** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$1.1 monthly plan premium* |
$0 annual deductible.* |
$3 400 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
** 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 |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$1.1 monthly plan premium* |
$0 annual deductible.* |
$3 400 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
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 |
Plan covers 90 days each benefit period. |
$0 annual service category deductible* |
$0 copay* |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.* |
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. |
$0 annual service category deductible* |
$0 copay* |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve 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. |
$0 annual service category deductible* |
$0 copay for SNF services* |
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. |
$0 copay for each Medicare-covered primary care doctor visit.* |
$0 copay for each Medicare-covered specialist visit.* |
Chiropractic Services |
Authorization rules may apply. |
$0 copay for Medicare-covered chiropractic visits* |
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. |
$0 copay for Medicare-covered podiatry visits* |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 copay for: |
- each Medicare-covered individual therapy visit*
|
each Medicare-covered group therapy visit* |
$0 copay for: |
- each Medicare-covered individual therapy visit with a psychiatrist*
|
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. |
$0 copay for: |
- each Medicare-covered individual substance abuse outpatient treatment visit*
|
each Medicare-covered group substance abuse outpatient treatment visit* |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
Emergency Care |
$0 annual service category deductible* |
$0 copay for Medicare-covered emergency room visits* |
$25 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. |
Urgently Needed Care |
$0 copay for Medicare-covered urgently-needed-care visits* |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits* |
$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 annual service category deductible* |
Authorization rules may apply. |
$0 copay for Medicare-covered durable medical equipment* |
Prosthetic Devices |
Authorization rules may apply. |
$0 copay for Medicare-covered prosthetic devices* |
Diabetes Programs and Supplies |
Authorization rules may apply. |
$0 copay for Medicare-covered Diabetes self-management training* |
$0 copay for Medicare-covered: |
- Diabetes monitoring supplies*
|
Therapeutic shoes or inserts* |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests* |
X-rays* |
diagnostic radiology services (not including X-rays)* |
therapeutic radiology services* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
$0 copay for: |
- Medicare-covered Cardiac Rehabilitation Services*
|
Medicare-covered Intensive Cardiac Rehabilitation Services* |
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: |
- Health Club Membership/Fitness Classes
|
Kidney Disease and Conditions |
Authorization rules may apply. |
$0 copay for Medicare-covered renal dialysis* |
$0 copay for Medicare-covered kidney disease education services* |
Outpatient Prescription Drugs |
$0 yearly deductible for Medicare Part B drugs.* |
$0 copay for 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.youroptimumhealthcare.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 you the plan and Medicare. |
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 Optimum Emerald Full (HMO SNP) for certain drugs. |
The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. |
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 a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
You can get drugs the following way(s): |
- one-month (30-day) supply
|
three-month (90-day) supply |
You can get drugs the following way(s): |
- one-month (31-day) supply of generic drugs
|
31-day supply of brand drugs. |
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. |
You can get drugs the following way(s): |
- one-month (30-day) supply
|
three-month (90-day) supply |
You pay a $0 copay. |
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 Optimum Emerald Full (HMO SNP). |
You can get out-of-network drugs the following way: |
- one-month (30-day) supply
|
Depending on your income and institutional status you will be reimbursed by Optimum Emerald Full (HMO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: A $0 copay or A $1.15 copay or A $2.65 copay For all other drugs purchased out-of-network either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
You will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
$0 annual service category deductible for Medicare-covered dental benefits* |
$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 2 fluoride treatment(s) every year |
$0 to $75 copay for up to 1 dental x-ray(s) |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams* |
$0 copay for : |
- up to 1 supplemental routine hearing exam(s) every two years
|
up to 1 fitting-evaluation(s) for a hearing aid every two years |
$0 copay for up to 1 hearing aid(s) every two years |
$500 plan coverage limit for hearing aids every two years. |
** Additional Benefits ** |
Vision Services |
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye* |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
|
- $0 copay for up to 1 supplemental 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. Contact plan for details. |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
$0 annual service category deductible* |
$0 copay* |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.* |
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. |
$0 copay for each Medicare-covered primary care doctor visit.* |
$0 copay for each Medicare-covered specialist visit.* |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 copay for Medicare-covered ambulance benefits.* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 annual service category deductible* |
Authorization rules may apply. |
$0 copay for Medicare-covered durable medical equipment* |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests* |
X-rays* |
diagnostic radiology services (not including X-rays)* |
therapeutic radiology services* |
** Additional Benefits ** |
Over-the-Counter Items |
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. |
Transportation |
$0 copay for up to 12 one-way trip(s) to plan-approved location every year |