2013 AARP MedicareComplete Plus (HMO-POS) in WI Plan Benefits Details

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2013 Medicare Advantage Plan Benefit Details for the AARP MedicareComplete Plus (HMO-POS)

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2013 Medicare Advantage Plan Details
Medicare Plan Name:	AARP MedicareComplete Plus (HMO-POS)
Location:	Vernon, Wisconsin Click to see other locations
Plan ID:	H5253 - 028 - 0 Click to see other plans
Member Services:	1-800-643-4845 TTY users 711
— 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
Email a copy of the AARP MedicareComplete Plus (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:	$0.00 (see Plan Premium Details below)
Annual Deductible:	$0
Annual Initial Coverage Limit (ICL):	$2,970
Health Plan Type:	Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):	$3,400
Additional Gap Coverage?	No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:	3,825 drugs	Browse the AARP MedicareComplete Plus (HMO-POS) Formulary
This plan has 5 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:	$3.00	$6.00	$45.00	$95.00	33%
• Number of Drugs per Tier:	66	1218	1243	796	532
Plan's Pharmacy Search:	http://www.UHCMedicareSolutions.com
Plan Offers Mail Order?	Yes
Number of Members enrolled in this plan in (H5253 - 028):		2,734 members
Plan’s Summary Star Rating:		4 out of 5 Stars.
• Customer Service Rating:		4 out of 5 Stars.
• Member Experience Rating:		4 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 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
$0 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.
$3 400 out-of-pocket limit for Medicare-covered services.
Doctor and Hospital Choice
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
Plan covers you when you travel in the U.S. or its territories.
Extra Benefits
Over-the-Counter Items
The plan does not cover Over-the-Counter items.
Point of Service
Point of Service coverage is available for the following benefits:
Medicare-covered Inpatient Hospital Acute Inpatient Hospital Psychiatric Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Outpatient Substance Abuse Outpatient Blood Services <
Supplemental Podiatry Services Outpatient Blood Services Additional Preventive Services Annual Physical Exam Supplemental Education/Wellness Programs Eye Exams Hearing Exams
$395 copay per hospital day.
For Inpatient Psychiatric Hospital stays:
Days 1 - 90: $395 copay per day
$15 copay for Medicare-covered Primary Care Physician Services
$35 copay for Medicare-covered Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Podiatry Services Physical Therapy and Speech-Language Pathology Services Eye Exams Hearing Exams Supplemental Podiatry Services Eye Exams Hearing Exams
30% of the cost for Medicare-covered Diagnostic Radiological Services Therapeutic Radiological Services Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Prosthetics/Medical Supplies Diabetic Supplies and Services Kidney Disease Education Services Diabetes Self-Management Training Medicare Part B Rx Drugs Eye Wear Supplemental Additional Preventive Services Annual Physical Exam
$13 copay [or 30% of the cost] for Medicare-covered Outpatient Diagnostic Procedures/Tests/Lab Services
$21 copay for Medicare-covered Outpatient X-Rays
$75 copay for Medicare-covered Partial Hospitalization
$200 copay for Medicare-covered Ambulance Services
$35 to $45 copay for Medicare-covered Mental Health Specialty Services Psychiatric Services Outpatient Substance Abuse
$0 copay for Medicare-covered Outpatient Blood Services Supplemental Outpatient Blood Services Supplemental Education/Wellness Programs
0% to 30% of the cost for Medicare-covered Medicare-covered Preventive Services
$15 to $35 copay for Medicare-covered Other Health Care Professional
Transportation
This plan does not cover supplemental routine transportation.
Important Information
Premium and Other Important Information
$0 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.
$3 400 out-of-pocket limit for Medicare-covered services.
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
Plan covers you when you travel in the U.S. or its territories.
Inpatient Care
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 18: $195 copay per day
Days 19 - 90: $0 copay per day
$0 copay for each additional hospital day.
