans have allowances for hearing aids and eye wear. You pay 100% of the cost of dental services. You receive dental coverage, with services ranging from preventive to comprehensive care, depending on the plan. You pay 100% of gym membership fees. You receive 100% covered membership to in-network health clubs. You do not receive wellness rewards or incentives. You have the opportunity to earn wellness rewards and incentives for tracking your healthy behaviors. 2 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 2
Service Area The service area for is Brown, Kewaunee and Oconto counties. You must live in one of these counties to join a plan. If you have questions about our service area, please contact Sales Support at 1-877-234-0126 (TTY: 711) or a local agent to learn more about other Medicare plans offered by Dean. Our Sales Representatives are available 8 am 8 pm, weekdays (year-round) and weekends (Oct. 1 Mar. 31). Member Services: 1-877-232-7566 (TTY: 711) H9096 001 HMO Member Name: JOHN Q SMITH-JOHNSON SR Member Number: A0 3456789 01 Issuer: 80840 Product: Assurance Group Number: MA 1234 PCP: SARAH WILLIAMS $ 10 $ 40 RxBIN: 610602 RxPCN: NVTD RxGrp: DHID Copays*: PCP: Specialist: *Please refer to your plan materials for your additional financial responsibility including, but not limited to, deductible, coinsurance and other out-of-pocket costs. prevea360.com/medicare from Dean Health Plan Oconto Kewaunee One plan. One card. One strong network. Brown 1-877-234-0126 (TTY:711) prevea360.com/medicare 3 p360_mapd_18_473824_m_plan_guide.indd 3
At-a-Glance Plans Choose the plan that suits you. Plan names Monthly Hospital Copay Doctor's Maximum Specialist Premium (per day) Office Copay Out-of-Pocket Copay (per visit) (per year)* (per visit) E R Essential $0 per month $385 Copay for Days 1-4; $0 per day thereafter, up to 90 days $20 $6,300 $45 Assurance $40 per month $325 Copay for Days 1-4; $0 per day thereafter, up to 90 days $15 $4,000 $40 Balance $85 per month $250 Copay for Days 1-4; $0 per day thereafter, up to 90 days $10 $3,000 $30 Complete $226 per month $0 Copay for up to 90 days $0 $400 $0 Benefits, premiums and/or co-payments/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. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. You must continue to pay your Medicare Part B premium. * Payments for prescription drugs do not count toward annual maximum out-of-pocket limits. 4 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 4
Preventive care is covered at 100% Emergency Room Copay (per visit) Urgent Care Copay Ambulance (Emergency, per ride) Therapy: Physical, Occupational, Speech Outpatient Surgery Worldwide Emergency Coverage $80 $45 $225 $40 $300 Copay $80 Copay/ $75,000 Maximum $80 $40 $200 $40 $250 Copay $80 Copay/ $75,000 Maximum $80 $30 $175 $30 $200 Copay $50 Copay/ $75,000 Maximum $50 $0 $50 $0 $0 Copay $0 Copay/ $75,000 Maximum Out-of-network/non-contracted providers are under no obligation to treat members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. 1-877-234-0126 (TTY:711) prevea360.com/medicare 5 p360_mapd_18_473824_m_plan_guide.indd 5
Not Covered by Original Medicare Additional Services Plan Name Hearing Services Allowance for Vision Services Allowance (per visit, Hearing Aids (per visit, for Eye wear member pays) member pays) Essential NC NC $20 Copay $100 Allowance every year Assurance $40 Copay We Pay 80% to a maximum benefit of $500, per ear, per year $15 Copay $125 Allowance every year Balance $20 Copay We Pay 80% to a maximum benefit of $750, per ear, per year $10 Copay $150 Allowance every year Complete $0 Copay We pay 80% to a maximum of $1,000 per ear, per year $0 Copay $250 Allowance every year NC = Not Covered 6 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 6
Routine Chiropractic Services Preventive Dental Services Restorative & Comprehensive Dental Services Health Rewards US Vacation/Travel Program $20 Copay/ 12 Visits $0 Copay 1 cleaning & 1 exam yearly NC $25 Reward NC $15 Copay/ 12 Visits $0 Copay 2 cleanings & 2 exams yearly NC $50 Reward NC $10 Copay/ 24 Visits $0 Copay 2 cleanings, 2 exams, 1 X-ray yearly NC $100 Reward NC $0 Copay/ 24 Visits $0 Copay 2 cleanings, 2 exams, 1 X-ray yearly 20% Coinsurance Restorative and 50% Coinsurance Comprehensive (see page 9) $200 Reward Covered when traveling outside of Wisconsin* *United States Only 1-877-234-0126 (TTY:711) prevea360.com/medicare 7 p360_mapd_18_473824_m_plan_guide.indd 7
Preventive Dental Services Plan Name Preventive Dental Services Oral Exam Routine Dental Cleanings Fluoride Treatment X-rays ( Essential 1/Year 1/Year NC NC Assurance 2/Year 2/Year NC NC Balance 2/Year 2/Year NC 1/Year Complete 2/Year 2/Year NC 1/Year NC = Not Covered 8 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 8
Comprehensive Dental Services Restorative (fillings: amalgam and composite) Endodontics Periodontics Extractions Other* Maximum Benefit NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC NC 20% Coinsurance Fillings - amalgam and composite 50% Coinsurance 50% Coinsurance 50% Coinsurance 50% Coinsurance $1,500 * Prosthodontics, Other Oral/Maxillofacial Surgery/Other 1-877-234-0126 (TTY:711) prevea360.com/medicare 9 p360_mapd_18_473824_m_plan_guide.indd 9
At-a-Glance Part D Prescription Drug Coverage Initial Coverage Plan Name Tier Stage 1: Deductible You pay: Stage 2: Initial Coverage Copay and Coinsurance up to $3,820 You pay: Stage 3: Coverage Gap (Donut Hole) $3,821 to $5,100 You pay: Essential Assurance Balance Complete 1 $0 $9 2 $20 3 $415 $47 Applies to 4 Tiers 2 5 only $100 5 25% 1 $4 $0 2 $12 3 $300 $45 4 Applies to $100 5 Tiers 3 5 only 27% 1 $3 $0 2 $9 3 $200 $45 4 Applies to $100 5 Tiers 3 5 only 29% 1 $3 2 $6 3 $0 $45 4 $100 5 33% Generic: 37% coinsurance Brand: 25% coinsurance Generic: 37% coinsurance Brand: 25% coinsurance Generic: 37% coinsurance Brand: 25% coinsurance Generic: 37% coinsurance Brand: 25% coinsurance 10 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 10
Stage 4: Catastrophic Coverage More than $5,100 You pay (whichever amount is larger): Generic: 5% or $3.40 Brand: 5% or $8.50 Stages 1 and 2: Initial Coverage Stage 1: You pay your deductible if it applies to the prescription Tier Stage 2: You pay copays or a percentage of the drug s total cost (coinsurance) You stay in this stage until your total drug costs reach $3,820 within a plan year Stage 3: Coverage Gap (Donut Hole) Once your total drug costs reach $3,821 you pay: 25% of the cost of brand name drugs 37% of the cost of generic drugs You stay in this stage until your total out-of-pocket costs reaches $5,101 within a plan year Stage 4: Catastrophic Coverage After your total out-of-pocket costs reach $5,101 you: Pay a small copay or co-insurance for your medications You stay in this stage for the remainder of the plan year Generic: 5% or $3.40 Brand: 5% or $8.50 Generic: 5% or $3.40 Brand: 5% or $8.50 Save Time and Money by Using the Mail Order Pharmacy 's mail order pharmacy can save you money as we offer reduced cost sharing on select drug tiers. You also save time and avoid multiple trips to the pharmacy! Drug dispensing fees may apply. If you qualify for extra help from Medicare, your costs may be different. You may be able to get extra help to pay for your prescription drug premiums and copays. To see if you qualify for extra help, please call 1-800-MEDICARE (1-800-633-4227). TTY users should dial 1-877-486-2048, 24 hours a day, 7 days a week. Or you may call the Social Security Office a 1-800-772-1213, 7 am 7 pm, Monday Friday. TTY users should dial 1-800-325-0778. Or you may contact your State Medical Assistance (Medicaid) Office. Quantity limitations and restrictions may apply. Generic: 5% or $3.40 Brand: 5% or $8.50 The coverage and benefit information found in this guide is not a full description of plan coverage. Please see our Medicare Advantage Summary of Benefits located in your Medicare Enrollment Kit for a more in-depth summary of what we cover and what you pay. KEY Tier 1 Preferred generic drugs Tier 2 Non-preferred generic drugs Tier 3 Preferred brand-name drugs Tier 4 Non-preferred brand-name drugs Tier 5 Specialty drugs 1-877-234-0126 (TTY:711) prevea360.com/medicare 11 p360_mapd_18_473824_m_plan_guide.indd 11
Discover the value of As a member, you receive preventive screenings and other valuable services at no additional cost to you. Annual wellness visit Vaccines, including flu, hepatitis B and pneumococcal shots Mammograms and pelvic exams Colonoscopy Prostate cancer screening Diagnostic laboratory tests Diabetes screenings, monitoring supplies and self-management training Many other covered benefits and services 12 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 12
Each of our plans provide comprehensive prescription drug coverage with a drug formulary that covers a wide-ranging list of generic, brand name and specialty drugs, with manageable copays and low or no deductibles. Members have access to an extensive pharmacy network that includes: Most national pharmacy chains, including Walgreens Many retail and grocery store pharmacies, including Walmart Many independent, local community pharmacies Mail order pharmacy through Costco, saving time and money by purchasing up to a three-month supply in one transaction If you need help finding 's Comprehensive Drug Formulary, please call 1-877-232-7566 (TTY: 711), or visit.com/medicare to access our online formulary, which is printer-friendly. If you would like a Provider/Pharmacy Directory mailed to you, or if you need help finding a network provider and/or pharmacy, please call 1-877-232-7566 (TTY: 711). You can always access our online searchable directory at prevea360.com/medicare. 1-877-234-0126 (TTY:711) prevea360.com/medicare 13 p360_mapd_18_473824_m_plan_guide.indd 13
Your Notes 14 - Medicare Coverage from Dean Health Plan p360_mapd_18_473824_m_plan_guide.indd 14
1-877-234-0126 (TTY:711) prevea360.com/medicare 15 p360_mapd_18_473824_m_plan_guide.indd 15
from Dean Health Plan.com/medicare Dean Health Plan, Inc. is a HMO/HMO-POS with a Medicare contract. Enrollment in Dean Health Plan, Inc. depends on contract renewal. Dean Health Plan markets under the names Dean Advantage and. This information is not a complete description of benefits. Call 1-877-234-0126 (TTY: 711) for more information. You must continue to pay your Medicare Part B premium. 2018 Dean Health Plan, Inc. from Dean Health Plan 1277 Deming Way Madison WI 53717 Toll-free 1-877-234-0126 TTY: 711 prevea360.com/medicare p360_mapd_18_473824_m_plan_guide.indd 16