2016 medicare advantage plans - maricopa county, arizona · things to consider in choosing a plan...
TRANSCRIPT
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2016
Medicare Advantage Plans in Maricopa County
There are a variety of different types of Medicare Health Plans to choose. The
attached comparison sheets should be used as a guideline in selecting the type of health
plan that meets your individual needs. Things to consider in choosing a plan include
cost, choice of doctor, benefits, prescription coverage, flexibility and convenience.
The following types of health plans are available to most individuals enrolled in
Medicare living in Maricopa County:
1. Health Maintenance Organizations (HMO) Pg. 3
2. Preferred Provider Organizations (PPO) Pg. 33 And Private Fee For Service Plans
Most current revision: 10/12/2015
BENEFITS ASSISTANCE PROGRAM A State Health Insurance Assistance Program (SHIP)
A program of the Area Agency on Aging, Region One
1366 East Thomas, Suite 108, Phoenix, AZ 85014
602-264-2255
The Benefits Assistance Program, part of the AZ State Health Insurance and Assistance Program
(SHIP), does not recommend or endorse any particular company or plan and is not responsible for the
service provided by these companies. These comparison sheets are provided as a guide to assist you
in making your health care decisions. This publication has been created or produced by the Area
Agency on Aging, Region One with financial assistance, in whole or in part, through a grant from the
Administration for Community Living.
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Health Maintenance Organizations (HMO)
A group of doctors, hospitals, and other health care providers who agree to give health
care to Medicare beneficiaries for a set amount of money from Medicare each month.
In an HMO, you generally must get all your care and services from doctors or hospitals
in the plan’s network (except emergency or urgent care). You generally must see a
primary care doctor to get a referral before you see any other health care provider. If
you get health care outside the plan’s network, you may have to pay the full cost.
Plans with Prescription Drug Coverage:
Page
1. AARP Medicare Complete Plan 1 3
2. AARP Medicare Complete Plan 2 5
3. Aetna Medicare Prime Plan 7
4. Blue Medicare Advantage Classic 9
5. Blue Medicare Advantage Plus 11
6. Blue Medicare Advantage Premier 13
7. CIGNA HealthSpring Preferred 15
8. CIGNA HealthSpring Preferred Plus 17
9. Health Net Ruby 1 19
10. Health Net Ruby Select 21
11. Humana Community HMO 23
12. Humana Gold Plus HMO 25
13. Phoenix Advantage 27
14. Phoenix Advantage Select 29
Plans WITHOUT Prescription Drug Coverage:
1. Health Net Green 31
Preferred Provider Organizations (PPOs) begin on page 33
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AARP MedicareComplete Plan 1 (HMO) Plan Number H0609-026 STAR RATING = 4.5 STARS
Optum Medical Network and Banner Health Network
United Healthcare
1-800-555-5757
aarpmedicareplans.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $6,700.00
Inpatient Hospital
Co-pay per day for days 1 –4 $395.00
Co-pay per day for days 5 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 62 $160.00
Co-pay per day for days 63 – 100 $0.00
Outpatient Mental Health
Co-pay per visit $30.00 to $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $30.00 to $40.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $250.00
Physician Services
Co-pay for Primary Care Physician $10.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per visit (Medicare covered and up to 6 supplemental visits) $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $15 to 20%
Outpatient Services
Facility co-pay at ambulatory surgical center 20%
Facility co-pay per outpatient hospital facility visit 20%
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00
Co-pay per annual vision exam $45.00
Frames-lenses/contacts benefit (every 2 years) $70.00/$105.00
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam $10.00
Hearing aid appliance $390.00 to $450.00
Transportation Not covered
Dental (limited services) (optional dental plan available) $45.00
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PRESCRIPTION DRUG COVERAGE
AARP Medicare Complete Plan 1 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $205.00 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$2 Tier 1: 30 day supply of preferred generic drugs
$8 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$95 Tier 4: 30 day supply of non-preferred brand drugs
28% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310.
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $95 non-preferred brand drug co-pay for that drug.
