MAPD HMO Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-877-795-6131 8 a.m. to 8 p.m. daily TTY/TDD 711 HealthAllianceRetiree.org/SOI ste-statemedsob-0914
SECTION I INTRODUCTION TO SUMMARY OF BENEFITS ENROLLMENT OPTIONS It is important to understand Health Alliance MAPD HMO s eligibility policies, and the possible impact to your retiree health care coverage options and other benefi ts, before submitting a request to enroll in a plan not offered by your Plan Sponsor, or a request to end your membership in our plan. Please call Health Alliance MAPD HMO Customer Service, at the number listed at the end of this introduction, or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. SECTIONS IN THIS BOOKLET Things to Know About Health Alliance MAPD HMO Monthly Premium, Deductible and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefi ts Prescription Drug Benefi ts 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 1-888-382-9771 or, for TTY users, 711. THINGS TO KNOW ABOUT HEALTH ALLIANCE MAPD HMO HOURS OF OPERATION 8:00 a.m. to 8:00 p.m. Monday through Friday HEALTH ALLIANCE MAPD HMO PHONE NUMBERS AND WEBSITE Call 1-877-795-6131. TTY users call 711. Visit HealthAllianceRetiree.org/SOI WHO CAN JOIN? You can join Health Alliance MAPD HMO if you are entitled to Medicare Part A, enrolled in Medicare Part B, live in the service area and you meet the eligibility requirements of your former employer, union group or trust administrator. 1
WHICH DOCTORS, HOSPITALS AND PHARMACIES CAN I USE? Health Alliance MAPD HMO members 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 and pharmacy directory at our website (HealthAllianceRetiree.org/SOI). Or, call us and we will send you a copy of the provider and pharmacy directories. 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. 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, HealthAllianceRetiree.org/SOI. Or, call us and we will send you a copy of the formulary. HOW WILL I DETERMINE MY DRUG COSTS? Our plan groups each medication into different levels of coverage: Preferred Generic (Tier 1), Non-Preferred Generic (Tier 2), Preferred Brand (Tier 3), Non-Preferred Brand (Tier 4) and Specialty (Tier 5). 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 benefi t you have reached. Later in this document we discuss the benefi t stages that occur after you meet your deductible: Initial Coverage, Coverage Gap and Catastrophic Coverage. 2
If you have any questions about this plan s benefi ts or costs, please contact Health Alliance Medical Plans for details. SECTION II SUMMARY OF BENEFITS MONTHLY PREMIUM, DEDUCTIBLE AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the Please see the TRAIL booklet for more information. Please see the TRAIL booklet for more information. monthly premium? How much is the deductible? $0 per year (medical) $0 per year (medical) Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? 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: $3,000 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. No. There are no limits on how much our plan will pay. 3 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: $3,000 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. No. There are no limits on how much our plan will pay. Health Alliance MAPD HMO is an HMO plan with a Medicare Contract. Enrollment in Health Alliance MAPD HMO depends on contract renewal. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture and Not covered Not covered Other Alternative Therapies Ambulance $0 $0
Chiropractic Care 1, 2 Dental Services Diabetes Supplies and Services Diagnostic Tests, Lab and Radiology Services and X-rays Doctor s Office Visits 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, fi lling, removal, or replacement of teeth): $30 copay Diabetes monitoring supplies: 4% of the cost, depending on the Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 4% of the cost Diagnostic radiology services (such as MRIs, CT scans): $0 Diagnostic tests and procedures: $0 Lab services: $0 Outpatient X-rays: $0 Therapeutic radiology services (such as radiation treatment for cancer): $30 Primary care physician visit: Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, fi lling, removal, or replacement of teeth): Diabetes monitoring supplies: 4% of the cost, depending on the Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 4% of the cost Diagnostic radiology services (such as MRIs, CT scans): $0 Diagnostic tests and procedures: $0 Lab services: $0 Outpatient X-rays: $0 Therapeutic radiology services (such as radiation treatment for cancer): $20 Primary care physician visit: Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Foot Care (Podiatry Services) 2 Specialist visit: $30 copay Specialist visit: $20 4% of the cost 4% of the cost Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: $30 copay Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: 4
Hearing Services Exam to diagnose and treat hearing and balance issues: $30 copay Exam to diagnose and treat hearing and balance issues: Hearing Exam (one routine hearing exam every 36 Routine hearing exam: Not Covered months): $150 Home Health Care 1 $30 $15 Mental Health Care 1, 2 Inpatient visit: Our plan covers up to 365 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital. Inpatient visit: Our plan covers up to 365 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital. $350 per admission Outpatient group therapy visit: Outpatient individual therapy visit: Outpatient Cardiac (heart) rehab services: $30 Rehabilitation 1 Occupational therapy visit: $30 copay $250 per admission Outpatient group therapy visit: Outpatient individual therapy visit: Cardiac (heart) rehab services: $20 Occupational therapy visit: Outpatient Substance Abuse 1 Outpatient Surgery Physical therapy and speech and language therapy visit: $30 copay Group therapy visit: Individual therapy visit: Outpatient Surgery: $250 copay Physical therapy and speech and language therapy visit: Group therapy visit: Individual therapy visit: Outpatient Surgery: $150 copay Over-the-Counter Items Prosthetic Devices (Braces, Artificial Limbs, etc.) 1 Outpatient Hospital Services: $0 copay Not covered Prosthetic devices: 4% of the cost Related medical supplies: 4% of the cost 5 Outpatient Hospital Services: $0 copay Not covered Prosthetic devices: 4% of the cost Related medical supplies: 4% of the cost
Renal Dialysis You pay nothing You pay nothing Transportation Not covered Not covered Urgent Care $30 copay Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $30 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Preventive Care You pay nothing You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 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. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 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. 6
Hospice INPATIENT CARE Inpatient Hospital Care You pay nothing for hospice care from a Medicarecertifi ed hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing for hospice care from a Medicarecertifi ed hospice. You may have to pay part of the cost for drugs and respite care. Our plan covers an unlimited number of days for an inpatient hospital stay. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 $350 per admission You pay nothing PRESCRIPTION DRUG BENEFITS How much do I pay? For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 120 days in a SNF. For Part B drugs such as chemotherapy drugs: You pay nothing Other Part B drugs: You pay nothing $250 per admission For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 120 days in a SNF. You pay nothing For Part B drugs such as chemotherapy drugs: You pay nothing Other Part B drugs: You pay nothing 7
Initial Coverage After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our plan. You may get your drugs at network retail pharmacies and mail-order pharmacies. Prescription drug deductible: $100 Network Retail Cost-Sharing Tier One-month Threemonth Preferred Generic (Tier 1) $8* $20* Non-Preferred Generic (Tier 2) $8* $20* Preferred Brand (Tier 3) $26 $65 Non-Preferred Brand (Tier 4) $50 $125 Specialty (Tier 5) $50 $125 * When you get your Tier 1 and Tier 2 drugs from a preferred network pharmacy, your cost-sharing is $0. After you pay your yearly deductible, you pay the following until your total yearly drug costs reach $2,960. Total yearly drug costs are the total drug costs paid by both you and our plan. You may get your drugs at network retail pharmacies and mail-order pharmacies. Prescription drug deductible: $0 Network Retail Cost-Sharing Tier One-month Threemonth Preferred Generic (Tier 1) $10* $25* Non-Preferred Generic (Tier 2) $10* $25* Preferred Brand (Tier 3) $20 $50 Non-Preferred Brand (Tier 4) $40 $100 Specialty (Tier 5) $40 $100 * When you get your Tier 1 and Tier 2 drugs from a preferred network pharmacy, your cost-sharing is $0. 8
Initial Coverage (continued) Coverage Gap Catastrophic Coverage Standard Mail-Order Cost-Sharing Tier One-month Threemonth Preferred Generic (Tier 1) $8 $20 Non-Preferred Generic (Tier 2) $8 $20 Preferred Brand (Tier 3) $26 $65 Non-Preferred Brand (Tier 4) $50 $125 Specialty (Tier 5) $50 $125 If you reside in a long-term care facility, you pay the same as at a network retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Costs remain the same through the Coverage Gap as they were in the Initial Coverage period. The Coverage Gap period starts when the total yearly drug cost (including what you and Health Alliance MAPD HMO paid) reached $2,960 and lasts until your total drug costs reach $4,700. Not everyone will reach the gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost for a 30-day, but no greater than $50, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. Standard Mail-Order Cost-Sharing Tier One-month Threemonth Preferred Generic (Tier 1) $10 $20 Non-Preferred Generic (Tier 2) $10 $20 Preferred Brand (Tier 3) $20 $40 Non-Preferred Brand (Tier 4) $40 $80 Specialty (Tier 5) $40 $80 If you reside in a long-term care facility, you pay the same as at a network retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Costs remain the same through the Coverage Gap as they were in the Initial Coverage period. The Coverage Gap period starts when the total yearly drug cost (including what you and Health Alliance MAPD HMO paid) reached $2,960 and lasts until your total drug costs reach $4,700. Not everyone will reach the gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay the greater of: 5% of the cost for a 30-day, but no greater than $40, or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs. 9
TRUE SERVICE When you call, you ll speak with a helpful member services representative based out of Champaign. Most have been with us for years and know our plans inside and out. They will: Answer your questions. Sign you up for a seminar. Arrange for someone to meet with you. Stop by 8 a.m. to 5 p.m. weekdays in the Champaign-Urbana area. We re at 206 W. Anthony Drive, near Alexander s Steakhouse just off Interstate 74 at Neil Street. Prospect Ave. I-74 Lincoln Ave. Neil St. KEEP YOUR DOCTOR With so many doctors in our network and more being added all the time chances are you can keep seeing the doctors you know and trust. Use our provider search at HealthAllianceRetiree.org/SOI or call today to learn more. With an HMO plan, your Primary Care Physician (PCP) helps you keep track of the care you need and connects you with specialists when you need them. EXTRAS SilverSneakers means free fitness club membership or at-home exercise kits. Information and support at SilverSneakers.com, too. Assist America helps with access to medical services while traveling. This free feature helps replace lost prescriptions and get members back home if they get sick. Plus, our members can call our 24-hour Anytime Nurse Line when their doctor s offi ce is closed. 10