2016 Summary of Benefits - HealthPlanOne · Select counties in New York and Maine January 1, 2016...

2016 Summary of Benefits

Select counties in NewYork and MaineJanuary 1, 2016 — December 31, 2016

Y0067_PRE_H2816_SBK02_0815 CMS Accepted 09/15/2015

Summary ofBenefitsJanuary 1, 2016— December 31, 2016This booklet gives you a summary of what wecover and what you pay. It doesn't list everyservice that we cover or list every limitation orexclusion. To get a complete list of services wecover, call us and ask for the "Evidence ofCoverage."

You have choices about how to get yourMedicare benefitsOne choice is to get your Medicare benefitsthrough Original Medicare (fee-for-serviceMedicare). Original Medicare is run directlyby the Federal government.Another choice is to get your Medicarebenefits by joining a Medicare health plan(suchasToday'sOptionsPremierPlus450B(PFFS),Today’sOptionsPremierPlus150A(PFFS), Today’s Options Premier 200(PFFS), and Today’s Options Premier 100(PFFS)). A Private Fee-for-Service plan is notMedicare supplement insurance. Providerswho do not contract with our plan are notrequired to see you except in an emergency.

Tips for comparing your Medicare choicesThis Summary of Benefits booklet gives you asummary of what Today's Options PremierPlus 450B (PFFS), Today’s Options PremierPlus 150A (PFFS), Today’s Options Premier200 (PFFS), and Today’s Options Premier100 (PFFS) cover and what you pay.If you want to compare our plans with otherMedicare health plans, ask the other plans fortheir Summary of Benefits booklets. Or, usethe Medicare Plan Finder on http://www.medicare.gov.

If you want to knowmore about the coverageand costs of Original Medicare, look in yourcurrent "Medicare & You" handbook. Viewit online at http://www.medicare.gov or geta copy by calling 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days aweek. TTY users should call 1-877-486-2048.

Sections in this bookletThings to Know About Today's OptionsPremierPlus450B(PFFS),Today’sOptionsPremierPlus150A(PFFS),Today’sOptionsPremier 200 (PFFS), and Today’s OptionsPremier 100 (PFFS)

Monthly Premium, Deductible, and Limits onHowMuch You Pay for Covered ServicesCovered Medical and Hospital BenefitsPrescription Drug Benefits

This document is available in other formats suchas Braille and large print.Thisdocumentmaybeavailable in anon-Englishlanguage. For additional information, call us at1-866-568-8921; TTY 711.Esta información está disponible gratis en otrosidiomas. Por favor llame a nuestro número deservicio al cliente al 1-866-568-8921; TTY 711.

Things to Know About Today's OptionsPremier Plus 450B (PFFS), Today’s OptionsPremier Plus 150A (PFFS), Today’s OptionsPremier 200 (PFFS), and Today’s OptionsPremier 100 (PFFS)

Hours of OperationFrom October 1 to February 14, you can callus 7 days a week from 8:00 a.m. to 12:00 a.m.Eastern time.From February 15 to September 30, you cancall usMonday through Friday from 8:00 a.m.to 8:00 p.m. Eastern time.

Today's Options Premier Plus 450B (PFFS),Today’s Options Premier Plus 150A (PFFS),Today’s Options Premier 200 (PFFS), and

Today’s Options Premier 100 (PFFS) PhoneNumbers and WebsiteIf you are a member of these plans, calltoll-free 1-866-568-8921; TTY 711.If you are not a member of these plans, calltoll-free 1-866-418-1923; TTY 711.Our website: www.TodaysOptions.com

Who can join?To join Today's Options Premier Plus 450B(PFFS), Today’s Options Premier Plus 150A(PFFS), Today’sOptionsPremier200 (PFFS),andToday’sOptionsPremier100(PFFS), youmust be entitled toMedicare Part A, be enrolledin Medicare Part B, and live in our service area.Our service area includes the following countiesinMaine: Androscoggin, Aroostook, Franklin,Hancock, Kennebec, Knox, Lincoln, Oxford,Penobscot, Piscataquis, Somerset, and Waldo;and New York: Cattaraugus, Chautauqua,Clinton, Columbia, Delaware, Essex, Franklin,Greene, Hamilton, Jefferson, Lewis, Monroe,Niagara, Otsego, Seneca, St. Lawrence, Steuben,Sullivan, Tompkins,Wayne,Wyoming, andYates.