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AARP MedicareComplete Plan 2 (HMO) Plan Number H0609-027 STAR RATING = 4.5 STARS
Optum Medical Network Only
United Healthcare
1-800-555-5757
aarpmedicareplans.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,200.00
Inpatient Hospital
Co-pay per day for days 1 –7 $150.00
Co-pay per day for days 8 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 40 $160.00
Co-pay per day for days 41 – 100 $0.00
Outpatient Mental Health
Co-pay per visit $30.00 to $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $25.00 to $40.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $150.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $25.00
Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per visit (Medicare covered and up to 6 supplemental visits) $25.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $15 to 20%
Outpatient Services
Facility co-pay at ambulatory surgical center $150.00
Facility co-pay per outpatient hospital facility visit $150.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00
Co-pay per annual vision exam $45.00
Frames/lenses/contacts benefit (every 2 years) $70.00/NO COST/$30.00
Hearing Services
Co-pay for Medicare covered hearing exam $25.00
Co-pay for annual hearing exam $0.00
Hearing aid appliance $390.00 to $450.00
Transportation Not covered
Dental (limited services) (optional plan available) $45.00
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PRESCRIPTION DRUG COVERAGE
AARP Medicare Complete Plan 2 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $205.00 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$2 Tier 1: 30 day supply of preferred generic drugs
$8 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$95 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310.
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
6. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
7. This plan allows for the purchase of 90 day supplies at retail pharmacies.
8. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
9. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
10. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $95 non-preferred brand drug co-pay for that drug.
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Aetna Medicare Prime Plan (HMO) Plan Number H3931-092 STAR RATING = 4 STARS
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $6,400.00
Inpatient Hospital
Co-pay per day for days 1 – 6 $195.00
Co-pay per day for days 7 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 0
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $30.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $0.00 to $60.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $315.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $30.00
Physical, Occupational, Speech Therapy
Co-pay per visit $30.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $30.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to 20%
Outpatient Services
Facility co-pay at ambulatory surgical center $195.00
Facility co-pay per outpatient hospital facility visit $30.00 to $195.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $30.00
Co-pay per annual vision exam $0.00
Eyeglasses or contacts annual benefit Optional plan available
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $30.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance Optional plan available
Transportation Not covered
Dental Optional plan available
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PRESCRIPTION DRUG COVERAGE
Aetna Medicare Prime Plan (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $100.00 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$8 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
42% Tier 4: 30 day supply of non-preferred brand drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities, may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $42% non-preferred brand drug co-pay for that drug.
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Blue Medicare Advantage Classic (HMO) Plan Number H0302-006 STAR RATING = 4 STARS
Banner Health Network and Other Providers
Blue Cross Blue Shield
1-800-422-0761
azbluemedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0
Maximum out-of-pocket limit $3,200.00
Inpatient Hospital
Co-pay per day for days 1 – 7 $190.00
Co-pay per day for days 8 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 10 $0.00
Co-pay per day for days 11 – 20 $25.00
Co-pay per day for days 21 – 100 $120.00
Outpatient Mental Health
Co-pay per visit $20.00 to $30.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $25.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $150.00 or 20%
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $30.00
Physical, Occupational, Speech Therapy
Co-pay per visit $15.00
Routine Podiatry Service
Co-pay per visit $40.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $300.00 (or 20%)
Outpatient Services
Facility co-pay at ambulatory surgical center $25.00 to $260.00
Facility co-pay per outpatient hospital facility visit $25.00 to $260.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $25.00
Co-pay per annual vision exam No coverage
Frames/lenses/contacts No coverage
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance (every 2 years) No coverage
Transportation No coverage
Dental No coverage
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PRESCRIPTION DRUG COVERAGE
Blue Medicare Advantage Classic (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$0 Tier 1: 30 day supply of preferred generic drugs
$10 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$95 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $95 non-preferred brand drug co-pay for that drug.
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Blue Medicare Advantage Plus (HMO) Plan Number H0302-001 STAR RATING = 4 STARS
Banner Health Network and Other Providers
Blue Cross Blue Shield
1-800-422-0761
azbluemedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $29.00 (LIS $0.00)
Maximum out-of-pocket limit $3,200.00
Inpatient Hospital
Co-pay per day for days 1 – 7 $160.00
Co-pay per day for days 8 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 10 $0.00
Co-pay per day for days 11 – 20 $25.00
Co-pay per day for days 21-100 $100.00
Outpatient Mental Health
Co-pay per visit $20.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $65.00
Co-pay per visit for urgent care $25.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $125.00 or 20%
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $15.00
Physical, Occupational, Speech Therapy
Co-pay per visit $10.00 to $15.00
Routine Podiatry Service
Co-pay per visit $20.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $275.00 (or 20%)
Outpatient Services
Facility co-pay at ambulatory surgical center $25.00 to $200.00
Facility co-pay per outpatient hospital facility visit $25.00 to $200.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit (includes respite care) $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam $0.00 to $20.00
Co-pay per annual vision exam No coverage
Frames/lenses/contacts No coverage
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental (cleaning, x-ray, oral exam annually; $500 preventive annual benefit) $0.00
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PRESCRIPTION DRUG COVERAGE
Blue Medicare Advantage Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$0 Tier 1: 30 day supply of preferred generic drugs
$10 Tier 2: 30 day supply of non-preferred generic drugs
$40 Tier 3: 30 day supply of preferred brand drugs
$90 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,500
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $90 non-preferred brand drug co-pay for that drug.
