2018 medicare advantage plans - area agency · 2018 medicare advantage plans in maricopa county ......
TRANSCRIPT
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2018
Medicare Advantage Plans in Maricopa County
There are a variety of different types of Medicare Health Plans to choose from. 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. 35
3. Private Fee for Service Plans (PFFS) Pg. 47
Most current revision: 11/2/2017
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
This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for
Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees
undertaking projects under government sponsorship are encouraged to express freely their findings
and conclusions. Points of view or opinions do not, therefore, necessarily represent official
Administration for Community Living policy.
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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. Aetna Medicare Platinum Plan 9
5. Allwell Medicare Essentials I 11
6. Allwell Medicare Essentials II 13
7. Allwell Medicare Premier 15
8. Blue Medicare Advantage Classic 17
9. Blue Medicare Advantage Plus 19
10. Bright Advantage 21
11. Bright Advantage Plus 23
12. CIGNA HealthSpring Preferred 25
13. Humana Gold Plus H2649-032 27
14. Humana Gold Plus H2649-063 29
15. Humana Gold Plus H2649-030 31
Plans WITHOUT Prescription Drug Coverage: Page
Allwell Medicare Complement 33
Preferred Provider Organizations (PPOs): Page
35
Private Fee for Service (PFFS) Page
47
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AARP MedicareComplete Plan 1 (HMO) Plan Number H0609-026
STAR RATING = 4 STARS
United Healthcare
1-800-555-5757
aarpmedicareplans.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $4,900.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 $285.00
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 – 51 $160.00
Co-pay per day for days 52 – 100 $0.00
Mental Health Outpatient Visits
Co-pay per visit $30.00 to $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
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 $230.00
Physician Services
Co-pay for Primary Care Physician $10.00
Co-pay for Specialist $45.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $45.00
Co-pay per visit for routine foot care – 6 visits per year $45.00
Chiropractic Care
Co-pay per visit – Limited servies $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $2.00 to 20%
Outpatient Services
Facility co-pay at hospital outpatient facility $285.00
Facility co-pay at ambulatory surgical center $285.00
Prescription Drugs See reverse side
Home Health Care Visits $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%
Transportation Not Covered
Routine Vision Services
Vision exams, lenses, glasses Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $10.00
Co-pay for routine hearing exam $10.00
Hearing aid appliance $330.00 - $380.00
Dental Optional plan available
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AARP Medicare Complete Plan 1 (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $230
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Heallthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
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AARP MedicareComplete Plan 2 (HMO) Plan Number H0609-027
STAR RATING = 4 STARS
United Healthcare
1-800-555-5757
aarpmedicareplans.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $4,000.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 –7 $225.00
Co-pay per day for days 8 – 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 45 $160.00
Co-pay per day for days 46 – 100 $0.00
Mental Health Outpatient Visits
Co-pay per visit $30.00 to $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
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 $150.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $30.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $30.00
Routine Podiatry Service
Co-pay for exams and treatment $30.00
Copay for routine foot care – 6 visits per year $30.00
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $2 to 20%
Outpatient Services
Co-pay at hospital outpatient facility $225.00
Co-pay at ambulatory surgical center $225.00
Prescription Drugs See reverse side
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%
Transportation Not covered
Vision Services
Vision exams, lenses, glasses Plan pays up to $70.00 $20.00
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Co-pay for routine fitting $0.00
Hearing aid appliance $330.00 to $380.00
Dental Optional plan available
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AARP Medicare Complete Plan 2 (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $ 0
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Abrazo Dignity Health West Campus (Goodyear) Arizona General
Central Campus Chandler Regional
Maryvale Mercy Gilbert
Phoenix (PV-Bell) St Joseph’s
Arrowhead St Joseph’s Westgate
Honor Health St Luke’s
Scottsdale Healthcare Osborn Tempe
ScottsdaleHealthcare Shea Phoenix
Scottsdale Healthcare Thompson Peak
John C Lincoln Deer Valley
John C Lincoln Phoenix
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Aetna Medicare Prime Plan (HMO) Plan Number H3931-092
STAR RATING = 3.5 STARS
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,000.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 $185.00
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 $167.00
Mental Health Outpatient Visits
Co-pay per visit $20.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $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 $20.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $20.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $20.00
Co-pay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to 250.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $185.00
Co-pay at ambulatory surgical center $185.00
Prescription Drugs See reverse side
Home Health Care
Co-pay per visit Not covered
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%
Transportation Not Covered
Vision Services
Vision exams, lenses, glasses One routine eye exam per year $0.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $20.00
Co-pay for routine hearing exam $0.00
Hearing aid appliance Not Covered
Dental Optional plan available
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Aetna Medicare Prime Plan (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Frys CVS Walgreens Osco
Safeway Costco Walmart Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Hlthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
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Aetna Medicare Platinum Plan (HMO) Plan Number H3931-130
STAR RATING = 3.5 STARS
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $26.00 (LIS $5.10)
Maximum out-of-pocket limit $6,000.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $350.00
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 $167.00
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $60.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $325.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $40.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $40.00
Co-pay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit– Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $10.00 to 20%
Outpatient Services
Co-pay at outpatient hospital facility $295.00
Co-pay at ambulatory surgical center $295.00
Prescription Drugs See reverse side
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
Vision exams, lenses, glasses One routine eye exam per year $0.00
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $40.00
Co-pay for routine hearing exam Not Covered
Hearing aid appliance Not Covered
Dental Optional plan available
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Aetna Medicare Platinum Plan (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $95.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Frys CVS Walgreens Osco
Safeway Costco Walmart Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
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Allwell Medicare Essentials I (HMO) Plan Number H9287-004
STAR RATING = N/A
Allwell
1-800-333-3930
allwell.healthnetadvantage.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,950.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 6 $225.00
Co-pay per day for days 7 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 No hospital stay required $0.00
Co-pay per day for days 21 – 100 $120.00
Mental Health Outpatient Visits
Co-pay per visit $35.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $20.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $350.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $35.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per exams and treatment $35.00
Co-pay for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services (optional plan available) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to $200.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $225.00
Co-pay at ambulatory surgical center $150.00
Prescription Drugs See reverse side
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
Vision exams, lenses, glasses Plan pays up to $100.00 $0.00
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $35.00
Co-pay for routine fitting Not Covered
Hearing aid appliance Not Covered
Dental Optional plan available
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Allwell Medicare Essentials I (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Costco CVS Frys Osco
Safeway Sams Walmart
Hospitals:
Abrazo St. Lukes Banner Arizona Heart Hospital Tempe Baywood
Arrowhead Phoenix Boswell
Central Campus Del Webb
Maryvale Desert
Phoenix (PV-Bell) Estrella
Scottsdale Campus Gateway
West Campus (Goodyear) Goldfield (Apache Junction)
University Medical Center
Ironwood
Thunderbird
Maricopa Medical Center
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Allwell Medicare Essentials II (HMO) Plan Number H0351-049-1
STAR RATING = 3 STARS
Allwell
1-800-333-3930
allwell.healthnetadvantage.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $4,000.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 -6 $195.00
Co-pay per day for days 7 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 No hospital stay required $0
Co-pay per day for days 21 – 100 $150.00
Mental Health Outpatient Visit
Co-pay per visit $25.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
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 $0.00
Co-pay for Specialist $25.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $20.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $25.00
Co-pay per visit for routine care Not Covered
Chiropractic Care
Co-pay per visit – Limited services (optional plan available) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to $200.00
Outpatient Services
Co-pay at outpatient hospital facility $150.00
Co-pay at ambulatory surgical center $100.00
Prescription Drugs See reverse side
Home Health Care
Visits $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
Vision exams, lenses and glasses Plan pays up to $100.00 Not covered
Transportation Up to 8 one-way trips per year $0.00
Hearing Services
Co-pay for Medicare covered hearing exam $25.00
Co-pay for annual hearing exam $ 0.00
Hearing aid appliance (every 3 years) $ 0.00
Dental Optional plan available
- 14 -
Allwell Medicare Essentials II (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Costco CVS Frys Osco
Safeway Sams Walmart
Hospitals:
Abrazo St. Lukes Banner Arizona Heart Hospital Tempe Baywood
Arrowhead Phoenix Boswell
Central Campus Del Webb
Maryvale Desert
Phoenix (PV-Bell) Estrella
Scottsdale Campus Gateway
West Campus (Goodyear) Goldfield (Apache Junction)
University Medical Center
Ironwood
Thunderbird
Maricopa Medical Center
- 15 -
Allwell Medicare Premier (HMO) Plan Number H0351-043
STAR RATING = 3 STARS
Allwell
1-800-333-3930
allwell.healthnetadvantage.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $59.00 (LIS $26.10)
Maximum out-of-pocket limit $3,800.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $100.00
Co-pay per day for days 6 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 No hospital stay required $0
Co-pay per day for days 21 – 100 $100.00
Mental Health Outpatient Visits
Co-pay per visit $15.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
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
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $10.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $15.00
Co-pay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services (optional plan available) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to $200.00 or 20%
Outpatient Services
Co-pay at hospital outpatient facility $75.00
Co-pay at ambulatory surgical center $50.00
Prescription Drugs See reverse side
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
Vision exams, lenses and glasses Plan pays up $100.00 $0.00
Transportation Up to 8 one-way trips Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $15.00
Co-pay for routine fitting $0.00
Hearing aid appliance ($2,000.00 every 3 years) $0.00
Dental Optional plan available
- 16 -
Allwell Medicare Premier (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Costco CVS Frys Osco
Safeway Sams Walmart
Hospitals:
Abrazo St. Lukes Banner Arizona Heart Hospital Tempe Baywood
Arrowhead Phoenix Boswell
Central Campus Del Webb
Maryvale Desert
Phoenix (PV-Bell) Estrella
Scottsdale Campus Gateway
West Campus (Goodyear) Goldfield (Apache Junction)
University Medical Center
Ironwood
Thunderbird
Maricopa Medical Center
- 17 -
Blue Medicare Advantage Classic (HMO) Plan Number H0302-006
STAR RATING = 3.5 STARS
Blue Cross Blue Shield
1-888-274-0367
azbluemedicare.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,400.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 Maximum out of pocket $1,750.00 $250.00
Co-pay per day for days 8 – 364 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 No hospital stay required $20.00
Co-pay per day for days 21 – 100 $165.00
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $100.00
Co-pay per visit for urgent care $25.00
Foreign Travel Emergency Coverage Not covered
Ambulance Services
Co-pay per trip $200.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $40.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $40.00
Co-pay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $40.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab, and imaging $0.00 to $300.00 (or 20%)
Outpatient Services
Co-pay at outpatient hospital facility $295.00
Co-pay at ambulatory surgical center $200.00
Prescription Drugs See reverse side
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%
Transportation Not Covered
Vision Services
Vision exams, lenses and glasses Not Covered
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Co-pay for routine hearing exam $45.00
Hearing aid appliance $699.00 - $999.00
Dental Not Covered
- 18 -
Blue Medicare Advantage Classic (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $195.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Banner Honor Health Baywood Scottsdale Healthcare Osborn
Boswell Scottsdale Healthcare Shea
Del Webb Scottsdale Healthcare Thompson Peak
Desert John C Lincoln Deer Valley
Estrella John C Lincoln Phoenix
Gateway
Goldfield (Apache Junction)
University Medical Center
Ironwood
Thunderbird
- 19 -
Blue Medicare Advantage Plus (HMO) Plan Number H0302-001
STAR RATING = 3.5 STARS
Blue Cross Blue Shield
1-888-274-0367
azbluemedicare.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $35.00 (LIS $3.00)
Maximum out-of-pocket limit $3,200.00
Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 Maximum out of pocket $1,575.00 $225.00
Co-pay per day for days 8 – 365 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 10 $0.00
Co-pay per day for days 11 – 20 $20.00
Co-pay per day for days 21-100 $100.00
Mental Health Outpatient Visits
Co-pay per visit $20.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $100.00
Co-pay per visit for urgent care $40.00
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 $20.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $20.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $20.00
Co-pay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to $275.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $225.00
Co-pay at ambulatory surgical center $160.00
Prescription Drugs See reverse side
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
Vision exams, lenses and glasses Not Covered
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Co-pay for routine exam $45.00
Hearing aid appliance $699.00 - $999.00
Dental (cleaning, x-ray, oral exam annually) Covers up to $500.00
- 20 -