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:
Days 1 - 9: $195 copay per day
Days 10 - 90: $0 copay per day
Skilled Nursing Facility (SNF)
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For Medicare-covered SNF stays:
Days 1 - 20: $50 copay per day
Days 21 - 36: $150 copay per day
Days 37 - 100: $0 copay per day
Home Health Care
$0 copay for each Medicare-covered home health visit
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
$10 copay for each Medicare-covered primary care doctor visit.
$30 copay for each Medicare-covered specialist visit.
Chiropractic Services
$20 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
$30 copay for each Medicare-covered podiatry visit
$30 copay for up to 6 supplemental routine podiatry visit(s) every year
Medicare-covered podiatry visits are for medically-necessary foot care.
Outpatient Mental Health Care
$40 copay for each Medicare-covered individual therapy visit
$30 copay for each Medicare-covered group therapy visit
$40 copay for each Medicare-covered individual therapy visit with a psychiatrist
$30 copay for each Medicare-covered group therapy visit with a psychiatrist
$60 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care
$40 copay for Medicare-covered individual substance abuse outpatient treatment visits
$30 copay for Medicare-covered group substance abuse outpatient treatment visits
Outpatient Services
20% of the cost for each Medicare-covered ambulatory surgical center visit
20% of the cost for each Medicare-covered outpatient hospital facility visit
Ambulance Services
$200 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 24-hour(s) for the same condition you pay $0 for the emergency room visit.
Urgently Needed Care
$30 to $40 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation Services
$30 copay for Medicare-covered Occupational Therapy visits
$30 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment
20% of the cost for Medicare-covered durable medical equipment
Prosthetic Devices
20% of the cost for Medicare-covered prosthetic devices
Diabetes Programs and Supplies
$0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered Diabetes monitoring supplies
20% of the cost for Medicare-covered Therapeutic shoes or inserts
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$13 copay for Medicare-covered lab services
20% of the cost for Medicare-covered diagnostic procedures and tests
$16 copay for Medicare-covered X-rays
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
20% of the cost for Medicare-covered therapeutic radiology services
Preventive Services
Cardiac and Pulmonary Rehabilitation Services
$30 copay for Medicare-covered Cardiac Rehabilitation Services
$30 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$30 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services and Wellness/Education Programs
$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.
$0 copay for an annual physical exam
The plan covers the following supplemental education/wellness programs:
Health Club Membership/Fitness Classes
Nursing Hotline
$0 copay for Additional Preventive Services. Contact plan for details.
Kidney Disease and Conditions
20% of the cost for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Outpatient Prescription Drugs
20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.UHCMedicareSolutions.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) providers.
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). 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 a Part D plan.
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
Your provider must get prior authorization from AARP MedicareComplete Plus (HMO-POS) 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 AARP MedicareComplete Plus (HMO-POS) approves the exception you will pay Tier 4: Non-Preferred Brand cost sharing for that drug.
$0 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
Tier 5: Specialty Tier
$3 copay for a one-month (31-day) supply of drugs in this tier
$6 copay for a one-month (31-day) supply of drugs in this tier
$45 copay for a one-month (31-day) supply of drugs in this tier
$95 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
$9 copay for a three-month (90-day) supply of drugs in this tier
$18 copay for a three-month (90-day) supply of drugs in this tier
$135 copay for a three-month (90-day) supply of drugs in this tier
$285 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
Tier 1: Preferred Generic
Tier 2: Non-Preferred Generic
Tier 3: Preferred Brand
Tier 4: Non-Preferred Brand
Tier 5: Specialty Tier
$3 copay for a one-month (31-day) supply of drugs in this tier
$6 copay for a one-month (31-day) supply of drugs in this tier
$45 copay for a one-month (31-day) supply of drugs in this tier
$95 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
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
Tier 5: Specialty Tier
$6 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$12 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$125 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$275 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
33% coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
$9 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$18 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$135 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
$285 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
33% coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
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: 5% coinsurance or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
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 AARP MedicareComplete Plus (HMO-POS).