- 13 -
Blue Medicare Advantage Premier (HMO) Plan Number H0302-007 STAR RATING = 4 STARS
Banner Health Network and Other Providers
Blue Cross Blue Shield
1-800-422-0761
azbluemedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $89.00 (LIS $55.80)
Maximum out-of-pocket limit $2,900.00
Inpatient Hospital
Co-pay per day for days 1 – 3 $100.00
Co-pay per day for days 4 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $100.00
Outpatient Mental Health
Co-pay per visit $20.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $50.00
Co-pay per visit for urgent care $15.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $50.00 or 20%
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $15.00
Physical, Occupational, Speech Therapy
Co-pay per visit $10.00
Routine Podiatry Service
Co-pay per visit $20.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $250.00 (or 20%)
Outpatient Services
Facility co-pay at ambulatory surgical center $25.00 to $125.00
Facility co-pay per outpatient hospital facility visit $25.00 to $125.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit (includes respite care) $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 10%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $15.00
Co-pay per annual vision exam $10.00
Frames/lenses/contacts $0 to 20%
Hearing Services
Co-pay for Medicare covered hearing exam $0.00 to $15.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental (annual cleaning, x-ray, oral exam; up to $5,000/yr preventive) $0.00
- 14 -
PRESCRIPTION DRUG COVERAGE
Blue Medicare Advantage Premier (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece
of durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,200:
$0 Tier 1: 30 day supply of preferred generic drugs
$9 Tier 2: 30 day supply of non-preferred generic drugs
$30 Tier 3: 30 day supply of preferred brand drugs
$80 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,500
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $80 non-preferred brand drug co-pay for that drug.
- 15 -
CIGNA HealthSpring Preferred (HMO) Plan Number H0354-001 STAR RATING = 5 STARS
CIGNA
1-855-561-3811
cignamedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $5,250.00
Inpatient Hospital
Co-pay per day for days 1 – 7 $225.00
Co-pay per day for days 8 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $25.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $300.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $30.00
Physical, Occupational, Speech Therapy
Co-pay per visit $30.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $30.00
Co-pay for each supplemental routine visit
Chiropractic Care
Co-pay per visit (up to 12 routine visits per year) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $300.00 (or 20%)
Outpatient Services
Facility co-pay at ambulatory surgical center $50.00 to $175.00
Facility co-pay per outpatient hospital facility visit $150.00 to $275.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0
Co-pay per vision exam (every 2 years) $15.00
Co-pay for eyeglasses or contacts No coverage
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $30.00
Co-pay for routine hearing exam $30.00
Hearing aid appliance No coverage
Transportation No coverage
Dental (limited services) (optional plan available) $30.00
- 16 -
PRESCRIPTION DRUG COVERAGE
CIGNA HealthSpring Preferred (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$0 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs, 0% on plan’s preferred generics
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan’s in-network prescription coverage may be limited to the plan’s service area. This
means that you may pay more for your prescription drugs if you get them at an in-network
pharmacy outside of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug.
- 17 -
CIGNA HealthSpring Preferred Plus (HMO) Plan Number H0354-023 STAR RATING = 5 STARS
CIGNA
1-855-561-3811
cignamedicare.com
Out-of-Network Services No coverage
Monthly Premium for this plan $75.00 (LIS $45.90)
Maximum out-of-pocket limit $5,000.00
Inpatient Hospital
Co-pay per day for days 1 – 7 $190.00
Co-pay per day for days 8 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $25.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $300.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $15.00
Physical, Occupational, Speech Therapy
Co-pay per visit $15.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $15.00
Chiropractic Care
Co-pay per visit (up to 12 routine visits per year) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $300.00 (or 20%)
Outpatient Services
Facility co-pay at ambulatory surgical center $50.00 to $175.00
Facility co-pay per outpatient hospital facility visit $150.00 to $275.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam $0.00 to $15.00
Co-pay per vision exam $15.00
Frames, Lenses, and Contacts Annual Benefit $300.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $15.00
Co-pay for routine hearing exam $15.00
Hearing aid appliance annual benefit $300.00
Transportation (check with plan for details) $0.00
Dental (2 cleanings, 1 x-ray, 4 exams every year) $5.00 to $15.00
- 18 -
PRESCRIPTION DRUG COVERAGE
CIGNA HealthSpring Preferred Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$0 Tier 1: 30 day supply of preferred generic drugs
$10 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$95 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs, 0% on plan’s preferred generics
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
6. This plan’s in-network prescription coverage may be limited to the plan’s service area. This
means that you may pay more for your prescription drugs if you get them at an in-network
pharmacy outside of the plan’s service area (for instance when you travel).
