** Cost ** |
Premium and Other Important Information |
$69 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 does not cover all Medicare-covered preventive services with zero cost sharing. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$6 700 out-of-pocket limit. |
In-Network: This limit includes only Medicare-covered services. |
Out-Of-Network: This limit includes only Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Extra Benefits ** |
Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
23% of the cost for Part B drugs out-of-network. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.univhc.com/medicare/members/medicare-formulary.php 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).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Any Any Any Platinum (PFFS) 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 Any Any Any Platinum (PFFS) approves the exception you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. |
The cost sharing for a partial fill of a new prescription will be prorated based on the cost sharing for a full fill of the same prescription. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (31-day) supply of drugs in this tier |
$3 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$65 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$9 copay for a three-month (90-day) supply of drugs in this tier |
$105 copay for a three-month (90-day) supply of drugs in this tier |
$195 copay for a three-month (90-day) supply of drugs in this tier |
33% 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. |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (34-day) supply of drugs in this tier |
$3 copay for a one-month (34-day) supply of drugs in this tier |
$35 copay for a one-month (34-day) supply of drugs in this tier |
$65 copay for a one-month (34-day) supply of drugs in this tier |
33% coinsurance for a one-month (34-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$6 copay for a three-month (90-day) supply of drugs in this tier |
$70 copay for a three-month (90-day) supply of drugs in this tier |
$130 copay for a three-month (90-day) supply of drugs in this tier |
33% 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. |
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 Any Any Any Platinum (PFFS). |
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: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (31-day) supply of drugs in this tier |
$3 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$65 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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.
|
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
$0 copay for routine exams. |
Vision Services |
$10 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $30 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 |
$10 copay for up to 1 pair(s) of glasses every year |
$10 copay for up to 1 pair(s) of contacts every year |
$100 plan coverage limit for eye wear every year. |
Plan offers additional vision benefits. |
$0 copay for eye exams. |
0% to 25% of the cost for eye wear. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for up to 1 oral exam(s) every year |
$0 copay for up to 2 cleaning(s) every year |
$0 copay for up to 1 fluoride treatment(s) every year |
$0 to $75 copay for up to 1 dental x-ray(s) every year |
$0 to $75 copay for preventive dental benefits. |
30% of the cost for comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$69 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 does not cover all Medicare-covered preventive services with zero cost sharing. |
This plan does not allow providers to balance bill (charging more than your cost share amount). |
$6 700 out-of-pocket limit. |
In-Network: This limit includes only Medicare-covered services. |
Out-Of-Network: This limit includes only Medicare-covered services. |
Doctor and Hospital Choice |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
** Inpatient Care ** |
Inpatient Hospital Care (Acute) |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. |
No limit to the number of days covered by the plan each benefit period. |
$1 000 copay for each Medicare-covered hospital stay |
$0 copay for additional hospital days |
$1 000 copay for each hospital stay. |
Inpatient Mental Health Care |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
$1 000 copay for each Medicare-covered hospital stay. |
$0 copay for additional hospital days |
$1 000 copay for each hospital stay. |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
Days 1 - 20: $50 copay per day |
Days 21 - 100: $128 copay per day |
For each SNF stay: |
Days 1 - 20: $50 copay per SNF day |
Days 21 - 100: $128 copay per SNF day |
Home Health Care |
$0 copay for Medicare-covered home health visits. |
$0 copay for home health visits. |
Hospice |
You must get care from a Medicare-certified hospice. |
** Outpatient Care ** |
Doctor Office Visits |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. |
$10 copay for each primary care doctor visit for Medicare-covered benefits. |
$30 copay for each specialist visit for Medicare-covered benefits. |
$10 copay for each primary care doctor visit. |
$30 copay for each specialist visit. |
Chiropractic Services |
$30 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. |
$30 copay for chiropractic benefits. |
Podiatry Services |
$30 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
$30 copay for podiatry benefits. |
Outpatient Mental Health Care |
$30 copay for each Medicare-covered individual or group therapy visit. |
$30 copay for Mental Health benefits. |
$30 copay for Mental Health benefits with a psychiatrist. |
Outpatient Substance Abuse Care |
$30 copay for Medicare-covered individual or group visits. |
$30 copay for outpatient substance abuse benefits. |
Outpatient Hospital Services |
10% of the cost for each Medicare-covered ambulatory surgical center visit. |
25% of the cost for each Medicare-covered outpatient hospital facility visit. |
10% of the cost for ambulatory surgical center benefits. |
25% of the cost for outpatient hospital facility benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits. |
