Join the WELLfluent GET FIT. EAT RIGHT. CONNECT. GROW. Summary of Benefits 2019 Broward County AvMed Medicare Choice HMO H1016, Plan 021 This is a summary of drug and health services covered by AvMed Medicare Choice (HMO) January 1, 2019 - December 31, 2019 AvMed Medicare Plan is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join AvMed Medicare (HMO), 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 county in Florida: Broward. If you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877- 486-2048. This document is available in other formats such as braille, large print or audio. For more information, please call us at 1-800-535-9355 (TTY users should call 711), or visit us at www.avmed.org. From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. and Saturdays 9:00 a.m. to 1:00 p.m. Eastern. AvMed Medicare is an HMO plan with a Medicare contract. Enrollment in AvMed Medicare depends on contract renewal.
Premiums and Benefits AvMed Medicare Choice Plan HMO What You Should Know Monthly Plan Premium You pay nothing You must continue to pay your Medicare Part B premium. Deductible You pay nothing This plan does not have a deductible. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $3,400 annually Includes copays and other costs for medical services for the year. Inpatient Coverage $0 copay per day for days 1 through 5 $40 copay per day days 6 through 20 You pay nothing per day for days 21-90 and beyond Outpatient Hospital Coverage $75 non-hospital affiliated $200 hospital affiliated $35 - $60 per treatment per day for radiation therapy Doctor Visits Primary Specialists copay per PCP visit You pay $10-$20 copay per specialist visit ($10 copay will apply when utilizing AvMed High Performance Network (HPN) providers). Our plan covers an unlimited number of days for an inpatient hospital stay. Requires prior authorizations in inpatient. May require prior authorization Referral from your PCP may be required for specialist visit. Preventive Care (e.g., flu vaccine, diabetic screenings) You pay nothing Any additional preventive services approved by Medicare during the contract year will be covered. There are some covered services that have a cost. Emergency Care You pay $120 copay per visit If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Urgently Needed Services You pay $20 copay per visit Diagnostic Services/Labs/ Imaging Diagnostic radiology service (e.g. MRI) Lab services Diagnostic tests and procedures Outpatient x-rays Hearing Services Hearing exam Hearing aid You pay $75 - $225 copay copay You pay $10 - $25 copay ($10 in office, $25 hospital or other facility) You pay $10 - $25 copay ($10 in office, $25 hospital or other facility) You pay $5 copay for each Medicare-covered diagnostic hearing exam. Hearing aid not covered Prior authorization is required for some services by your doctor, other network provider or health plan. Please contact the plan for more information. In general, routine hearing exams and hearing aids are not covered. 2 MEDICARE SUMMARY OF BENEFITS
January 1, 2019 - December 31, 2019 Premiums and Benefits AvMed Medicare Choice Plan HMO What You Should Know Dental Services Oral exam X-rays Cleaning Vision Services Routine eye exam Eyeglasses (frames and lenses) $0-$175 Medicare covered dental services - $25 (depending on the service) - $35 (depending on the service) - $45 (depending on the service) $0 routine eye exam $5 diabetic eye exam $200 eyewear allowance Please see Delta Dental Description of Benefits and Copayments. Mental Health Services Inpatient visit Outpatient group therapy visit Outpatient individual therapy visit You pay $150 per day for days 1-9 per day for days 10-90 You pay $15 outpatient group therapy visit You pay $15 outpatient individual therapy visit Skilled Nursing Facility You pay nothing per day for days 1 through 20 You pay $135 copay per day for days 21 through 100 Physical Therapy You pay $15 outpatient individual therapy visit Occupational therapy visit Physical therapy and speech and language therapy visit Our plan covers up to 100 days in an SNF per benefit period. Ambulance Transportation Medicare Part B Drugs Foot Care (podiatry services) Foot exams and treatment Routine foot care Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) Diabetic supplies Wellness Programs Fitness Health education Nursing Hotline SilverSneakers You pay $200 copay per one-way trip Not covered 10-20% of the cost for chemotherapy drugs 10-20% of the cost for other Part B drugs You pay $5 copay You pay $5 copay You pay 20% of the cost copay You pay nothing 10% in office or nonhospital affiliated 20% hospital affiliated For more information on Wellness Programs, please call us or access our Evidence of Coverage online. 3
Outpatient Prescription Drugs Part D Stages Initial Coverage: You pay the following until your total yearly drug costs reach $3,820. 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. Standard Retail Rx 30-day supply Preferred Mail Order/ Standard Retail Rx 90-day supply Standard Mail Order 90-day supply Tier 1: Preferred Generic Tier 2: Non- Preferred Generic Tier 3: Preferred Brand Tier 4: Non- Preferred Drug Tier 5: Specialty Tier You pay $5 You pay $40 You pay $75 You pay 33% You pay $12.50 You pay $100 You pay $187.50 Not offered You pay $15 You pay $120 You pay $225 Not offered Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the part D Benefit. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. 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, but may pay more than you pay at an in-network pharmacy. Part D Stages Coverage Gap: The coverage gap begins after the total yearly drug cost (including what you pay and the plan pays) reaches $3,820. After you enter the coverage gap, you pay $0-$5 for a one month supply for tier one and tier two drugs. For brand name drugs in tier three, four, and five, you pay 25% of the price. For generic drugs in tier three, four, and five, you pay 37%. Tier 1: Preferred Generic Tier 2: Non- Preferred Generic Catastrophic Coverage: Standard Retail Rx 30-day supply You pay $5 Preferred Mail Order/ Standard Retail Rx 90-day supply You pay $12.50 Standard Mail Order 90-day supply You pay $15 After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay the greater of: 5% of the costs, or $3.40 for a generic (including brand drugs treated as a generic) and $8.50 for all others. 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. This document is available in other formats such as braille, large print or audio. 4 MEDICARE SUMMARY OF BENEFITS
January 1, 2019 - December 31, 2019 A complete list of services is found in the Evidence of Coverage (EOC), or you can access by visiting www.avmed.org or by calling the number listed below. Toll-free 1-800-535-9355, TTY users should call 711. From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. You can see our plan s provider and pharmacy directory at our website at www.avmed.org. 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 at www.avmed.org. 5
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January 1, 2019 - December 31, 2019 Notes 7
MEDPRF-560 (09/18) 18-12926