2014 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | AARP MedicareComplete SecureHorizons Plan 3 (HMO) | ||||
Location: | Orange, California Click to see other locations | ||||
Plan ID: | H0543 - 153 - 0 Click to see other plans | ||||
Member Services: | 1-800-950-9355 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 |
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Email a copy of the AARP MedicareComplete SecureHorizons Plan 3 (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $16.20 (see Plan Premium Details below) | ||||
Annual Deductible: | $310 | ||||
Annual Initial Coverage Limit (ICL): | $2,850 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,760 drugs | Browse the AARP MedicareComplete SecureHorizons Plan 3 (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | 25% | 25% | 25% | 25% | 25% |
• Number of Drugs per Tier: | 60 | 1048 | 1278 | 733 | 641 |
Plan's Pharmacy Search: | http://www.UHCMedicareSolutions.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H0543 - 153): | 2,473 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 | |||||
$16.2 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. | |||||
$6 700 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 ** | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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Acupuncture | |||||
$10 copay per visit up to 6 visit(s) for acupuncture and other alternative therapies every year | |||||
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. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$16.2 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. | |||||
$6 700 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. | |||||
$1 220 copay for each Medicare-covered hospital stay | |||||
$0 copay for each additional non-Medicare-covered 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. | |||||
$1 220 copay for each Medicare-covered hospital stay. | |||||
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
You will not be charged additional cost sharing for professional services | |||||
Home Health Care | |||||
$0 copay for each Medicare-covered home health visit | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
20% of the cost for each Medicare-covered primary care doctor visit. | |||||
20% of the cost for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
20% of the cost 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). | |||||
Podiatry Services | |||||
20% of the cost for each Medicare-covered podiatry visit | |||||
$0 copay for up to 4 supplemental routine podiatry visit(s) every year | |||||
Medicare-covered podiatry visits are for medically necessary foot care. | |||||
Outpatient Mental Health Care | |||||
20% of the cost for each Medicare-covered individual therapy visit | |||||
20% of the cost for each Medicare-covered group therapy visit | |||||
20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist | |||||
20% of the cost for each Medicare-covered group therapy visit with a psychiatrist | |||||
20% of the cost for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits | |||||
20% of the cost for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
0% to 20% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost 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 | |||||
20% of the cost for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered. | |||||
20% of the cost for Medicare-covered Occupational Therapy visits | |||||
20% of the cost 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 | |||||
20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other 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 | |||||
$0 copay for Medicare-covered lab services | |||||
20% of the cost for Medicare-covered diagnostic procedures and tests | |||||
20% of the cost 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 | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 20% of the cost may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 20% of the cost may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
20% of the cost for Medicare-covered Cardiac Rehabilitation Services | |||||
20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
20% of the cost for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services | |||||
$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. | |||||
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 http://www.UHCMedicareSolutions.com on the web. | |||||
Different out-of-pocket costs may apply for people who
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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. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from AARP MedicareComplete SecureHorizons Plan 3 (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. | |||||
$310 annual deductible. | |||||
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 850. | |||||
Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. | |||||
You can get drugs the following way(s): | |||||
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Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. | |||||
You can get drugs the following way(s): | |||||
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Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. | |||||
You can get drugs the following way(s): | |||||
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After your total yearly drug costs reach $2 850 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 72% 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:
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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 AARP MedicareComplete SecureHorizons Plan 3 (HMO). | |||||
You can get out-of-network drugs the following way: | |||||
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After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 850. | |||||
You will be reimbursed up to 28% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. 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 $4 550. 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 $4 550 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 | |||||
20% of the cost for Medicare-covered dental benefits | |||||
$0 copay for up to 1 supplemental oral exam(s) every six months | |||||
$0 copay for up to 1 supplemental cleaning(s) every six months | |||||
$0 copay for up to 1 supplemental dental x-ray(s) | |||||
Hearing Services | |||||
In general supplemental routine hearing exams and hearing aids not covered. | |||||
20% of the cost for Medicare-covered diagnostic hearing exams | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk | |||||
$0 copay for up to 1 supplemental routine eye exam(s) every two years | |||||
$0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. | |||||
$0 copay for contact lenses | |||||
$0 copay for up to 1 pair(s) of eyeglass lenses every two years | |||||
$0 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 eyeglass frames every two years. | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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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 24 one-way trip(s) to plan approved location every year | |||||
Acupuncture | |||||
$10 copay per visit up to 6 visit(s) for acupuncture and other alternative therapies every year | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$1 220 copay for each Medicare-covered hospital stay | |||||
$0 copay for each additional non-Medicare-covered hospital day. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
20% of the cost for each Medicare-covered primary care doctor visit. | |||||
20% of the cost for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
0% to 20% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost 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 | |||||
$0 copay for Medicare-covered lab services | |||||
20% of the cost for Medicare-covered diagnostic procedures and tests | |||||
20% of the cost 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 | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 20% of the cost may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 20% of the cost may apply | |||||
** Additional Benefits ** | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
| |||||
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. |