7. This plan allows for the purchase of 90 day supplies at retail pharmacies.
8. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
9. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
10. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $95 non-preferred brand drug co-pay for that drug.
- 19 -
Health Net Ruby 1 (HMO) Plan Number H0351-043 STAR RATING = 3.5 STARS
Arizona Priority Care Network
Health Net of AZ
1-800-333-3930
healthnet.com
Out-of-Network Services No coverage
Monthly Premium for this plan $59.00 (LIS $59.00)
Maximum out-of-pocket limit $4,000.00
Inpatient Hospital Abrazo, Dignity, and St. Lukes Hospital Network
Co-pay per day for days 1 -5 $100.00
Co-pay per day for days 6 and beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0
Co-pay per day for days 21 – 100 $100.00
Outpatient Mental Health
Co-pay per visit $15.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $20.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $125.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $15.00
Physical, Occupational, Speech Therapy
Co-pay per visit $10.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $15.00
Chiropractic Care
Co-pay per visit (optional plan available with additional visits covered) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 - $200.00
Outpatient Services
Facility co-pay at ambulatory surgical center $50.00
Facility co-pay per outpatient hospital facility visit $75.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam $0.00 to $15.00
Co-pay per annual vision exam Optional plan available
Frames/lenses/contacts benefit Optional plan available
Hearing Services
Co-pay for Medicare covered hearing exam $15.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance (every 2 years) No coverage
Transportation No coverage
Dental Optional plan available
- 20 -
PRESCRIPTION DRUG COVERAGE
Health Net Ruby 1 (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310:
$5 Tier 1: 30 day supply of preferred generic drugs
$20 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred drugs
33% Tier 5: 30 day supply of specialty drugs
$0 Tier 6: 30 day supply of Select Care drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 preferred brand drug co-pay for that drug.
- 21 -
Health Net Ruby Select (HMO) Plan Number H0351-040 STAR RATING = 3.5 STARS
Arizona Priority Care Network
Health Net of AZ
1-800-333-3930
healthnet.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0
Maximum out-of-pocket limit $4,000.00
Inpatient Hospital Abrazo, Dignity, and St. Lukes Hospital Network
Co-pay per day for days 1 – 6 $195.00
Co-pay per day for days 6 and beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0
Co-pay per day for days 21 – 100 $100.00
Outpatient Mental Health
Co-pay per visit $25.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $20.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $275.00
Physician Services
Co-pay for Primary Care Physician $0
Co-pay for Specialist $25.00
Physical, Occupational, Speech Therapy
Co-pay per visit $20.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $25.00
Chiropractic Care
Co-pay per visit (optional plan available with additional visits covered) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $200.00
Outpatient Services
Facility co-pay at ambulatory surgical center $100.00
Facility co-pay per outpatient hospital facility visit $150.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $20.00
Co-pay per annual vision exam Optional plan available
Frames/lenses/contacts benefit Optional plan available
Hearing Services
Co-pay for Medicare covered hearing exam $25.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
- 22 -
PRESCRIPTION DRUG COVERAGE
Health Net Ruby Select (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310.00):
$10 Tier 1: 30 day supply of preferred generic drugs
$20 Tier 2: 30 day supply of non-preferred drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred drugs
33% Tier 5: 30 day supply of specialty drugs
$0 Tier 6: 30 day supply of Select Care drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310.
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 preferred brand drug co-pay for that drug.
- 23 -
Humana Community HMO (HMO) Plan Number H2649-032 STAR RATING = 4 STARS
Humana
1-800-833-2364
Humana-medicare.com
Out-of-Network Coverage No Coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $5,500
Inpatient Hospital NOT ACCEPTED AT BARROW NEUROLOGICAL INSTITUTE
Co-pay per day for days 1 – 6 $289.00
Co-pay per day for days 7 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $35.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $0.00 to $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $250.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $0.00 to $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $264.00
Outpatient Services
Facility co-pay at ambulatory surgical center $239.00
Facility co-pay per outpatient hospital facility visit $264.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 0% to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $15.00
Co-pay per annual vision exam $0.00
Frames/lenses/contacts Optional plan available
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam $0.00
Hearing aid appliance benefit (Every 3 years) $1,000
Transportation No coverage
Dental
Limited Services (optional plan available) $45.00
- 24 -
PRESCRIPTION DRUG COVERAGE
Humana Community HMO (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $225 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$5 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
28% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug.