You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network 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
Tier 5: Specialty Tier
$3 copay for a one-month (31-day) supply of drugs in this tier
$6 copay for a one-month (31-day) supply of drugs in this tier
$45 copay for a one-month (31-day) supply of drugs in this tier
$95 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 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).
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 $4 750 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: 5% coinsurance or $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
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
In general preventive dental benefits (such as cleaning) not covered.
$30 copay for Medicare-covered dental benefits
Hearing Services
$0 copay for:
$30 copay for Medicare-covered diagnostic hearing exams
$10 copay for up to 1 supplemental routine hearing exam(s) every year
$390 copay for up to 2 inner-ear hearing aid(s) every year
$340 copay for up to 2 over-the-ear hearing aid(s) every year
Additional Benefits
Vision Services
$0 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
$0 to $30 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.
$30 copay for up to 1 supplemental routine eye exam(s) every year
$15 copay for contacts
$0 copay for up to 1 pair(s) of lenses every two years
$15 copay for up to 1 frame(s) every two years
$105 plan coverage limit for contact lenses every two years.
$70 plan coverage limit for eye glass frames every two years.
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.
Point of Service
Point of Service coverage is available for the following benefits:
Medicare-covered Inpatient Hospital Acute Inpatient Hospital Psychiatric Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Outpatient Substance Abuse Outpatient Blood Services <
Supplemental Podiatry Services Outpatient Blood Services Additional Preventive Services Annual Physical Exam Supplemental Education/Wellness Programs Eye Exams Hearing Exams
$395 copay per hospital day.
For Inpatient Psychiatric Hospital stays:
Days 1 - 90: $395 copay per day
$15 copay for Medicare-covered Primary Care Physician Services
$35 copay for Medicare-covered Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Podiatry Services Physical Therapy and Speech-Language Pathology Services Eye Exams Hearing Exams Supplemental Podiatry Services Eye Exams Hearing Exams
30% of the cost for Medicare-covered Diagnostic Radiological Services Therapeutic Radiological Services Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Prosthetics/Medical Supplies Diabetic Supplies and Services Kidney Disease Education Services Diabetes Self-Management Training Medicare Part B Rx Drugs Eye Wear Supplemental Additional Preventive Services Annual Physical Exam
$13 copay [or 30% of the cost] for Medicare-covered Outpatient Diagnostic Procedures/Tests/Lab Services
$21 copay for Medicare-covered Outpatient X-Rays
$75 copay for Medicare-covered Partial Hospitalization
$200 copay for Medicare-covered Ambulance Services
$35 to $45 copay for Medicare-covered Mental Health Specialty Services Psychiatric Services Outpatient Substance Abuse
$0 copay for Medicare-covered Outpatient Blood Services Supplemental Outpatient Blood Services Supplemental Education/Wellness Programs
0% to 30% of the cost for Medicare-covered Medicare-covered Preventive Services
$15 to $35 copay for Medicare-covered Other Health Care Professional
Inpatient Care
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
Days 1 - 18: $195 copay per day
Days 19 - 90: $0 copay per day
$0 copay for each additional hospital day.
Outpatient Care
Doctor Office Visits
$10 copay for each Medicare-covered primary care doctor visit.
$30 copay for each Medicare-covered specialist visit.
Outpatient Services
20% of the cost for each Medicare-covered ambulatory surgical center visit
20% of the cost for each Medicare-covered outpatient hospital facility visit
Ambulance Services
$200 copay for Medicare-covered ambulance benefits.
Outpatient Medical Services and Supplies
Durable Medical Equipment
20% of the cost for Medicare-covered durable medical equipment
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$13 copay for Medicare-covered lab services
20% of the cost for Medicare-covered diagnostic procedures and tests
$16 copay for Medicare-covered X-rays
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)
20% of the cost for Medicare-covered therapeutic radiology services
Additional Benefits
Over-the-Counter Items
The plan does not cover Over-the-Counter items.
Transportation
This plan does not cover supplemental routine transportation.

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