Worldwide coverage. |
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. |
$30 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits. |
$30 copay [or 25% of the cost] for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$30 copay [or 25% of the cost] for Medicare-covered Cardiac Rehab services. |
$30 [or 25% of the cost] for Occupational Therapy benefits. |
$30 [or 25% of the cost] for Physical and/or Speech and Language Therapy visits. |
$30 [or 25% of the cost] for Cardiac Rehab services. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered items. |
20% of the cost for durable medical equipment. |
Prosthetic Devices |
20% of the cost for Medicare-covered items. |
20% of the cost for prosthetic devices. |
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies |
$0 copay for Diabetes self-monitoring training. |
$0 to $30 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
$0 copay for Diabetes self-monitoring training. |
$30 copay for Nutrition Therapy for Diabetes. |
20% of the cost for Diabetes supplies. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement |
$0 copay for Medicare-covered bone mass measurement. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
$0 copay for colorectal screenings. |
Immunizations |
$0 copay for Flu and Pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
$0 copay for immunizations. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams. |
$0 copay for pap smears and pelvic exams. |
Prostate Cancer Screening Exams |
$0 copay for - Medicare-covered prostate cancer screening
|
$0 copay for prostate cancer screening. |
** Additional Benefits ** |
Dialysis |
20% of the cost for renal dialysis |
$0 to $30 copay for Nutrition Therapy for End-Stage Renal Disease. |
20% of the cost for renal dialysis. |
$30 copay for Nutrition Therapy for End-Stage Renal Disease. |
Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
23% of the cost for Part B drugs out-of-network. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.univhc.com/medicare/members/medicare-formulary.php 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).
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). |
Total yearly drug costs are the total drug costs paid by both you and the plan. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Any Any Any Platinum (PFFS) 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 Any Any Any Platinum (PFFS) approves the exception you will pay Tier 4: Non-Preferred Brand Drugs cost sharing for that drug. |
The cost sharing for a partial fill of a new prescription will be prorated based on the cost sharing for a full fill of the same prescription. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (31-day) supply of drugs in this tier |
$3 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$65 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$9 copay for a three-month (90-day) supply of drugs in this tier |
$105 copay for a three-month (90-day) supply of drugs in this tier |
$195 copay for a three-month (90-day) supply of drugs in this tier |
33% 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. |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (34-day) supply of drugs in this tier |
$3 copay for a one-month (34-day) supply of drugs in this tier |
$35 copay for a one-month (34-day) supply of drugs in this tier |
$65 copay for a one-month (34-day) supply of drugs in this tier |
33% coinsurance for a one-month (34-day) supply of drugs in this tier |
Tier 1: Preferred Generic Drugs |
Tier 2: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$6 copay for a three-month (90-day) supply of drugs in this tier |
$70 copay for a three-month (90-day) supply of drugs in this tier |
$130 copay for a three-month (90-day) supply of drugs in this tier |
33% 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. |
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 Any Any Any Platinum (PFFS). |
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: Generic Drugs |
Tier 3: Preferred Brand Drugs |
Tier 4: Non-Preferred Brand Drugs |
Tier 5: Specialty Tier Drugs |
$0 copay for a one-month (31-day) supply of drugs in this tier |
$3 copay for a one-month (31-day) supply of drugs in this tier |
$35 copay for a one-month (31-day) supply of drugs in this tier |
$65 copay for a one-month (31-day) supply of drugs in this tier |
33% coinsurance for a one-month (31-day) supply of drugs in this tier |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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. |
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
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.
|
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. |
Dental Services |
$0 copay for Medicare-covered dental benefits. |
$0 copay for up to 1 oral exam(s) every year |
$0 copay for up to 2 cleaning(s) every year |
$0 copay for up to 1 fluoride treatment(s) every year |
$0 to $75 copay for up to 1 dental x-ray(s) every year |
$0 to $75 copay for preventive dental benefits. |
30% of the cost for comprehensive dental benefits. |
Hearing Services |
Hearing aids not covered. |
$30 copay for Medicare-covered diagnostic hearing exams |
$30 copay for up to 1 routine hearing test(s) every year |
$30 copay for hearing exams. |
Vision Services |
$10 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $30 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 |
$10 copay for up to 1 pair(s) of glasses every year |
$10 copay for up to 1 pair(s) of contacts every year |
$100 plan coverage limit for eye wear every year. |
Plan offers additional vision benefits. |
$0 copay for eye exams. |
0% to 25% of the cost for eye wear. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
$0 copay for routine exams. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
Nutritional Training |
Nutritional benefit |
Additional Smoking Cessation |
Health Club Membership/Fitness Classes |
Nursing Hotline |
Other Wellness Benefits |
$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. |
$0 copay for Health and Wellness services. |
Transportation |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |