HealthPartners Freedom (Cost) Group Plan with Rx 2018 Summary of Benefits Minnesota Jan. 1, 2018 Dec. 31, 2018 Hennepin County #3096 Use this summary document to get to know the Freedom plan. It shows you what the plan covers and what you pay for those services. It doesn t list everything we cover, or every limitation or exclusion. For a complete list of covered services, give us a call at the numbers below and ask for the Evidence of Coverage. We re here to help Call us at 952-883-7979 or 800-233-9645. (TTY 711) Oct. 1 to Feb. 14 8 a.m. to 8 p.m. CT, seven days a week Feb. 15 to Sept. 30 8 a.m. to 8 p.m. CT, Monday through Friday #3096 Freedom Hennepin County (9/17) 2017 HealthPartners H2462_106742 IR Approved 09/28/2017
MEDICAL BENEFITS BENEFITS Monthly Premium: You must continue to pay your Medicare Part B premium. Deductible Maximum out-ofpocket responsibility (The most you ll pay out-of-pocket for the year; does not include prescription drugs) Inpatient hospital coverage (We cover an unlimited number of Outpatient hospital coverage WHAT YOU PAY PLAN 1 PLAN 2 $263.10 $233.70 Your plan does not have a deductible. $3,000 annually $3,000 annually Your plan does not have a deductible. $100 per benefit period. $200 per benefit period. $0 $0 Outpatient surgery $0 $0 Doctor visits Primary: $20 Specialists: $20 Preventive care $0 $0 Emergency care (If you re admitted to the hospital within 24 hours, you don t pay your share of the cost for emergency care.) Urgently needed services Diagnostic services/labs/imaging (Cost for these services may vary based on place of service.) Hearing services Dental services (Up to two cleanings and two oral exams per year. One X-ray per year.) $100 $100 $20 $25 Diagnostic radiology (i.e. MRI, CT scans): $0 Labs: $0 Diagnostic tests and procedures: $0 Outpatient X-rays: $0 Hearing exam: $0 Diagnostic exam: $20 Hearing aids: You pay $0 up to $1,000 every two years. Medicare-covered dental: $0 Oral exam, cleaning and X-ray: $20 Primary: $25 Specialists: $25 Diagnostic radiology (i.e. MRI, CT scans): $0 Labs: $0 Diagnostic tests and procedures: $0 Outpatient X-rays: $0 Hearing exam: $0 Diagnostic exam: $25 Hearing aids: You pay $0 up to $1,000 every two years. Medicare-covered dental: $0 Oral exam, cleaning and X-ray: Not offered
Vision services Mental health services (Including inpatient) Up to one routine eye exam per year: $0 Diagnostic exam: $0-$20 Glasses or contact lenses after cataract surgery: $0 Inpatient visit: $100 per benefit period. (We cover an unlimited number of Outpatient group therapy visit: $20 Outpatient individual therapy visit: $20 Up to one routine eye exam per year: $0 Diagnostic exam: $0-$25 Glasses or contact lenses after cataract surgery: $0 Inpatient visit: $200 per benefit period. (We cover an unlimited number of Outpatient group therapy visit: $25 Outpatient individual therapy visit: $25 Skilled nursing facility $0 (We cover up to 100 $0 (We cover up to 100 Occupational therapy visit: $20 Occupational therapy visit: $25 Rehabilitation services Physical therapy visit: $20 Physical therapy visit: $25 Speech and language therapy visit: Speech and language therapy visit: $20 $25 Ambulance 20% 20% Transportation Not covered. Not covered. Foot care (Podiatry services) Foot exams and treatment: $20 Foot exams and treatment: $25 Chiropractic care $20 $25 Medical equipment/supplies (Things like wheelchairs, oxygen, braces, artificial limbs, etc.) Durable medical equipment: 10% Prosthetics: 10% Diabetes supplies: 10% Durable medical equipment: 20% Prosthetics: 20% Diabetes supplies: 20% Wellness programs Medicare Part B drugs (Prior authorization may be required.) The Silver&Fit Exercise & Healthy Aging Program Get membership at a large network of fitness facilities. Or, a home fitness option for members who prefer to work out at home. Tobacco cessation visits Get additional face-to-face counseling sessions. Plus, interactive online and phone-based coaching. 0-20% of the cost for chemotherapy drugs and other Part B drugs
PRESCRIPTION DRUG BENEFITS Costs may change depending on the pharmacy you choose and when you enter another Part D phase. Call us or check the Evidence of Coverage online at healthpartners.com/medicare for more information. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Phase 1: Deductible (If you have one.) Phase 2: Initial Coverage (After you reach your deductible, if you have one.) Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-preferred Drugs Tier 5: Specialty Phase 3: Coverage Gap ( Donut Hole ) Phase 4: Catastrophic Coverage Your plan does not have a deductible. Plan 1 and Plan 2: What you pay at standard retail and standard mail-order pharmacies: Plan 1: Plan 2: One-month supply One-month supply Tier 1: $15 Tier 1: $15 Tier 2: $20 Tier 2: $20 Tier 3: $30 Tier 3: $30 Tier 4: $60 Tier 4: $60 Tier 5: $40 Tier 5: 25% Three-month supply Tier 1: $45 Tier 2: $60 Tier 3: $90 Tier 4: $180 Tier 5: Not Offered Three-month supply Tier 1: $45 Tier 2: $60 Tier 3: $90 Tier 4: $180 Tier 5: Not Offered At preferred cost-sharing mail-order pharmacies, you get a three month-supply for the price of two months. You pay the same amount listed above for a one-month supply. Plan 1 and Plan 2: You pay the same amounts listed in the Initial Coverage phase for a one-month and three-month supply. Plan 1 and Plan 2: You pay up to the amounts per tier listed in the Initial Coverage phase, but never more than those amounts. ADDITIONAL BENEFITS Remote Access Technologies Real-time Interactive Audio and Video Technologies: $20 Electronic visit (e-visit) Scheduled Telephone Visit virtuwell CareLine SM Services Real-time Interactive Audio and Video Technologies: $25 Electronic visit (e-visit) Scheduled Telephone Visit virtuwell CareLine SM Services
Make sure your doctors and pharmacies are covered You can find the Freedom provider and pharmacy directories at healthpartners.com/medicare. Prefer printed copies of the Freedom directories? Call our Sales team at the numbers on the front page. To see if your meds are covered, check the Freedom formulary at healthpartners.com/medicarerx. Or, give us a call at the numbers on the front and we ll make sure you find what you re looking for. Who can join? Anyone who has Medicare Parts A and B and lives in our service area can join HealthPartners Freedom. Our service area includes all 87 counties in Minnesota and the following Wisconsin counties: Barron Burnett Douglas Dunn Pierce Polk St. Croix Washburn Know all your options You can get your Medicare coverage through a private health insurance plan, like HealthPartners, or through Original Medicare. To learn more about what Original Medicare covers and what it costs, read through your Medicare & You handbook. Or, visit medicare.gov to view it online. Want a hard copy? Call 800-MEDICARE (800-633-4227) to get yours. They re available 24 hours a day, seven days a week. (TTY 877-486-2048.) This document is available in other formats such as Braille, large print or audio. HealthPartners is a Cost plan with a Medicare contract. Enrollment in HealthPartners 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 copayments/co-insurance may change on January 1 of each year.