Blue Medicare Advantage Plus (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $100.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Banner Honor Health Baywood Scottsdale Healthcare Osborn
Boswell Scottsdale Healthcare Shea
Del Webb Scottsdale Thompson Peak
Desert John C Lincoln Deer Valley
Estrella John C Lincoln Phoenix
Gateway
Goldfield (Apache Junction)
University Medical Center
Ironwood
Thunderbird
- 21 -
Bright Advantage (HMO) Plan Number H4853-001
STAR RATING = N/A
Bright Health
1-844-679-2028
brighthealthplan.com/medicare
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,750.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 $185.00
Co-pay per day for days 8 – 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $145.00
Mental Health Outpatient Visits
Co-pay per visit $10.00 - $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $30.00
Foreign Travel Emergency Coverage No coverage
Ambulance Services
Co-pay per trip $200.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $30.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $25.00
Co-pay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $10.00 - 20%
Outpatient Services
Co-pay at outpatient hospital facility $250.00
Co-pay at ambulatory surgical center $175.00
Prescription Drugs See reverse side
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
One routine exam every 12 months Optional plan available
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Hearing aid appliance ($2,000.00 every 3 years) $0.00
Dental Exam, cleaning, one set of bitewing X-rays (optional plan available) $0.00
Silver & Fit Membership at participating facility $0.00
Acupuncture – 12 visits per year, copay per visit $20.00
- 22 -
Bright Advantage (HMO)
Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Abrazo Dignity Health Arizona Heart Hospital Arizona General Hospital
Arrowhead Chandler Regional Medical Center
Central Campus Mercy Gilbert Medical Center
Maryvale St Joseph’s Hospital and Medical Center
Phoenix (PV-Bell) St Joseph’s Westgate Medical Center
Scottsdale Campus
West Campus (Goodyear)
- 23 -
Bright Advantage Plus (HMO) Plan Number H4853-002
STAR RATING = N/A
Bright Health
1-844-679-2028
brighthealthplan.com/medicare
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $28.00 (LIS $0.00)
Maximum out-of-pocket limit $3,500.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $170.00
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 $155.00
Mental Health Outpatient Visits
Co-pay per visit $10.00 - $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $75.00
Co-pay per visit for urgent care $30.00
Foreign Travel Emergency Coverage No coverage
Ambulance Services
Co-pay per trip $200.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $20.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $25.00
Copay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiolog tests, lab and imaging $10.00 to 20%
Outpatient Services
Co-pay at outpatient hospital facility $250.00
Co-pay at ambulatory surgical center $150.00
Prescription Drugs See reverse side
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%
Transportation Not Covered
Vision Services
Co-pay for one annual vision exam. Frames or contacts, $130.00
covered per year
$0.00
Hearing Services
Co-pay for Medicare covered hearing exam $0.00
Hearing aid appliance ($2,000.00 every 3 years) $0.00
Dental Exam, cleaning, one set of bitewing X-rays, 2 fluoride treatments $0.00
Silver & Fit Membership at participating facility $0.00
Acupuncture – 12 visits per year, copay per visit $20.00
- 24 -
Bright Advantage Plus (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
No restricted network for this plan
Hospitals:
Abrazo Dignity Health Arizona Heart Hospital Arizona General Hospital
Arrowhead Chandler Regional Medical Center
Central Campus Mercy Gilbert Medical Center
Maryvale St Joseph’s Hospital and Medical Center
Phoenix (PV-Bell) St Joseph’s Westgate Medical Center
Scottsdale Campus
West Campus (Goodyear)
- 25 -
CIGNA HealthSpring Preferred (HMO) Plan Number H0354-001
STAR RATING = 4 STARS
CIGNA
1-855-561-3811
cignahealthspring.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,950.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 $200.00
Co-pay per day for days 8 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21-100 $167.00
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $25.00
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 $30.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $30.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $30.00
Copay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited coverage plus 12 routine visits per year $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiolog tests, lab and imaging $0.00 - $150.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $325.00
Co-pay at ambulatory surgical center $150.00
Prescription Drugs See reverse side
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
Vision exams, lenses, glasses Not Covered
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $30.00
Co-pay for annual hearing exam $30.00
Hearing aid appliance Not Covered
Dental Not Covered
- 26 -
CIGNA Healthspring Preferred (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $200.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Cigna Medical Gp Frys Osco Safeway
Sams Walgreens Walmart
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix Maricopa Integrated Health
- 27 -
Humana Gold Plus (HMO) H2649-032 Plan Number H2649-032
STAR RATING = 3.5 STARS
Humana
1-800-833-2364
humana.com/medicare
