Summary of Benefits 2017 Y0027_16-092_EN CMS Accepted 08/30/2016
Summary of Benefits January 1, 2017 December 31, 2017 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. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Essence Advantage (HMO) or ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Essence Advantage and Essence Advantage Plus covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. 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 http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet Things to Know About Essence Advantage and Essence Advantage Plus Table of Contents ly Premium, Deductible and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Other Covered Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at 1-866-597-9560. Y0027_16-092_EN CMS Accepted 08/30/2016 1
Things to Know About Essence Advantage and Essence Advantage Plus Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central Time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central Time. Essence Advantage/Essence Advantage Plus Phone Numbers and Website If you have questions, call toll-free 1-866-509-5399 TTY: 711. Our website: http://www.essencehealthcare.com Who can join? To join Essence Advantage or Essence Advantage Plus, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Illinois: Madison, Monroe and St. Clair and Missouri: Jefferson, St. Charles, St. Francois, St. Louis and St. Louis City. Which doctors, hospitals and pharmacies can I use? Essence Advantage and Essence Advantage Plus have 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 must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan s provider directory at our website (http://www.essencehealthcare.com). Or, call us and we will send you a copy of the provider directory. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. What drugs do we cover? We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.essencehealthcare.com Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plans group each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur: Initial Coverage, Coverage Gap and Catastrophic Coverage. If you have questions about the different benefit stages, please contact the Plan for more information or access the Evidence of Coverage on our website. Essence Healthcare is an HMO plan with a Medicare contract. Enrollment in Essence Healthcare depends on contract renewal. 2
Table of Contents Inpatient Hospital Care... 4 Doctor s Office Visits... 5 Preventive Care... 5 Emergency Care... 6 Urgently Needed Services... 6 Diagnostic Tests, Lab and Radiology Services, and X-Rays... 6 Hearing Services... 6 Dental Services... 7 Vision Services... 7 Mental Health Care... 8 Inpatient Mental Health Care... 8 Skilled Nursing Facility (SNF)... 8 Rehabilitation Services... 9 Ambulance... 9 Transportation... 9 Foot Care... 9 Durable Medical Equipment... 10 Wellness Programs... 10 Prescription Drugs... 10 Medicare Part B Drugs... 10 Deductible... 10 Initial Coverage... 10 Coverage Gap... 13 Catastrophic Coverage... 14 Chiropractic Care... 15 Diabetes Supplies and Services... 15 Home Health Care... 15 Outpatient Substance Abuse... 15 Outpatient Surgery... 15 Prosthetic Devices... 16 Renal Dialysis... 16 Hospice... 16 3
ly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. $79 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $2,450 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $2,250 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Covered Medical and Hospital Benefits e: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your PCP. Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $265 per day for days 1 through 9 You pay nothing per day for days 10 through 90 You pay nothing per day for days 91 and beyond Authorization rules apply to inpatient hospital benefits. Our plan covers an unlimited number of days for an inpatient hospital stay. $195 per day for days 1 through 9 You pay nothing per day for days 10 through 90 You pay nothing per day for days 91 and beyond Authorization rules apply to inpatient hospital benefits. 4
