** Cost ** |
Premium and Other Important Information |
$99 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: - Transportation Services
- Acupuncture
- Preventive Dental
- Comprehensive Dental
- Eye Exams
- Eye Wear
|
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network specialists (for certain benefits). |
** Extra Benefits ** |
Prescription Drugs |
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.welbornhealthplans.com 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. |
Some drugs have quantity limits. |
Your provider must get prior authorization from WHP Platinum Rx (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 WHP Platinum Rx (HMO) approves the exception you will pay Tier 4: Specialty Tier Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of drugs in this tier |
$30 copay for a one-month (30-day) supply of drugs in this tier |
$60 copay for a one-month (30-day) supply of drugs in this tier |
30% coinsurance for a one-month (30-day) supply of drugs in this tier |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$180 copay for a three-month (90-day) supply of drugs in this tier |
30% 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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (31-day) supply of drugs in this tier |
$30 copay for a one-month (31-day) supply of drugs in this tier |
$60 copay for a one-month (31-day) supply of drugs in this tier |
30% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a three-month (90-day) supply of drugs in this tier |
$60 copay for a three-month (90-day) supply of drugs in this tier |
$120 copay for a three-month (90-day) supply of drugs in this tier |
30% 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. |
The plan covers many formulary generics (65%-99% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. |
You pay the following: |
Tier 1: Generic Drugs |
$5 copay for a one-month (30-day) supply of all drugs covered in this tier |
$15 copay for a three-month (90-day) supply of all drugs covered 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: Generic Drugs |
$5 copay for a one-month (31-day) supply of all drugs covered in this tier |
Tier 1: Generic Drugs |
$10 copay for a three-month (90-day) supply of all drugs covered 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 limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 WHP Platinum Rx (HMO). |
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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of drugs in this tier |
$30 copay for a one-month (30-day) supply of drugs in this tier |
$60 copay for a one-month (30-day) supply of drugs in this tier |
30% coinsurance for a one-month (30-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 for these drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of all drugs covered 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 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 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 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 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 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 the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$25 copay for up to 1 routine eye exam(s) every year |
$25 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$120 plan coverage limit for eye wear every two years. |
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 1 cleaning(s) every year |
$0 copay for up to 1 dental x-ray(s) every year |
Plan offers additional comprehensive dental benefits. |
** Important Information ** |
Premium and Other Important Information |
$99 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: - Transportation Services
- Acupuncture
- Preventive Dental
- Comprehensive Dental
- Eye Exams
- Eye Wear
|
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network 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 - 8: $125 copay per day |
Days 9 - 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 |
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. |
For Medicare-covered hospital stays: |
Days 1 - 8: $125 copay per day |
Days 9 - 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. |
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 - 20: $0 copay per day |
Days 21 - 100: $50 copay per day |
Home Health Care |
Authorization rules may apply. |
$0 copay for each Medicare-covered home health visit. |
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. |
$0 to $15 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each in-area network urgent care Medicare-covered visit. |
$0 to $25 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
Authorization rules may apply. |
$15 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 |
$25 copay for each Medicare-covered visit. |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
$25 copay for each Medicare-covered individual or group therapy visit. |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$25 copay for Medicare-covered individual or group visits. |
Outpatient Hospital Services |
Authorization rules may apply. |
$95 copay for each Medicare-covered ambulatory surgical center visit. |
$95 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 12-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. |
$25 copay for Medicare-covered Occupational Therapy visits. |
$25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$25 to $95 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. |
$5 copay for Diabetes supplies. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
** Preventive Services ** |
Bone Mass Measurement |
$0 copay for Medicare-covered bone mass measurement. |
Colorectal Screening Exams |
$0 copay for Medicare-covered colorectal screenings. |
Immunizations |
Authorization rules may apply. |
$0 copay for Flu and Pneumonia vaccines. |
No referral needed for Flu and pneumonia vaccines. |
$0 copay for Hepatitis B vaccine. |
Pap Smears and Pelvic Exams |
$0 copay for Medicare-covered pap smears and pelvic exams |
Prostate Cancer Screening Exams |
$0 copay for Medicare-covered prostate cancer screening. |
** Additional Benefits ** |
Dialysis |
$0 copay for renal dialysis |
$0 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. |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.welbornhealthplans.com 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. |
Some drugs have quantity limits. |
Your provider must get prior authorization from WHP Platinum Rx (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 WHP Platinum Rx (HMO) approves the exception you will pay Tier 4: Specialty Tier Drugs cost sharing for that drug. |
$0 deductible. |
You pay the following until total yearly drug costs reach $2 840: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of drugs in this tier |
$30 copay for a one-month (30-day) supply of drugs in this tier |
$60 copay for a one-month (30-day) supply of drugs in this tier |
30% coinsurance for a one-month (30-day) supply of drugs in this tier |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$90 copay for a three-month (90-day) supply of drugs in this tier |
$180 copay for a three-month (90-day) supply of drugs in this tier |
30% 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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (31-day) supply of drugs in this tier |
$30 copay for a one-month (31-day) supply of drugs in this tier |
$60 copay for a one-month (31-day) supply of drugs in this tier |
30% coinsurance for a one-month (31-day) supply of drugs in this tier |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$10 copay for a three-month (90-day) supply of drugs in this tier |
$60 copay for a three-month (90-day) supply of drugs in this tier |
$120 copay for a three-month (90-day) supply of drugs in this tier |
30% 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. |
The plan covers many formulary generics (65%-99% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap. |
You pay the following: |
Tier 1: Generic Drugs |
$5 copay for a one-month (30-day) supply of all drugs covered in this tier |
$15 copay for a three-month (90-day) supply of all drugs covered 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: Generic Drugs |
$5 copay for a one-month (31-day) supply of all drugs covered in this tier |
Tier 1: Generic Drugs |
$10 copay for a three-month (90-day) supply of all drugs covered 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 limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 WHP Platinum Rx (HMO). |
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: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of drugs in this tier |
$30 copay for a one-month (30-day) supply of drugs in this tier |
$60 copay for a one-month (30-day) supply of drugs in this tier |
30% coinsurance for a one-month (30-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 for these drugs purchased out-of-network up to the full cost of the drug minus the following: |
Tier 1: Generic Drugs |
Tier 2: Preferred Brand Drugs |
Tier 3: Non-Preferred Brand Drugs |
Tier 4: Specialty Tier Drugs |
$5 copay for a one-month (30-day) supply of all drugs covered 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 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 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 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 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 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 1 cleaning(s) every year |
$0 copay for up to 1 dental x-ray(s) every year |
Plan offers additional comprehensive dental benefits. |
Hearing Services |
Hearing aids not covered. |
$25 copay for Medicare-covered diagnostic hearing exams |
$25 copay for up to 1 routine hearing test(s) every year |
$50 plan coverage limit for routine hearing tests every year. |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $25 copay for exams to diagnose and treat diseases and conditions of the eye. |
$25 copay for up to 1 routine eye exam(s) every year |
$25 copay for up to 1 pair(s) of glasses every two years |
$0 copay for up to 1 pair(s) of contacts every two years |
$120 plan coverage limit for eye wear every two years. |
Physical Exams |
$0 copay for routine exams. |
Limited to 1 exam(s) every year. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Separate Office Visit cost sharing of $15 to $25 may apply. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
Written health education materials including Newsletters |
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 |
This plan does not cover routine transportation. |
Acupuncture |
This plan does not cover Acupuncture. |