Which doctors, hospitals, and pharmaciescan I use?Today’s Options Premier Plus 450B (PFFS)and Today’s Options Premier Plus 150A(PFFS)have anetworkof doctors, hospitals, andother providers. If you use the providers in ournetwork, you may pay less for your coveredservices. But if you want to, you can also useproviders that are not in our network.Some providers that are not in our networkhave already agreed to accept the plans' termsand conditions for payment, but youwill needto pay more.Other providers that are not in our networkandhavenot already agreed to accept theplancan decide at every visit whether or not toaccept the plan and treat you.

You must generally use network pharmacies tofill your prescriptions for covered Part D drugs.

Someof ournetworkpharmacieshavepreferredcost-sharing. You may pay less if you use thesepharmacies.You can see our plans' provider directories atour website (www.TodaysOptions.com). Youcan see our plans' pharmacy directories at ourwebsite (www.TodaysOptions.com).Or, call us and we will send you a copy of theprovider and pharmacy directories.Today’s Options Premier 200 (PFFS) andToday’s Options Premier 100 (PFFS) have anetwork of doctors, hospitals, and otherproviders. If you use the providers in ournetwork, you may pay less for your coveredservices. But if you want to, you can also useproviders that are not in our network.Some providers that are not in our networkhave already agreed to accept the plan's termsand conditions for payment, but youwill needto pay more.Other providers that are not in our networkandhavenot already agreed to accept theplancan decide at every visit whether or not toaccept the plan and treat you.

You can see our plans' provider directories atour website (www.TodaysOptions.com).Or, call us and we will send you a copy of theprovider directories.

What do we cover?Like all Medicare health plans, we covereverything that Original Medicare covers - andmore.Our plan members get all of the benefitscovered by Original Medicare. For some ofthesebenefits, youmaypaymore inourplanthan you would in Original Medicare. Forothers, you may pay less.Our plan members also getmore than whatis covered by Original Medicare. Some of theextra benefits are outlined in this booklet.Today’s Options Premier Plus 450B(PFFS) and Today’s Options Premier Plus150A (PFFS) cover Part D drugs. In addition,we cover Part B drugs such as chemotherapyand some drugs administered by your provider.

You can see the complete plan formularies(list of Part D prescription drugs) and anyrestrictions on our website,www.TodaysOptions.com.Or, call us and we will send you a copy of theformulary.

Today’s Options Premier 200 (PFFS) andToday’s Options Premier 100 (PFFS) coverPart B drugs including chemotherapy and somedrugs administered by your provider. However,these plans do not cover Part D prescriptiondrugs. You may join a separate MedicarePrescription Drug Plan.

How will I determine my drug costs?Today’s Options Premier Plus 450B (PFFS)and Today’s Options Premier Plus 150A(PFFS) group each medication into one of five"tiers." You will need to use your formulary tolocate what tier your drug is on to determinehowmuch it will cost you. The amount you paydependson thedrug's tier andwhat stage of thebenefit youhave reached. Later in this documentwe discuss the benefit stages that occur: InitialCoverage, Coverage Gap, and CatastrophicCoverage.

Summary of BenefitsJanuary 1, 2016— December 31, 2016

Today's Options Premier 100(PFFS)


Today's Options Premier Plus150A (PFFS)

Today's Options Premier Plus450B (PFFS)

$25 per month. In addition, youmust keep paying yourMedicare Part B premium.

$0 per month. In addition, you mustkeep paying your Medicare Part Bpremium.



How much is themonthlypremium?

This plan does not have adeductible.




How much is thedeductible?

Yes. Like all Medicare health plans,our plan protects you by having




Is there any limiton how much Iwill pay for my yearly limits on your out-of-pocket

costs for medical and hospital care.yearly limits on your out-of-pocketcosts for medical and hospital care.

yearly limits on your out-of-pocketcosts for medical and hospital care.

yearly limits on your out-of-pocketcosts for medical and hospital care.covered

services? Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:Your yearly limit(s) in this plan:$3,400 for services you receivefrom any provider.

$4,400 for services you receivefrom any provider.



If you reach the limit onout-of-pocket costs, you keep




getting covered hospital and getting covered hospital andgetting covered hospital andgetting covered hospital andmedical services and we will paythe full cost for the rest of the year.

medical services and we will paythe full cost for the rest of the year.



Please note that you will still needto pay your monthly premiums and

Please note that you will still needto pay your monthly premiums.

Please note that you will still needto pay your monthly premiums.

Please note that you will still needto pay your monthly premiums andcost-sharing for your Part Dprescription drugs.

cost-sharing for your Part Dprescription drugs.

No. There are no limits on howmuch our plan will pay.




Is there a limit onhow much theplan will pay?





Today’s Options® PFFS is a Medicare Advantage plan with a Medicare contract. Enrollment in Today’s Options® PFFS depends on contract renewal.Covered Medical and Hospital Benefits

Outpatient Care and Services

Not coveredNot coveredNot coveredNot coveredAcupuncture

Ambulance In-network: $300 copayIn-network: $300 copayIn-network: $300 copayIn-network: $300 copay

Out-of-network: $300 copay Out-of-network: $300 copayOut-of-network: $300 copayOut-of-network: $300 copay

Manipulation of the spine to correcta subluxation (when 1 or more of




Chiropractic Care

the bones of your spine move outof position):




In-network: $20 copayIn-network: $20 copayIn-network: $20 copayIn-network: $20 copay

Out-of-network: 20% of the cost Out-of-network: 20% of the costOut-of-network: 20% of the costOut-of-network: 20% of the cost

Limited dental services (this doesnot include services in connection




Dental Services

with care, treatment, filling,removal, or replacement of teeth):






Diabetes monitoring supplies:Diabetes monitoring supplies:Diabetes monitoring supplies:Diabetes monitoring supplies:DiabetesSupplies andServices

In-network: 0-20% of the cost,depending on the supply





Diabetes self-management training:Diabetes self-management training: Diabetes self-management training:Diabetes self-management training:In-network: You pay nothingIn-network: You pay nothing In-network: You pay nothingIn-network: You pay nothing

Out-of-network: 20% of the costOut-of-network: 20% of the costOut-of-network: 20% of the cost Out-of-network: 20% of the cost





DiabetesSupplies andServicescontinued

Therapeutic shoes or inserts:Therapeutic shoes or inserts:Therapeutic shoes or inserts:Therapeutic shoes or inserts:In-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the cost


Covered diabetes supplies include:blood glucose monitor, blood




glucose test strips, lancet devicesglucose test strips, lancet devices glucose test strips, lancet devicesglucose test strips, lancet devicesand lancets, and glucose-controlsolutions for preferred brands.

and lancets, and glucose-controlsolutions for preferred brands.



Diagnostic radiology services (suchas MRIs, CT scans):




Diagnostic Tests,Lab andRadiology In-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the costServices, and Out-of-network: 20% of the costOut-of-network: 20% of the costOut-of-network: 20% of the costOut-of-network: 20% of the costX-Rays (Costs for

Diagnostic tests and procedures:Diagnostic tests and procedures:Diagnostic tests and procedures:Diagnostic tests and procedures:these services mayvary based onplace of service)

In-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothing


Lab services:Lab services: Lab services:Lab services:In-network: You pay nothingIn-network: You pay nothing In-network: You pay nothingIn-network: You pay nothing


Outpatient x-rays:Outpatient x-rays:Outpatient x-rays:Outpatient x-rays:In-network: $15 copayIn-network: $15 copayIn-network: $15 copayIn-network: $15 copay


Therapeutic radiology services(such as radiation treatment forcancer):




In-network: 20% of the costIn-network: 20% of the cost In-network: 20% of the costIn-network: 20% of the cost






Primary care physician visit:Primary care physician visit:Primary care physician visit:Primary care physician visit:Doctor's OfficeVisits In-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothingIn-network: $10 copay


Specialist visit:Specialist visit: Specialist visit:Specialist visit:In-network: $25 copayIn-network: $35 copay In-network: $25 copayIn-network: $30 copay

Out-of-network: $50 copayOut-of-network: $35 copayOut-of-network: $60 copay Out-of-network: $35 copay

Durable MedicalEquipment(wheelchairs,oxygen, etc.)

In-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the cost


$75 copay$75 copay$75 copay$75 copayEmergency Care

If you are admitted to the hospitalwithin 24 hours, you do not have to




pay your share of the cost forpay your share of the cost forpay your share of the cost forpay your share of the cost foremergency care. See the "Inpatientemergency care. See the "Inpatientemergency care. See the "Inpatientemergency care. See the "InpatientHospital Care" section of thisbooklet for other costs.

Hospital Care" section of thisbooklet for other costs.



Worldwide Emergency: 20% of thecost of emergency service outside




of the U.S.A.; Worldwide Emergentof the U.S.A.; Worldwide Emergentof the U.S.A.; Worldwide Emergentof the U.S.A.; Worldwide EmergentCare coverage includes emergencyCare coverage includes emergencyCare coverage includes emergencyCare coverage includes emergencyroom visits, emergency hospitalroom visits, emergency hospitalroom visits, emergency hospitalroom visits, emergency hospitaladmissions and ambulance tripsadmissions and ambulance tripsadmissions and ambulance tripsadmissions and ambulance tripswhere you are taken to thewhere you are taken to thewhere you are taken to thewhere you are taken to theemergency room up to $20,000emergency room up to $20,000emergency room up to $20,000emergency room up to $20,000when outside the U.S.A. Limited towhen outside the U.S.A. Limited towhen outside the U.S.A. Limited towhen outside the U.S.A. Limited to60 days coverage throughout theyear.

60 days coverage throughout theyear.







Foot exams and treatment if youhave diabetes-related nerve




Foot Care (podiatryservices)

damage and/or meet certainconditions:






Exam to diagnose and treat hearingand balance issues:




Hearing Services



Routine hearing exam:Routine hearing exam: Routine hearing exam:Routine hearing exam:In-network: $20 copay. You arecovered for up to 1 every year.

In-network: $20 copay. You arecovered for up to 1 every year.



Out-of-network: 20% of thecost.There may be a limit to howoften these services are covered.




Home HealthCare

In-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothing


Part-time or intermittent SkilledNursing and home health-aide




services, fewer than 8 hours a dayservices, fewer than 8 hours a day services, fewer than 8 hours a dayservices, fewer than 8 hours a dayand 35 hours per week, includingand 35 hours per week, including and 35 hours per week, includingand 35 hours per week, includingphysical therapy, occupationalphysical therapy, occupational physical therapy, occupationalphysical therapy, occupationaltherapy, and speech therapy,therapy, and speech therapy, therapy, and speech therapy,therapy, and speech therapy,medical and social services,medical equipment & supplies.

medical and social services,medical equipment & supplies.







Inpatient visit:Inpatient visit:Inpatient visit:Inpatient visit:Mental HealthCare Our plan covers up to 190 days in

a lifetime for inpatient mental healthOur plan covers up to 190 days ina lifetime for inpatient mental health

Our plan covers up to 190 days ina lifetime for inpatient mental health

Our plan covers up to 190 days ina lifetime for inpatient mental health

care in a psychiatric hospital. Thecare in a psychiatric hospital. Thecare in a psychiatric hospital. Thecare in a psychiatric hospital. Theinpatient hospital care limit does notinpatient hospital care limit does notinpatient hospital care limit does notinpatient hospital care limit does notapply to inpatient mental servicesprovided in a general hospital.

apply to inpatient mental servicesprovided in a general hospital.



Our plan covers 90 days for aninpatient hospital stay.




Our plan also covers 60 "lifetimereserve days." These are "extra"




days that we cover. If your hospitaldays that we cover. If your hospitaldays that we cover. If your hospitaldays that we cover. If your hospitalstay is longer than 90 days, you canstay is longer than 90 days, you canstay is longer than 90 days, you canstay is longer than 90 days, you canuse these extra days. But once youuse these extra days. But once youuse these extra days. But once youuse these extra days. But once youhave used up these extra 60 days,have used up these extra 60 days,have used up these extra 60 days,have used up these extra 60 days,your inpatient hospital coverage willbe limited to 90 days.

your inpatient hospital coverage willbe limited to 90 days.



In-network:In-network:In-network:In-network:$298 copay per day for days 1through 5

$350 copay per stay$235 copay per day for days 1through 6

$350 copay per stay

Out-of-network: Out-of-network:You pay nothing per day fordays 7 through 90

You pay nothing per day fordays 6 through 90 $250 copay per day for days 1

through 7$250 copay per day for days 1through 7

Out-of-network: Out-of-network: You pay nothing per day fordays 8 through 90

You pay nothing per day fordays 8 through 90$305 copay per day for days 1


Outpatient group therapy visit:Outpatient group therapy visit:You pay nothing per day fordays 8 through 90

You pay nothing per day fordays 8 through 90In-network: $30 copay In-network: $30 copay

Out-of-network: 20% of the costOut-of-network: 20% of the costOutpatient group therapy visit: Outpatient group therapy visit:

Outpatient individual therapy visit: Outpatient individual therapy visit:In-network: $40 copayIn-network: $40 copayIn-network: $30 copayIn-network: $30 copay





Mental HealthCarecontinued

Out-of-network: 20% of the cost Out-of-network: 20% of the costOut-of-network: 20% of the cost Out-of-network: 20% of the costOutpatient individual therapy visit: Outpatient individual therapy visit:

In-network: $40 copay In-network: $40 copayOut-of-network: 20% of the cost Out-of-network: 20% of the cost

Cardiac (heart) rehab services (fora maximum of 2 one-hour sessions




OutpatientRehabilitation

per day for up to 36 sessions up to36 weeks):






Occupational therapy visit:Occupational therapy visit: Occupational therapy visit:Occupational therapy visit:In-network: $15 copayIn-network: $40 copay In-network: $15 copayIn-network: $35 copay


Physical therapy and speech andlanguage therapy visit:






Group therapy visit:Group therapy visit:Group therapy visit:Group therapy visit:OutpatientSubstance Abuse In-network: $30 copayIn-network: $40 copayIn-network: $30 copayIn-network: $40 copay


Individual therapy visit:Individual therapy visit: Individual therapy visit:Individual therapy visit:In-network: $30 copayIn-network: $40 copay In-network: $30 copayIn-network: $40 copay


Ambulatory surgical center:Ambulatory surgical center:Ambulatory surgical center:Ambulatory surgical center:OutpatientSurgery In-network: $75 copayIn-network: $150 copayIn-network: $75 copayIn-network: $250 copay





OutpatientSurgerycontinued


Outpatient hospital:Outpatient hospital: Outpatient hospital:Outpatient hospital:In-network: $150 copayIn-network: $300 copay In-network: $150 copayIn-network: $200 copay


Not CoveredNot CoveredNot CoveredNot CoveredOver-the-CounterItems

Prosthetic devices:Prosthetic devices:Prosthetic devices:Prosthetic devices:ProstheticDevices (braces,artificial limbs, etc.)



Related medical supplies:Related medical supplies: Related medical supplies:Related medical supplies:In-network: 20% of the costIn-network: 20% of the cost In-network: 20% of the costIn-network: 20% of the cost


Renal Dialysis In-network: 20% of the costIn-network: 20% of the costIn-network: 20% of the costIn-network: $30 copay


Not coveredNot coveredNot coveredNot coveredTransportation

$35 copay$35 copay$35 copay$35 copayUrgently NeededServices If you are admitted to the hospital

within 24 hours, you do not have toIf you are admitted to the hospitalwithin 24 hours, you do not have to



pay your share of the cost forpay your share of the cost forpay your share of the cost forpay your share of the cost forurgently needed services. See theurgently needed services. See theurgently needed services. See theurgently needed services. See the"Inpatient Hospital Care" section ofthis booklet for other costs.

"Inpatient Hospital Care" section ofthis booklet for other costs.



Exam to diagnose and treatdiseases and conditions of the eye




Vision Services





Vision Servicescontinued

(including yearly glaucomascreening):






Routine eye exam:Routine eye exam: Routine eye exam:Routine eye exam:In-network: $0 copay. You arecovered for up to 1 every year.




Out-of-network: 20% of the cost.There may be a limit to how oftenthese services are covered.




Eyeglasses or contact lenses aftercataract surgery:






Preventive Care In-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothingIn-network: You pay nothing


Our plan covers many preventiveservices, including:




Abdominal aortic aneurysmscreening




Alcohol misuse counselingAlcohol misuse counselingAlcohol misuse counseling Alcohol misuse counseling

Bone mass measurementBone mass measurementBone mass measurementBone mass measurement

Breast cancer screening(mammogram)




Cardiovascular disease(behavioral therapy)




Cardiovascular screeningsCardiovascular screeningsCardiovascular screenings Cardiovascular screenings





Preventive Carecontinued

Cervical and vaginal cancerscreening




Colorectal cancer screenings*(Colonoscopy, Fecal occult bloodtest, Flexible sigmoidoscopy)




Depression screeningDepression screening Depression screeningDepression screening

Diabetes screeningsDiabetes screeningsDiabetes screenings Diabetes screenings

HIV screeningHIV screeningHIV screeningHIV screening

Medical nutrition therapy services Medical nutrition therapy servicesMedical nutrition therapy servicesMedical nutrition therapy services

Obesity screening and counselingObesity screening and counseling Obesity screening and counselingObesity screening and counseling

Prostate cancer screenings (PSA)Prostate cancer screenings (PSA)Prostate cancer screenings (PSA) Prostate cancer screenings (PSA)

Sexually transmitted infectionsscreening and counseling




Tobacco use cessationcounseling (counseling for peoplewith no sign of tobacco-relateddisease)




Vaccines, including Flu shots,Hepatitis B shots, Pneumococcalshots




"Welcome to Medicare"preventive visit (one-time)




Yearly "Wellness" visitYearly "Wellness" visitYearly "Wellness" visitYearly "Wellness" visit

Any additional preventive servicesapproved by Medicare during thecontract year will be covered.




*A colonoscopy or sigmoidoscopyconducted for polyp removal or




biopsy is a surgical procedure biopsy is a surgical procedurebiopsy is a surgical procedurebiopsy is a surgical procedure





Preventive Carecontinued

subject to the outpatient surgerycost sharing described later in thisbenefit grid.




You pay nothing for hospice carefrom a Medicare-certified hospice.




Hospice

You may have to pay part of theYou may have to pay part of theYou may have to pay part of theYou may have to pay part of thecost for drugs and respite care.cost for drugs and respite care.cost for drugs and respite care.cost for drugs and respite care.Hospice is covered outside of ourHospice is covered outside of ourHospice is covered outside of ourHospice is covered outside of ourplan. Please contact us for moredetails.

plan. Please contact us for moredetails.



Inpatient Care

Our plan covers an unlimitednumber of days for an inpatienthospital stay.




Inpatient HospitalCare

In-network:In-network:In-network:In-network:$298 copay per day for days 1through 5

$350 copay per stay$235 copay per day for days 1through 6

$350 copay per stay

You pay nothing per day fordays 91 and beyond

You pay nothing per day fordays 91 and beyondYou pay nothing per day for

days 7 through 90You pay nothing per day fordays 6 through 90

Out-of-network: Out-of-network:You pay nothing per day fordays 91 and beyond

You pay nothing per day fordays 91 and beyond $250 copay per day for days 1


Out-of-network: You pay nothing per day fordays 8 and beyond

Out-of-network:You pay nothing per day fordays 8 and beyond$305 copay per day for days 1








For inpatient mental health care,see the "Mental Health Care"section of this booklet.




Inpatient MentalHealth Care

Our plan covers up to 100 days ina SNF.




Skilled NursingFacility (SNF)

In-network:In-network:In-network:In-network:You pay nothing per day fordays 1 through 20

You pay nothing per day fordays 1 through 20



$75 copay per day for days 21through 100

$150 copay per day for days21 through 100

$75 copay per day for days 21through 100


Out-of-network:Out-of-network: Out-of-network:Out-of-network:You pay nothing per day fordays 1 through 20








Prescription Drug Benefits

For Part B drugs such aschemotherapy drugs:




How much do Ipay?



Other Part B drugs:Other Part B drugs: Other Part B drugs:Other Part B drugs:In-network: 20% of the costIn-network: 20% of the cost In-network: 20% of the costIn-network: 20% of the cost


Our plan does not cover Part Dprescription drugs.

Our plan does not cover Part Dprescription drugs.





You pay the following until your totalyearly drug costs reach $3,310.

You pay the following until your totalyearly drug costs reach $3,310.

Initial Coverage

Total yearly drug costs are the totalTotal yearly drug costs are the totaldrug costs paid by both you and ourPart D plan.

drug costs paid by both you and ourPart D plan.

You may get your drugs at networkretail pharmacies and mail orderpharmacies.

You may get your drugs at networkretail pharmacies and mail orderpharmacies.

Standard Retail Cost-SharingThree-monthsupply

One-monthsupply

Tier

$12.50copay

$5 copayTier 1(PreferredGeneric)

$25 copay$10 copayTier 2(Generic)

$112.50copay

$45 copayTier 3(PreferredBrand)

$212.50copay

$85 copayTier 4(Non-PreferredBrand)

Not Offered33% of thecost

Tier 5(SpecialtyTier)

Standard Retail Cost-SharingThree-monthsupply

One-monthsupply

Tier

$17.50copay



$117.50copay


$250 copay$100 copayTier 4(Non-PreferredBrand)







Initial Coveragecontinued

Preferred Retail Cost-SharingThree-monthsupply

One-monthsupply

Tier

$0$0Tier 1(PreferredGeneric)

$12.50copay

$5 copayTier 2(Generic)

$87.50copay


$187.50copay




Preferred Retail Cost-SharingThree-monthsupply

One-monthsupply

Tier

$5 copay$2 copayTier 1(PreferredGeneric)

$17.50copay

$7 copayTier 2(Generic)

$92.50copay










Standard Mail Order Cost-SharingThree-monthsupply

One-monthsupply

Tier

$12.50copay



$112.50copay


$212.50copay




Standard Mail Order Cost-SharingThree-monthsupply

One-monthsupply

Tier

$17.50copay



$117.50copay










Preferred Mail OrderCost-Sharing

Three-monthsupply

One-monthsupply

Tier

$0$0Tier 1(PreferredGeneric)


$70 copay$35 copayTier 3(PreferredBrand)




Preferred Mail OrderCost-Sharing

Three-monthsupply

One-monthsupply

Tier

$2 copay$2 copayTier 1(PreferredGeneric)


$74 copay$37 copayTier 3(PreferredBrand)




If you reside in a long-term carefacility, you pay the same as at aretail pharmacy.

If you reside in a long-term carefacility, you pay the same as at aretail pharmacy.

You may get drugs from anout-of-network pharmacy at the

You may get drugs from anout-of-network pharmacy at the

same cost as an in-networkpharmacy.

same cost as an in-networkpharmacy.