- 25 -
Humana Gold Plus (HMO) Plan Number H2649-030 STAR RATING = 4 STARS
Humana
1-800-833-2364
Humana-medicare.com
Monthly Premium for this plan $85.00 (LIS $85.00)
Maximum out-of-pocket limit $4,900
Inpatient Hospital NOT ACCEPTED AT BARROW NEUROLOGICAL INSTITUTE
Co-pay per day for days 1 – 6 $289.00
Co-pay per day for days 7 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $5.00 to $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $300.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00 to $45.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $264.00
Outpatient Services
Facility co-pay at ambulatory surgical center $239.00
Facility co-pay per outpatient hospital facility visit $264.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 0% to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00
Co-pay per annual vision exam $0.00
Frames/lenses/contacts $200.00 annual benefit
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation (check with plan for details) $0.00
Dental (limited services) (optional plan available) $45.00
- 26 -
PRESCRIPTION DRUG COVERAGE
Humana Gold Plus (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $205 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$5 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
28% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
Note: A few generic and brand drugs are less expensive in gap
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
6. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
7. This plan allows for the purchase of 90 day supplies at retail pharmacies.
8. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
9. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
10. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug
- 27 -
Phoenix Advantage (HMO) Plan Number H5985-001 STAR RATING = 2.5 STARS
NOTE: $0.00 co-pay for renal dialysis
Phoenix Health Plans
1-888-864-1114
phoenixhealthplans.com
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $5,250.00
Inpatient Hospital NOT ACCEPTED AT ANY SCOTTSDALE HEALTH CARE FACILITY
Co-pay per day for days 1 – 6 $250.00
Co-pay per day for days 7 – 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 - 100 $150.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit (No Coverage Outside U.S.) $75.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $250.00
Physician Services
Co-pay for Primary Care Physician $10.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $10.00 to $40.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $150.00
Outpatient Services
Facility co-pay at ambulatory surgical center $225.00
Facility co-pay per outpatient hospital facility visit $325.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $30.00 to $40.00
Co-pay per annual vision exam No coverage
Frames/lenses/contacts benefit No coverage
Hearing Services
Co-pay for Medicare covered hearing exam $35.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental (cleanings, x-rays, and exams) (limited additional services) 50%
- 28 -
PRESCRIPTION DRUG COVERAGE
Phoenix Advantage (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
$20% co-pay for the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0.00
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$3 Tier 1: 30 day supply of preferred generic drugs
$10 Tier 2: 30 day supply of non-preferred generic drugs
$45 Tier 3: 30 day supply of preferred brand drugs
$95 Tier 4: 30 day supply of non-preferred brand drugs
33% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850. you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $95 preferred brand drug co-pay for that drug.
- 29 -
Phoenix Advantage Select (HMO) Plan Number H5985-005 STAR RATING = 2.5 STARS
$0.00 co-pay for renal dialysis
Phoenix Health Plans
1-888-864-1114
phoenixhealthplans.com
Plan Permits Direct Specialist Access w/o PCP referral Check with plan
Monthly Premium for this plan $39.00 (LIS = $11.10)
Maximum out-of-pocket limit $4,750.00
Inpatient Hospital NOT ACCEPTED AT ANY SCOTTSDALE HEALTH CARE FACILITY
Co-pay per day for days 1 – 6 $200.00
Co-pay per day for days 7 – 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 10 $0.00
Co-pay per day for days 21 - 100 $100.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $250.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $40.00
Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $5.00 to $35.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $150.00
Outpatient Services
Facility co-pay at ambulatory surgical center $150.00
Facility co-pay per outpatient hospital facility visit $300.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $30.00
Co-pay per annual vision exam $10.00
Frames/lenses/contacts benefit $250.00 every two years
Hearing Services
Co-pay for Medicare covered hearing exam $30.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental
Oral exam, cleaning, and x-ray 20%
- 30 -
PRESCRIPTION DRUG COVERAGE
Phoenix Advantage Select (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
$20% co-pay for the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0.00
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$3 Tier 1: 30 day supply of preferred generic drugs
$10 Tier 2: 30 day supply of non-preferred generic drugs
$25 Tier 3: 30 day supply of preferred brand drugs
$75 Tier 4: 30 day supply of non preferred brand drugs
33% Tier 4: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
6. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
7. This plan allows for the purchase of 90 day supplies at retail pharmacies.
8. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
9. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
10. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $75 preferred brand drug co-pay for that drug.
- 31 -
Health Net Green (HMO) Plan Number H0351-030 STAR RATING = 3.5 STARS
No Prescription Coverage
Health Net of AZ
1-800-333-3930
healthnet.com/medicare
Out-of-Network Services No coverage
Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $6,700.00
Inpatient Hospital NOT ACCEPTED AT ANY SCOTTSDALE HEALTH CARE FACILITY
Co-pay per day for days 1 – 8 $195.00
Co-pay per day for days 9 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0
Co-pay per day for days 21 – 100 $100.00
Outpatient Mental Health
Co-pay per visit $35.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit (waived if admitted) $75.00
Co-pay per visit for urgent care $20.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $300.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $35.00
Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per visit $35.00
Chiropractic Care
Co-pay per Medicare-covered visit (optional plan w/ additional visits) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $200.00
Outpatient Services
Facility co-pay at ambulatory surgical center $125.00
Facility co-pay per outpatient hospital facility visit $175.00
Prescription Drugs See next page
20% of Part B chemotherapy and other Part B drugs 20%
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $30.00
Co-pay per annual vision exam Optional plan available
Frames/lenses/contacts Optional plan available
Hearing Services
Co-pay for Medicare covered hearing exam $15.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental (limited services) (optional plan available) $35.00
- 32 -
PRESCRIPTION DRUG COVERAGE
Health Net Green (HMO)
THIS PLAN DOES
NOT
PROVIDE
PRESCRIPTION
DRUG COVERAGE
- 33 -
Preferred Provider Organizations
(PPO)
A health care plan in which you use doctors, hospitals, and providers that belong to the
network. You can receive services outside of the network for an additional cost. You
do not need a referral from a primary care physician to see a specialist.
Plans with Prescription Drug Coverage:
Local PPO (provider network is county-wide)
Page
1. Aetna Medicare Prime Plan (MAPD) 35
2. Aetna Medicare Connect Plus (MAPD) 37
3. Humana Choice Local PPO (MAPD) 39
Regional PPO (provider network is state-wide)
1. Humana Choice Regional PPO (MAPD) 41
Plans without Prescription Drug Coverage:
1. Humana Choice Regional PPO (MA) 43
Private Fee For Service
PFFS
Private Fee For Service (nationwide coverage w/o a network or contracts)
1. Humana Gold Choice (PFFS) 41
- 34 -
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page
left
blank
intentionally
- 35 -
Aetna Medicare Prime Plan (PPO) Plan Number H5521-100 STAR RATING = 4.5 STARS
All co-pays for in-network services
Aetna Medicare
1-855-3387027
aetnamedicare.com
Out-of-Network Services Up to 40%
Monthly Premium for this plan $89.00 (LIS $81.70)
Maximum out-of-pocket limit in-network/out-of-network $6,700.00/$10,000
Inpatient Hospital
Co-pay per day for days 1 – 6 $255.00
Co-pay per day for days 7 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 0
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $5.00 to $60.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $400.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $25.00
Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $25.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0-$25.00 to 20%
Outpatient Services
Facility co-pay at ambulatory surgical center $195.00
Facility co-pay per outpatient hospital facility visit $25.00 to $195.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 0% to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $25.00
Co-pay per annual vision exam $0.00
Eyeglasses or contacts annual benefit $125.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $25.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance No coverage
Transportation Not covered
Dental cleaning, x-ray, and oral exam annually up to $500.00/year $0.00
- 36 -
PRESCRIPTION DRUG COVERAGE
Aetna Medicare Prime Plan (PPO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0.00
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$5 Tier 1: 30 day supply of preferred generic drugs
$12 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
50% Tier 4: 30 day supply of non-preferred brand drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
6. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
7. This plan allows for the purchase of 90 day supplies at retail pharmacies.
8. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
9. Individuals who have limited incomes or who live in long term care facilities, may have lower
out-of-pocket drug costs.
10. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay 50% non-preferred brand drug co-pay for that drug.
- 37 -
Aetna Medicare Connect Plus (PPO) Plan Number H5521-052 STAR RATING = 4.5 STARS
All co-pays for in-network services
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services Up to 40%
Monthly Premium for this plan $188.00 (LIS $181.40)
Maximum out-of-pocket limit in-network/out-of-network $4,500.00/$7,500.00
Inpatient Hospital
Co-pay per day for days 1 – 4 $200.00
Co-pay per day for days 5 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 0
Co-pay per day for days 21 – 100 $75.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $0.00 to $50.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $100.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $15.00
Physical, Occupational, Speech Therapy
Co-pay per visit $15.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $15.00
Chiropractic Care
Co-pay per visit $15.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $125.00
Outpatient Services
Facility co-pay at ambulatory surgical center $150.00
Facility co-pay per outpatient hospital facility visit $15.00 to $150.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 0% to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $15.00
Co-pay per annual vision exam $0.00
Eyeglasses or contacts annual benefit $150.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $15.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance annual benefit $500.00
Transportation Not covered
Dental (cleaning, exam, and x-ray annually up to $150.00) $0.00
- 38 -
PRESCRIPTION DRUG COVERAGE
Aetna Medicare Connect Plus (PPO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $0.00
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$6 Tier 1: 30 day supply of preferred generic drugs
$12 Tier 2: 30 day supply of non-preferred preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
50% Tier 4: 30 day supply of non-preferred brand drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
11. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
12. This plan allows for the purchase of 90 day supplies at retail pharmacies.
13. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
14. Individuals who have limited incomes or who live in long term care facilities, may have lower
out-of-pocket drug costs.
15. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay 50% non-preferred brand drug co-pay for that drug.
- 39 -
Humana Choice Local PPO (MAPD)
Plan Number H6609-133 STAR RATING = 4 STARS
Humana Health Plan
800-833-2364
humana-medicare.com
Amounts are for in-network; can go out-of-network with extra costs
Monthly Premium for this plan $129.00 ($95.80 LIS)
Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000
Inpatient Hospital (In-Network)
Co-pay per day for days 1-6 $289.00
Co-pay per day for days 7 - beyond $0.00
Skilled Nursing Facility (In Network)
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $5.00 to $65.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $300.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per Medicare-Covered visit $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $264.00
Outpatient Services
Facility co-pay at ambulatory surgical center $239.00
Facility co-pay per outpatient hospital facility visit $264.00
Prescription Drugs See next page
Home Health Care (In Network)
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 - $45.00
Co-pay per annual vision exam $0.00
Co-pay for Frames/lenses/contacts Optional plan available
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
Annual cleaning, x-ray, and oral exam (limited additional services) $0.00
- 40 -
PRESCRIPTION DRUG COVERAGE
Humana Choice Local PPO (MAPD)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $225 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$5 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
28% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
Note: A few generic and brand drugs are less expensive in the gap
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
whichever is greater:
$2.95 for generic drugs and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug.
- 41 -
Humana Choice Regional PPO (MAPD) Plan Number R5826-014 STAR RATING = 3.5 STARS
Humana Health Plan
800-833-2364
humana-medicare.com
Amounts are for in-network; can go out-of-network for extra costs
Monthly Premium for this plan $159.00 ($125.80 LIS
Maximum out-of-pocket limit in network/out of network $6,700.00
Inpatient Hospital (In-Network)
Co-pay per day for days 1-6 $289.00
Co-pay per day for days 7 – beyond $0.00
Skilled Nursing Facility (In Network)
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $15.00 to $65.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $350.00
Physician Services
Co-pay for Primary Care Physician $15.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per Medicare-Covered visit $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to 264.00
Outpatient Services
Facility co-pay at ambulatory surgical center $239.00
Facility co-pay per outpatient hospital facility visit $264.00
Prescription Drugs See next page
Home Health Care (In Network)
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00
Co-pay per annual vision exam $0.00
Co-pay for Frames/lenses/contacts Optional plan avail.
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
Limited services $45.00
- 42 -
PRESCRIPTION DRUG COVERAGE
Humana Choice Regional PPO (MAPD)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered drugs and chemotherapy drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $280 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$6 Tier 1: 30 day supply of preferred generic drugs
$12 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
26% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
Note: A few generic and brand drugs are less expensive in the gap
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850 you pay
whichever is greater:
$2.95 for generic drugs and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
1. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
2. This plan allows for the purchase of 90 day supplies at retail pharmacies.
3. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
4. Individuals who have limited incomes or who live in long term care facilities may have lower
out-of-pocket drug costs.
5. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug.
- 43 -
Humana Choice Regional PPO (MA) Plan Number R5826-070 STAR RATING = 3.5 STARS
Humana Health Plan
800-833-2364
humana-medicare.com
Amounts are for in-network; can go out-of-network for extra costs
Monthly Premium for this plan $0.00
Annual Deductible for out of network services $599.00
Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000
Inpatient Hospital (In-Network)
Co-pay per day for days 1-6 $289.00
Co-pay per day for days 7 - beyond $0.00
Skilled Nursing Facility (In Network)
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $15.00 to $65.00
Foreign Travel Emergency Coverage Check with the plan
Ambulance Services
Co-pay per trip $350.00
Physician Services
Co-pay for Primary Care Physician $15.00
Co-pay for Specialist $40.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per Medicare-Covered visit $40.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to 264.00
Outpatient Services
Facility co-pay at ambulatory surgical center $239.00
Facility co-pay per outpatient hospital facility visit $264.00
Prescription Drugs See next page
Home Health Care (In Network)
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 to 20%
Co-pay per piece of equipment 15%
Co-pay per prosthetic device 15%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 - $40.00
Co-pay per annual vision exam $0.00
Co-pay for Frames/lenses/contacts Optional plan avail.
Hearing Services
Co-pay for Medicare covered hearing exam $40
Co-pay for annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental
Limited services with $40.00 co-pay Optional plan avail.
- 44 -
PRESCRIPTION DRUG COVERAGE
THIS
PLAN
DOES
NOT
PROVIDE
PRESCRIPTION
DRUG
COVERAGE
- 45 -
Humana Gold Choice (PFFS) Plan Number H8145-103 STAR RATING = 4 STARS
Co-pays for in-network services
Humana Insurance
1-800-833-2364
Humana-medicare.com
Out-of-Network Services Potentially Nationwide
Monthly Premium for this plan $185.00 (LIS $151.80)
Maximum out-of-pocket limit $6,700.00
Inpatient Hospital
Co-pay per day for days 1 – 5 $275.00
Co-pay per day for days 6 – beyond $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $160.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $20.00 to $65.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $350.00
Physician Services
Co-pay for Primary Care Physician $20.00
Co-pay for Specialist $45.00
Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per Medicare-covered visit $45.00
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to 25%
Outpatient Services
Facility co-pay at ambulatory surgical center $225.00
Facility co-pay per outpatient hospital facility visit $250.00
Prescription Drugs See next page
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies 0% to 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Co-pay per Medicare covered eye exam & eyewear post-cataract surgery $0.00 to $45.00
Co-pay per annual vision exam $0.00
Eyeglasses or contacts annual benefit (optional plan available) $130.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $45.00
Co-pay for routine annual hearing exam No coverage
Hearing aid appliance Optional plan available
Transportation Not covered
Dental (limited services available for $45.00 co-pay) Optional plan available
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PRESCRIPTION DRUG COVERAGE
Aetna Medicare Prime Plan (HMO)
Prescription drugs may be covered under Part B or Part D depending on use or place of
administration. Typically, drugs administered as part of a physician service or used with a piece of
durable medical equipment are billed as Part B and all others are covered under Part D.
Drugs Covered under Medicare Part B (amount you will pay):
20% of the cost for Part B-covered chemotherapy drugs and other Part B drugs
Drugs Covered under Medicare Part D:
ANNUAL DEDUCTIBLE: $225 (for brand and specialty drugs)
CO-PAY per prescription (Before the total yearly drug costs, paid by both you and your plan, reach
$3,310):
$5 Tier 1: 30 day supply of preferred generic drugs
$15 Tier 2: 30 day supply of non-preferred generic drugs
$47 Tier 3: 30 day supply of preferred brand drugs
$100 Tier 4: 30 day supply of non-preferred brand drugs
28% Tier 5: 30 day supply of specialty drugs
COVERAGE GAP: After your yearly total drug costs, paid by both you and your plan, reach $3,310,
you pay:
45% on brand drugs, not including dispensing fee
58% on generic drugs
CATASTROPHIC COVERAGE: After your yearly out-of-pocket drug costs reach $4,850, you pay
the greater of:
$2.95 for generic drug and $7.40 for all other drugs or
5% coinsurance for all drugs
IMPORTANT NOTES:
16. This plan offers national in-network prescription coverage. This means that you will pay the
same amount for your prescription drugs if you get them at an in-network pharmacy outside
of the plan’s service area (for instance when you travel).
17. This plan allows for the purchase of 90 day supplies at retail pharmacies.
18. You may have to pay more than your normal cost-sharing amount if you get your drugs at an
out-of-network pharmacy.
19. Individuals who have limited incomes or who live in long term care facilities, may have lower
out-of-pocket drug costs.
20. If you request a formulary exception for a drug, and the plan approves the exception, you will
pay $100 non-preferred brand drug co-pay for that drug.
Benefits Assistance/Medicare Advantage/2016 Advantage Plans/HMOs, PPOs, and PFFS
Revised: 10/12/2016