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $5,500.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 7 $225.00
Co-pay per day for days 8 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21-100 $167.50
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $35.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $0.00
Co-pay for Specialist $35.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $35.00
Copay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiolog tests, lab and imaging $0.00 - $200.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $200.00
Co-pay ambulatory surgical center $175.00
Prescription Drugs See reverse side
Home Health Care
Co-pay per visit $0.00
Durable Medical Equipment (DME)
Co-pay per item for Diabetic supplies $0.00 – 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Vision exams, lenses, glasses Plan pays up to $200.00
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $35.00
Co-pay for annual hearing exam $0.00
Hearing aid appliance $699.00 - $999.00
Dental (cleaning, x-ray, oral exam annually) Optional plan available
- 28 -
Humana Gold Plus (HMO) H2649-032 Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s part D Deductible $225.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 29 -
Humana Gold Plus (HMO) H2649-063 Plan Number H2649-063
STAR RATING = 3.5 STARS
Humana
1-800-833-2364
humana.com/medicare
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $0.00
Maximum out-of-pocket limit $3,200.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $175.00
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 $167.50
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $0.00 - $35.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $0.00 - $20.00
Co-pay for Specialist $25.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $25.00
Copay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiolog tests, lab and imaging $0.00 - $150.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $150.00
Co-pay at ambulatory surgical center $125.00
Prescription Drugs See reverse side
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 - 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Vision exams, lenses, glasses Plan pays up to $200.00
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $25.00
Co-pay for annual hearing exam $0.00
Hearing aid appliance $399.00 - $699.00
Dental (cleaning, x-ray, oral exam annually) Optional plan available
- 30 -
Humana Gold Plus (HMO) H2649-063
Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $0.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Hlthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 31 -
Humana Gold Plus (HMO) H2649-030 Plan Number H2649-030
STAR RATING = 3.5 STARS
Humana
1-800-833-2364
humana.com/medicare
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $83.00 (LIS $83.00)
Maximum out-of-pocket limit $4,900.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 6 $289.00
Co-pay per day for days - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21-100 $167.50
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $45.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00 - $45.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $45.00
Copay per visit for routine foot care Not Covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiolog tests, lab and imaging $0.00 - $264.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $264.00
Co-pay at ambulatory surgical center $239.00
Prescription Drugs See reverse side
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 - 20%
Co-pay per piece of equipment 20%
Co-pay per prosthetic device 20%
Vision Services
Vision exams, lenses, glasses Plan pays up to $200.00
Transportation 12 one-way trips $0.00
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for annual hearing exam $0.00
Hearing aid appliance $699.00 - $999.00
Dental (cleaning, x-ray, oral exam annually) Optional plan available
- 32 -
Humana Gold Plus (HMO) H2649-030 Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s part D Deductible $205.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 33 -
Allwell Medicare Complement (HMO) Plan Number H0351-030
STAR RATING = N/A
Allwell
1-800-333-3930
allwell.healthnetadvantage.com
Out-of-Network Services No coverage
Additional Monthly Premium for this plan $83.00
Maximum out-of-pocket limit $6,700.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 8 $195.00
Co-pay per day for days 9 - 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 No hospital stay required $0.00
Co-pay per day for days 21 – 100 $100.00
Mental Health Outpatient Visits
Co-pay per visit $35.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
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
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $25.00
Routine Podiatry Service
Co-pay per exams and treatment $35.00
Co-pay for routine foot care Not Covered
Chiropractic Care
Co-pay per visit - Limited services (optional plan available) $20.00
Diagnostic Tests, X-Rays, and Lab Services
Radiology tests, lab and imaging $0.00 to $200.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $175.00
Co-pay at ambulatory surgical center $125.00
Prescription Drugs No Coverage
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
Vision exams, lenses, glasses Optional plan available
Transportation Not Covered
Hearing Services
Co-pay for Medicare covered hearing exam $15.00
Co-pay for routine fitting Not covered
Hearing aid appliance (every 3 years) Not covered
Dental Optional plan available
- 34 -
Allwell Medicare Complement (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – This plan does not cover Part D drugs
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Not applicable
Hospitals:
Abrazo St. Lukes Banner West Campus (Goodyear) Tempe Baywood
Central Campus Phoenix Boswell
Maryvale Del Webb
Phoenix (PV-Bell) Desert
Arrowhead Estrella
Gateway
Goldfield (Apache Junction)
Maricopa Medical Center University Medical Center
Ironwood
Thunderbird
- 35 -
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 (Maricopa county-wide only)
Page
1. Aetna Medicare Prime Plan (MAPD) 37
2. Aetna Medicare Platinum Plan (MAPD) 39
Select Counties PPO (Maricopa, Pima, Pinal & Santa Cruz county-wide)
3. Humana Choice PPO (MAPD) 41
Regional PPO (provider network is state-wide)
4. Humana Choice Regional PPO (MAPD) 43
Plans WITHOUT Prescription Drug Coverage:
5. Humana Choice Regional PPO (MA) 45
Private Fee For Service
PFFS
Private Fee For Service (nationwide coverage w/o a network or contracts)
1. Humana Gold Choice (PFFS) 47
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Aetna Medicare Prime Plan (PPO) Plan Number H5521-100
STAR RATING = 4 STARS
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services Up to 40%
Additional Monthly Premium for this plan $66.00 (LIS $33.10)
Maximum out-of-pocket limit in-network/out-of-network $6,700.00/$10,000
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $269.00
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 $167.00
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $60.00
Foreign Travel Emergency Coverage $80.00
Ambulance Services
Co-pay per trip $325.00
Physician Services
Co-pay for Primary Care Physician $10.00
Co-pay for Specialist $35.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $30.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $35.00
Co-pay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0-$40.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $275.00
Co-pay at ambulatory surgical center $275.00
Prescription Drugs See reverse side
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
Vision exams, lenses, glasses Plan pays up to $125.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $35.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance benefit Plan pays up to $500
Transportation Not covered
Dental (preventive & comprehensive dental services) Plan pays up to $500
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Aetna Medicare Prime Plan (PPO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $150.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Frys CVS Walgreens Osco
Safeway Costco Walmart Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
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Aetna Medicare Platinum Plan (PPO) Plan Number H5521-184
STAR RATING = 4 STARS
Aetna Medicare
1-855-338-7027
aetnamedicare.com
Out-of-Network Services Up to 40%
Additional Monthly Premium for this plan $106.00 (LIS $77.30)
Maximum out-of-pocket limit in-network/out-of-network $5,000.00/$8,200
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $295.00
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 $167.00
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $50.00
Foreign Travel Emergency Coverage $80.00
Ambulance Services
Co-pay per trip $275.00
Physician Services
Co-pay for Primary Care Physician $.00
Co-pay for Specialist $30.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $35.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $30.00
Copay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0-$30.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $240.00
Co-pay at ambulatorty surgical center $240.00
Prescription Drugs See reverse side
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
Vision exam, lenses, glasses Plan pays up to $150.00
Hearing Services
Co-pay for Medicare covered diagnostic hearing exam $30.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance benefit Plan pays up to $300
Transportation Not covered
Dental (preventive & comprehensive dental services) Plan pays up to $750
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Aetna Medicare Platinum Plan (PPO) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s Part D Deductible $250.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Frys CVS Walgreens Osco
Safeway Costco Walmart Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 41 -
Humana Choice PPO (MAPD)
Plan Number H5216-034
STAR RATING = 4 STARS
Humana Health Plan
1-800-833-2364
humana-medicare.com
Out-of- Network Services; contact plan for out-of-network costs Up to 40%
Additional Monthly Premium for this plan $123.00 (LIS $94.10 )
Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000
Inpatient Hospital (In-Network) See reverse side for network hospitals
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 $167.50
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $5.00
Co-pay for Specialist $45.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00 - $45.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $45.00
Co-pay for visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $264.00 (or 20%)
Outpatient Services
Co-pay at outpatient hospital facility $264.00
Co-pay at ambulatory surgical facility $239.00
Prescription Drugs See reverse side
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
Vision exams, lenses, glasses Plan pays up to $40.00
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for routine annual hearing exam $0.00
Hearing aid appliance $699.00 - $999.00
Transportation No coverage
Dental (limited benefits) Optional plan available
- 42 -
Humana Choice PPO (MAPD)
Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s part D Deductible $225.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 43 -
Humana Choice Regional PPO (MAPD) Plan Number R7220-002
STAR RATING = 3 STARS
Humana Health Plan
1-800-833-2364
humana-medicare.com
Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $164.00 (LIS $135.30)
Maximum out-of-pocket limit in network/out of network $6,700.00
Inpatient Hospital (In-Network) See reverse side for network hospitals
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 $167.50
Outpatient Mental Health
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $15.00
Co-pay for Specialist $45.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $30.00 to $45.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $45.00
Co-pay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0 to $264.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $264.00
Co-pay at ambulatory surgical center $239.00
Prescription Drugs See reverse Side
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
Vision exams, lenses glasses Plan pays up to $40.00
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for routine annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
- 44 -
Humana Choice Regional PPO (MAPD) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s part D Deductible $340.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 45 -
Humana Choice Regional PPO (MA) Plan Number R7220-001
STAR RATING = N/A
Humana Health Plan
1-800-833-2364
humana-medicare.com
Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan 0.00
Maximum out-of-pocket limit in network/out of network $6,700.00
Inpatient Hospital (In-Network) See reverse side for network hospitals
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 $167.50
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $40.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $15.00
Co-pay for Specialist $40.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $40.00
Co-pay per visit for routine foot care
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 to $264.00 or 20%
Outpatient Services
Co-pay at outpatient hospital facility $264.00
Co-pay at ambulatory surgical center $239.00
Prescription Drugs Not Covered 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 15%
Co-pay per prosthetic device 15%
Vision Services
Vision exams, lenses, glasses Plan pays up to $40.00
Hearing Services
Co-pay for Medicare covered hearing exam $40.00
Co-pay for routine annual hearing No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
- 46 -
Humana Choice Regional PPO (MA) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan does not cover Part D drugs
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Not applicable
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
- 47 -
Humana Gold Choice (PFFS) Plan Number H8145-103
STAR RATING = 3.5 STARS
Humana Insurance
1-800-833-2364
humana-medicare.com
Out-of-Network Services; contact plan for out-of-network costs Up to 50%
Additional Monthly Premium for this plan $190.00 (LIS $159.90)
Maximum out-of-pocket limit $6,700.00
Inpatient Hospital See reverse side for network hospitals
Co-pay per day for days 1 – 5 $275.00
Co-pay per day for days 6 – 90 $0.00
Skilled Nursing Facility
Co-pay per day for days 1 – 20 $0.00
Co-pay per day for days 21 – 100 $167.50
Mental Health Outpatient Visits
Co-pay per visit $40.00
Emergency/Urgent Care
Co-pay per hospital emergency room visit $80.00
Co-pay per visit for urgent care $45.00
Foreign Travel Emergency Coverage Check with plan
Ambulance Services
Co-pay per trip $265.00
Physician Services
Co-pay for Primary Care Physician $20.00
Co-pay for Specialist $45.00
Rehabilitation Services - Physical, Occupational, Speech Therapy
Co-pay per visit $40.00 - $45.00
Routine Podiatry Service
Co-pay per visit for exams and treatment $45.00
Co-pay per visit for routine foot care Not covered
Chiropractic Care
Co-pay per visit – Limited services $20.00
Diagnostic Tests, X-Rays, and Lab Services
Clinical/diagnostic lab service $0.00 - $250.00 or 20 - 25%
Outpatient Services
Co-pay at outpatient hospital facility $250.00
Co-pay at ambulatory surgical center $225.00
Prescription Drugs See reverse
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
Vision exams, lenses, glasses Plan pays up to $130.00
Hearing Services
Co-pay for Medicare covered hearing exam $45.00
Co-pay for routine annual hearing exam No coverage
Hearing aid appliance No coverage
Transportation No coverage
Dental Optional plan available
- 48 -
Humana Gold Choice (PFFS) Prescription Drug Coverage, Pharmacy and Hospital Network
Prescription drugs may be covered under Part A, Part B or Part D
Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of
the hospital charges, with no copay.
Part B drugs – Vaccinations such as flu shots, pneumonia shots, and hepatitis B; transplant drugs; drugs administered in a doctor’s office or outpatient setting, such as chemotherapy, etc., which generally have 20% coinsurance.
Part D drugs – all other prescription drugs covered on the plan’s formulary.
This plan’s part D Deductible $225.00
Preferred pharmacies:
If your plan's network includes preferred cost sharing pharmacies, you may save money by using
them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred
cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.
Bashas Costco CVS Frys Osco
Safeway Sams Walmart Walgreens Albertson’s
Hospitals:
Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Healthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
Programs/Benefits Assistance/Medicare Advantage/2018 Advantage Plans/2018 HMO PPO PFFS rev 11/2/2017