2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Group Health Cooperative Clear Care Essential (HMO) | ||||
Location: | Thurston, Washington State Click to see other locations | ||||
Plan ID: | H5050 - 009 - 0 Click to see other plans | ||||
Member Services: | 1-888-901-4600 TTY users 1-800-833-6388 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Group Health Cooperative Clear Care Essential (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $153.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $250 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,970 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $2,500 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 5,235 drugs | Browse the Group Health Cooperative Clear Care Essential (HMO) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $4.00 | $18.00 | $20.00 | 50% | |
• Number of Drugs per Tier: | 1845 | 425 | 638 | 2332 | |
Plan's Pharmacy Search: | http://www.ghc.org/medicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H5050 - 009): | 12,418 members | ||||
Plan’s Summary Star Rating: | 5 out of 5 Stars. This plan qualifies for the 5-star rating Special Enrollment period. Read more. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 5 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$153 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. | |||||
$2 500 out-of-pocket limit for Medicare-covered services. | |||||
** 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 ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$153 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. | |||||
$2 500 out-of-pocket limit for Medicare-covered services. | |||||
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 | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
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$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 of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
For Medicare-covered hospital stays: | |||||
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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: | |||||
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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. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
Authorization rules may apply. | |||||
$10 copay for each Medicare-covered primary care doctor visit. | |||||
$35 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
$10 copay for each Medicare-covered chiropractic 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. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
$35 copay for each Medicare-covered podiatry visit | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$10 copay for each Medicare-covered individual therapy visit | |||||
$10 copay for each Medicare-covered group therapy visit | |||||
$10 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$10 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$0 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$10 copay for Medicare-covered individual substance abuse outpatient treatment visits | |||||
$10 copay for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$200 copay for each Medicare-covered ambulatory surgical center visit | |||||
$200 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$0 to $150 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 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. | |||||
Urgently Needed Care | |||||
$10 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$10 copay for Medicare-covered Occupational Therapy visits | |||||
$10 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered prosthetic devices | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
20% of the cost for Medicare-covered Diabetes monitoring supplies | |||||
Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies. | |||||
20% of the cost for Medicare-covered Therapeutic shoes or inserts | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
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$50 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$10 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
Authorization rules may apply. | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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Kidney Disease and Conditions | |||||
$0 copay for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
$0 copay for Medicare Part B 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 https://www1.ghc.org/medicare/formulary on the web. | |||||
Different out-of-pocket costs may apply for people who
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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 a Part D plan. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from Group Health Cooperative Clear Care Essential (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. | |||||
You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as "free first fill" on the plan?s website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If you request a formulary exception for a drug and Group Health Cooperative Clear Care Essential (HMO) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug. | |||||
$250 annual deductible. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 970: | |||||
Tier 1: Preferred Generic | |||||
Tier 2: Non-Preferred Generic | |||||
Tier 3: Preferred Brand | |||||
Tier 4: Non-Preferred Brand | |||||
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Tier 1: Preferred Generic | |||||
Tier 2: Non-Preferred Generic | |||||
Tier 3: Preferred Brand | |||||
Tier 4: Non-Preferred Brand | |||||
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Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. | |||||
Tier 1: Preferred Generic | |||||
Tier 2: Non-Preferred Generic | |||||
Tier 3: Preferred Brand | |||||
Tier 4: Non-Preferred Brand | |||||
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After your total yearly drug costs reach $2 970 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 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750. | |||||
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
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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 Essential (HMO). | |||||
After you pay your yearly deductible you will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 970: | |||||
Tier 1: Preferred Generic | |||||
Tier 2: Non-Preferred Generic | |||||
Tier 3: Preferred Brand | |||||
Tier 4: Non-Preferred Brand | |||||
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You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). | |||||
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed for drugs purchased out-of-network up to the plan’s cost of the drug minus your cost share which is the greater of:
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Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered dental benefits | |||||
This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.") | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$10 copay for Medicare-covered diagnostic hearing exams | |||||
$10 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for
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Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
| |||||
$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. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
Authorization rules may apply. | |||||
$10 copay for each Medicare-covered primary care doctor visit. | |||||
$35 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$200 copay for each Medicare-covered ambulatory surgical center visit | |||||
$200 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$0 to $150 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors. | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
| |||||
$50 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - Clear Care Dental: | |||||
$51 monthly premium in addition to your $153 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
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$1 500 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 1 - Clear Care Dental: | |||||
$51 monthly premium in addition to your $153 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
| |||||
$1 500 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
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$1 500 plan coverage limit for dental benefits every year |