You will be reimbursed up to theplan's cost of the drug minus the

You will be reimbursed up to theplan's cost of the drug minus the

copay or co-insurance for drugscopay or co-insurance for drugspurchased out-of-network until totalpurchased out-of-network until totalyearly drug costs reach $3,310.Youyearly drug costs reach $3,310.Youwill likely have to pay thewill likely have to pay the






pharmacy’s full charge for the drugsand submit documentation toreceive reimbursement.

pharmacy’s full charge for the drugsand submit documentation toreceive reimbursement.

Most Medicare drug plans have acoverage gap (also called the

Most Medicare drug plans have acoverage gap (also called the

Coverage Gap

"donut hole"). This means that"donut hole"). This means thatthere's a temporary change in whatthere's a temporary change in whatyou will pay for your drugs. Theyou will pay for your drugs. Thecoverage gap begins after the totalcoverage gap begins after the totalyearly drug cost (including what ouryearly drug cost (including what ourplan has paid and what you havepaid) reaches $3,310.

plan has paid and what you havepaid) reaches $3,310.

After you enter the coverage gap,you pay 45% of the plan's cost for

After you enter the coverage gap,you pay 45% of the plan's cost for

covered brand name drugs andcovered brand name drugs and58% of the plan's cost for covered58% of the plan's cost for coveredgeneric drugs until your costs totalgeneric drugs until your costs total$4,850, which is the end of the$4,850, which is the end of thecoverage gap. Not everyone willenter the coverage gap.

coverage gap. Not everyone willenter the coverage gap.

After your yearly out-of-pocket drugcosts (including drugs purchased

After your yearly out-of-pocket drugcosts (including drugs purchased

CatastrophicCoverage

through your retail pharmacy andthrough your retail pharmacy andthrough mail order) reach $4,850,you pay the greater of:

through mail order) reach $4,850,you pay the greater of:

5% of the cost, or5% of the cost, or

$2.95 copay for generic(including brand drugs treated asgeneric) and a $7.40 copaymentfor all other drugs.

$2.95 copay for generic(including brand drugs treated asgeneric) and a $7.40 copaymentfor all other drugs.

Member Services1-866-568-8921

8:00 a.m. to 12:00 a.m. in your local time zone,(TTY users call 711) 7 days a week.

www.TodaysOptions.com

The number of stars shows how well our plan performs.

HHHHH excellentHHHH above averageHHH average

HH below averageH poor

2015 Medicare Star Ratings*The Medicare Program rates all health and prescription drug plans each year, based on a plan’s quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan’s performance to other plans. The two main types of Star Ratings are:

1. An Overall Star Rating that combines all of our plan’s scores.2. Summary Star Rating that focuses on our medical or our prescription drug services.

Some of the areas Medicare reviews for these ratings include:● How our members rate our plan’s services and care;● How well our doctors detect illnesses and keep members healthy;● How well our plan helps our members use recommended and safe prescription medications.

Y0067_PRE_H2816_NPFFSPLNRTG_1014 CMS Accepted 10/15/2014 H2816-NPFFSPLNRTG.v2-15

Learn more about our plan and how we are different from other plans at www.medicare.gov.You may also contact us 7 days a week from 8:00 a.m. to 12:00 a.m. Eastern time at 866-418-1923 (toll-free) or 711 (TTY), from October 15 to December 7. Our hours of operation for the rest of the year are Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Current members please call 866-568-8921 (toll-free) or 711 (TTY).

For 2015, Universal American Corp. received the following Overall Star Rating from Medicare.

HHHH4 Stars

We received the following Summary Star Rating for Universal American Corp.’s health/drug plan services:Health Plan Services:HHHH3.5 StarsDrug Plan Services:HHHHH4.5 Stars

*Star Ratings are based on 5 Stars. Star Ratings are assessed each year and may change from one year to the next.

Universal American Corp. – H2816

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2016 Summary of Benefits - HealthPlanOne · Select counties in New York and Maine January 1, 2016...

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