Doctor s Office Visits 2 Preventive Care Primary care physician visit: $5 Specialist visit: $40 A referral is required for Physician Specialist Services. You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Aortic aneurysm screenings Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings Glaucoma screenings HIV screening Medical nutrition therapy services Nutrition therapy for End Stage Renal Disease Obesity screening and counseling Physical exams Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Primary care physician visit: $5 Specialist visit: $30 A referral is required for Physician Specialist Services. You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Aortic aneurysm screenings Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings Glaucoma screenings HIV screening Medical nutrition therapy services Nutrition therapy for End Stage Renal Disease Obesity screening and counseling Physical exams Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. 5
Emergency Care $75 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Emergency Care is available worldwide. $75 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Emergency Care is available worldwide. Urgently Needed Services $35 Urgently Needed Services is available nationwide. $75 outside of the United States $25 Urgently Needed Services is available nationwide. $75 outside of the United States Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1, 2 Diagnostic radiology services (such as MRIs, CT scans): 20% co-insurance Diagnostic tests and procedures: 20% co-insurance Lab services: You pay nothing Outpatient x-rays: $20 Therapeutic radiology services (such as radiation treatment for cancer): 20% co-insurance. Authorization and referral rules may apply for certain outpatient diagnostic procedures or tests. There is no for abdominal aneurysm screening, diabetes screening or prostate cancer screening when they are ordered as a preventative service. Diagnostic radiology services (such as MRIs, CT scans): 20% co-insurance Diagnostic tests and procedures: 20% co-insurance Lab services: You pay nothing Outpatient x-rays: $20 Therapeutic radiology services (such as radiation treatment for cancer): 20% co-insurance. Authorization and referral rules may apply for certain outpatient diagnostic procedures or tests. There is no for abdominal aneurysm screening, diabetes screening or prostate cancer screening when they are ordered as a preventative service. Hearing Services Exam to diagnose and treat hearing and balance issues: $20 Routine hearing exam: $20 Hearing Aids are not covered. Exam to diagnose and treat hearing and balance issues: $20 Routine hearing exam: $20 Hearing Aids are not covered. 6
Dental Services 2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $35 Dental services: $35 for a single office visit that includes: Cleaning (up to 2 every year) Dental x-ray(s) (up to 1 every year) Fluoride treatment (up to 1 every year) Oral exam (up to 2 every year) The preventive dental x-ray coverage is for horizontal bite-wing x-rays only. A referral may be required for some dental services. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $35 Dental services: $35 for a single office visit that includes: Cleaning (up to 2 every year) Dental x-ray(s) (up to 1 every year) Fluoride treatment (up to 1 every year) Oral exam (up to 2 every year) The preventive dental x-ray coverage is for horizontal bite-wing x-rays only. A referral may be required for some dental services. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $40 Routine eye exam (up to 1 every year): $35 Contact lenses (up to 1 every year): $35 Our plan pays up to $100 every year for contact lenses. Eyeglass frames (up to 1 every year): $35 Our plan pays up to $100 every year for eyeglass frames. Eyeglass lenses (up to 1 every year, this includes single, bifocal and trifocal): You pay nothing. Eyeglasses or contact lenses after cataract surgery: $35 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $30 Routine eye exam (up to 1 every year): $35 Contact lenses (up to 1 every year): $35 Our plan pays up to $100 every year for contact lenses. Eyeglass frames (up to 1 every year): $35 Our plan pays up to $100 every year for eyeglass frames. Eyeglass lenses (up to 1 every year, this includes single, bifocal and trifocal): You pay nothing. Eyeglasses or contact lenses after cataract surgery: $35 7
