** Cost ** |
Premium and Other Important Information |
$19 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$3 200 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Aids
|
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Extra Benefits ** |
Prescription Drugs |
$0 copay for Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.ghc.org/health_plans/index.jhtml?reposid=/common/healthPlans/Medicare/aboutPartDFormulary.html on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Group Health Cooperative Clear Care Vital (HMO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and Group Health Cooperative Clear Care Vital (HMO) approves the exception you will pay Tier 2: Preferred Brand Drugs cost sharing for that drug. |
$310 yearly deductible. |
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$69 copay for a three-month (90-day) supply of drugs in this tier |
50% coinsurance for a three-month (90-day) supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (31-day) supply of drugs in this tier |
$23 copay for a one-month (31-day) supply of drugs in this tier |
50% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$69 copay for a three-month (90-day) supply of drugs in this tier |
50% coinsurance for a three-month (90-day) supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Group Health Cooperative Clear Care Vital (HMO). |
After you pay your yearly deductible you will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
$0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for up to 1 routine eye exam(s) every year |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') |
0% of the cost for Medicare-covered dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$19 monthly plan premium in addition to your monthly Medicare Part B premium. |
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. |
This plan covers all Medicare-covered preventive services with zero cost sharing. |
$3 200 out-of-pocket limit. |
There is no limit on cost sharing for the following services: Supplemental Services: - Preventive Dental
- Comprehensive Dental
- Eye Wear
- Hearing Aids
|
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
No limit to the number of days covered by the plan each benefit period. |
For Medicare-covered hospital stays: |
Days 1 - 3: $350 copay per day |
Days 4 - 90: $0 copay per day |
$0 copay for additional hospital days |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
For Medicare-covered hospital stays: |
Days 1 - 3: $350 copay per day |
Days 4 - 90: $0 copay per day |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 100: $75 copay per day |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. |
Authorization rules may apply. |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$20 copay for each in-area network urgent care Medicare-covered visit. |
$40 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
$20 copay for each Medicare-covered visit. |
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. |
Podiatry Services |
Authorization rules may apply. |
$40 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$20 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$20 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$300 copay for each Medicare-covered ambulatory surgical center visit. |
$300 copay for each Medicare-covered outpatient hospital facility visit. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
$20 copay for Medicare-covered Occupational Therapy visits. |
$20 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$20 copay for Medicare-covered Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Prosthetic Devices |
Authorization rules may apply. |
20% of the cost for Medicare-covered items. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
Authorization rules may apply. |
$0 copay for Diabetes self-monitoring training. |
$0 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
** Preventive Services ** |
Bone Mass Measurement |
Authorization rules may apply. |
$0 copay for Medicare-covered bone mass measurement |
Colorectal Screening Exams |
Authorization rules may apply. |
$0 copay for Medicare-covered colorectal screenings. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
No referral needed for Flu and pneumonia vaccines. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
Authorization rules may apply. |
$0 copay for - Medicare-covered prostate cancer screening
|
** Additional Benefits ** |
Dialysis |
Authorization rules may apply. |
$0 copay for renal dialysis |
$0 copay for Nutrition Therapy for End-Stage Renal Disease |
Prescription Drugs |
$0 copay for Part B-covered drugs. |
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.ghc.org/health_plans/index.jhtml?reposid=/common/healthPlans/Medicare/aboutPartDFormulary.html on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service).
|
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Group Health Cooperative Clear Care Vital (HMO) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and Group Health Cooperative Clear Care Vital (HMO) approves the exception you will pay Tier 2: Preferred Brand Drugs cost sharing for that drug. |
$310 yearly deductible. |
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$69 copay for a three-month (90-day) supply of drugs in this tier |
50% coinsurance for a three-month (90-day) supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (31-day) supply of drugs in this tier |
$23 copay for a one-month (31-day) supply of drugs in this tier |
50% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
$12 copay for a three-month (90-day) supply of drugs in this tier |
$69 copay for a three-month (90-day) supply of drugs in this tier |
50% coinsurance for a three-month (90-day) supply of drugs in this tier |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. |
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Group Health Cooperative Clear Care Vital (HMO). |
After you pay your yearly deductible you will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs |
$4 copay for a one-month (30-day) supply of drugs in this tier |
$23 copay for a one-month (30-day) supply of drugs in this tier |
50% coinsurance for a one-month (30-day) supply of drugs in this tier |
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. |
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of: - A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
- 5% coinsurance.
|
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') |
0% of the cost for Medicare-covered dental benefits. |
Hearing Services |
Hearing aids not covered. |
$20 copay for Medicare-covered diagnostic hearing exams |
$20 copay for up to 1 routine hearing test(s) |
$0 copay for up to 1 hearing aid fitting evaluation(s) |
Vision Services |
$0 copay for - one pair of eyeglasses or contact lenses after cataract surgery
|
$0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for up to 1 routine eye exam(s) every year |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
Nursing Hotline |
$0 copay for each Medicare-covered smoking cessation counseling session. |
$0 copay for each Medicare-covered HIV screening. |
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. |
Transportation |
Authorization rules may apply. |
$200 copay for one-way trips to Plan-approved location. |
Acupuncture |
This plan does not cover Acupuncture. |
** Cost ** |
Premium and Other Important Information |
Package: 1 - Clear Care Dental: |
$49 monthly premium in addition to your $19 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 500 plan coverage limit every year for these benefits. |
** Extra Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 fluoride treatment(s) every six months |
up to 1 dental x-ray(s) every six months |
$1 500 plan coverage limit for dental benefits every year. |
** Important Information ** |
Premium and Other Important Information |
Package: 1 - Clear Care Dental: |
$49 monthly premium in addition to your $19 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: - Preventive Dental
- Comprehensive Dental
|
$1 500 plan coverage limit every year for these benefits. |
** Additional Benefits ** |
Dental Services |
Plan offers additional comprehensive dental benefits. |
$0 copay for the following preventive dental benefits: |
up to 1 oral exam(s) every six months |
up to 1 cleaning(s) every six months |
up to 1 fluoride treatment(s) every six months |
up to 1 dental x-ray(s) every six months |
$1 500 plan coverage limit for dental benefits every year. |