Mental Health Care 1 Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. $250 per day for days 1 through 7 You pay nothing per day for days 8 through 90 You pay nothing per day for days 91 and beyond Outpatient group therapy visit: $25 Outpatient individual therapy visit: $35 Authorization rules may apply to Mental Health benefits. Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. $195 per day for days 1 through 6 You pay nothing per day for days 7 through 90 You pay nothing per day for days 91 and beyond Outpatient group therapy visit: $25 Outpatient individual therapy visit: $35 Authorization rules may apply to Mental Health benefits. Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. $20 per day for days 1 through 20 $125 per day for days 21 through 100 No inpatient hospital stay is required prior to SNF admission. Co-payments are applied per day, per stay. Authorization rules apply to Skilled Nursing Facility benefits. Our plan covers up to 100 days in a SNF. $20 per day for days 1 through 20 $125 per day for days 21 through 100 No inpatient hospital stay is required prior to SNF admission. Co-payments are applied per day, per stay. Authorization rules apply to Skilled Nursing Facility benefits. 8
Rehabilitation Services 2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day up to 36 sessions up to 36 weeks): $30 Copayment for Cardiac Rehab Services applies per day. Occupational therapy visit: $30 A separate ment for Occupational Therapy will apply if other outpatient therapy services are rendered on the same day. Physical therapy and speech and language therapy visit: $30 A referral is required for Cardiac and Pulmonary Rehabilitation Services, Occupational therapy, Physical Therapy and Speech and Language Pathology Services. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day up to 36 sessions up to 36 weeks): $20 Copayment for Cardiac Rehab Services applies per day. Occupational therapy visit: $20 A separate ment for Occupational Therapy will apply if other outpatient therapy services are rendered on the same day. Physical therapy and speech and language therapy visit: $20 A referral is required for Cardiac and Pulmonary Rehabilitation Services, Occupational therapy, Physical Therapy and Speech and Language Pathology Services. Ambulance 1 $220 Authorization rules may apply to Ambulance benefits. $150 Authorization rules may apply to Ambulance benefits. Transportation Transportation benefit limited to 20 one-way trips to plan-approved locations every year. Transportation benefit limited to 20 one-way trips to plan-approved locations every year. Foot Care (podiatry services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 A referral is required for Podiatrist Services. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $30 A referral is required for Podiatrist Services. 9
Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 20% co-insurance. Authorization rules may apply to Durable Medical Equipment benefits. 20% co-insurance. Authorization rules may apply to Durable Medical Equipment benefits. Wellness Programs Health Club Membership/Fitness classes through SilverSneakers: Health Club Membership/Fitness classes through SilverSneakers: Prescription Drug Benefits Medicare Part B Drugs For Part B drugs such as chemotherapy drugs 1 : 20% co-insurance. Other Part B drugs 1 : 20% co-insurance. For Part B drugs such as chemotherapy drugs 1 : 20% co-insurance. Other Part B drugs 1 : 20% co-insurance. Authorization may be required for some Part B drugs. Authorization may be required for some Part B drugs. Deductible This plan does not have a deductible. This plan does not have a deductible. Initial Coverage You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Retail Cost-Sharing Preferred Retail Cost-Sharing 1 Generic) 1 Generic) 10
2 (Generic) 2 (Generic) 3 $34 $68 $102 3 $29 $58 $87 4 (Non- Preferred $65 $130 $195 4 (Non- Preferred $55 $110 $165 5 (Specialty ) 33% co-insurance 5 (Specialty ) 33% co-insurance Standard Retail Cost-Sharing Standard Retail Cost-Sharing 1 Generic) $4 $8 $12 1 Generic) $4 $8 $12 2 (Generic) $12 $24 $36 2 (Generic) $12 $24 $36 3 $47 $94 $141 3 $42 $84 $126 4 (Non- Preferred $100 $200 $300 4 (Non- Preferred $80 $160 $240 11
5 (Specialty ) 33% co-insurance 5 (Specialty ) 33% co-insurance Standard Mail Order Cost-Sharing Standard Mail Order Cost-Sharing 1 Generic) $12 1 Generic) $12 2 (Generic) $36 2 (Generic) $36 3 $141 3 $126 4 (Non- Preferred $300 4 (Non- Preferred $240 5 (Specialty ) 33% co-insurance 5 (Specialty ) 33% co-insurance 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-ofnetwork pharmacy at the same cost as an in-network pharmacy. 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-ofnetwork pharmacy at the same cost as an in-network pharmacy. 12
Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700 After you enter the coverage gap, you pay 40% of the plan s cost for covered brand name drugs and 51% of the plan s cost for covered generic drugs until your costs total $4,950, which is the end of the coverage gap. everyone will enter the coverage gap. Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan s cost for covered brand name drugs until your out-of-pocket costs total $4,950, which is the end of the coverage gap. everyone will enter the coverage gap. Under this plan, you may pay even less for the generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug s tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Drugs Covered 1 Generic) All $2 $4 $6 2 (Generic) All $5 $10 $15 13
Preferred Retail Cost-Sharing Drugs Covered 1 Generic) All 2 (Generic) All Standard Mail Order Cost-Sharing Drugs Covered Two 1 Generic) All $6 2 (Generic) All $15 Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% co-insurance, or $3.30 for generic (including brand drugs treated as generic) and a $8.25 for all other drugs. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% co-insurance, or $3.30 for generic (including brand drugs treated as generic) and a $8.25 for all other drugs. 14
Other Covered Benefits Chiropractic Care 2 Diabetes Supplies and Services 1 Home Health Care 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 A referral is required for Chiropractic Services. Diabetes monitoring supplies (including glucose monitors, lancets and test strips): You pay nothing. When glucose meters and test strips are obtained at a pharmacy, coverage is limited to specific Bayer/Ascensia products. Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% co-insurance Authorization is required for diabetic shoes and inserts. You pay nothing A referral is required for Home Health Services. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $15 A referral is required for Chiropractic Services. Diabetes monitoring supplies (including glucose monitors, lancets and test strips): You pay nothing. When glucose meters and test strips are obtained at a pharmacy, coverage is limited to specific Bayer/Ascensia products. Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 20% co-insurance Authorization is required for diabetic shoes and inserts. You pay nothing A referral is required for Home Health Services. Outpatient Substance Abuse 1 Group therapy visit: $25 Individual therapy visit: $35 Authorization rules may apply to Substance Abuse benefits. Group therapy visit: $25 Individual therapy visit: $35 Authorization rules may apply to Substance Abuse benefits. Outpatient Surgery 1, 2 Ambulatory surgical center: $175 Outpatient hospital: $225 or 20% co-insurance., depending on the service Authorization rules may apply for some Ambulatory Surgical Center and Outpatient Hospital Surgery services. Ambulatory surgical center: $100 Outpatient hospital: $125 or 20% co-insurance., depending on the service Authorization rules may apply for some Ambulatory Surgical Center and Outpatient Hospital Surgery services. 15
Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: 20% co-insurance. Related medical supplies: 20% co-insurance. Authorization rules may apply for some Prosthetics/Medical supplies. Prosthetic devices: 20% co-insurance. Related medical supplies: 20% co-insurance. Authorization rules may apply for some Prosthetics/Medical supplies. Renal Dialysis 20% co-insurance 20% co-insurance Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 16
Index Ambulance... 9 Chiropractic Care... 15 Dental Services... 7 Diabetes Supplies and Services... 15 Diagnostic Tests, Lab and Radiology Services, and X-Rays... 6 Doctor s Office Visits... 5 Durable Medical Equipment... 10 Emergency Care... 6 Foot Care... 9 Hearing Services... 6 Home Health Care... 15 Hospice... 16 Inpatient Hospital Care... 4 Inpatient Mental Health Care... 8 Mental Health Care... 8 Outpatient Substance Abuse... 15 Outpatient Surgery... 15 Preventive Care... 5 Prescription Drugs... 10 Medicare Part B Drugs... 10 Deductible... 10 Initial Coverage... 10 Coverage Gap... 13 Catastrophic Coverage... 14 Prosthetic Devices... 16 Rehabilitation Services... 9 Renal Dialysis... 16 Skilled Nursing Facility (SNF)... 8 Transportation... 9 Urgently Needed Services... 6 Vision Services... 7 Wellness Programs... 10 17
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13900 Riverport Drive Maryland Heights, MO 63043 www.essencehealthcare.com Local: 314-209-2700 Toll-free: 1-866-597-9560 TTY users dial: 711 8 a.m. to 8 p.m. seven days a week You may receive a messaging service on weekends and holidays from February 15 through September 30. Please leave a message and your call will be returned the next business day. Essence Healthcare is an HMO plan with a Medicare contract. Enrollment in Essence Healthcare depends on contract renewal. SB-11