WHICH PLAN WILL YOU CHOOSE?
Transcripción
WHICH PLAN WILL YOU CHOOSE?
IMPORTANT CONTACT INFORMATION YOUR AGENT: a dva n t a g e p la n s At Allegian Health Plans, we take your health care personally! We offer plans designed around your needs. WHICH PLAN WILL YOU CHOOSE? Member Services: (855) 805-4152 (TTY 711) Hours of operation are October 1, 2015 – February 14, 2016: 8 a.m. to 8 p.m., seven days a week, and February 15, 2016 – September 30, 2016: 8 a.m. to 8 p.m., Monday through Friday Visit us online: AllegianAdvantage.com Allegian Health Plans is an HMO plan with a Medicare contract. Enrollment in Allegian Health Plans depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium, and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B Premium. This information is available for free in other languages. Please contact our Member Services number at (855) 805-4152 for additional information. (TTY users should call 711). Hours of operation are October 1, 2015 – February 14, 2016: 8 a.m. to 8 p.m. seven days a week, and February 15, 2016 – September 30, 2016: 8 a.m. to 8 p.m., Monday through Friday. Esta información está disponible gratuitamente en otros lenguajes. Por favor llame a servicio al miembro al (855) 805-4152 para información adicional. (Usuarios de TTY llamar al 711). Horario es 1 octubre, 2015–14 febrero, 2016: 8 a.m. a 8 p.m., los siete días a la semana, y 15 febrero–30 septiembre, 2016: 8 a.m. a 8 p.m., de lunes a viernes. a dva n t a g e p la n s Y0102_008-2016_FINAL_TXv2 BENEFITS ORIGINAL MEDICARE* Allegian Advantage (HMO) $0 Monthly Premium Allegian Advantage Select (HMO) $39 Monthly Premium Maximum Out-of-Pocket (MOOP) N/A $4,000 annual limit $3,400 annual limit Primary Care Visit 20% coinsurance $0 copay $0 copay Specialist Visit 20% coinsurance $40 copay $30 copay Inpatient Hospitalization For each benefit period, you pay: Days 1-60: $1,260 deductible and $0 coinsurance Days 61-90: $315 coinsurance Days 91 & beyond: $630 coinsurance $200 copay/day for days 1 – 6 $0 copay for days 7-90; annual benefit period $175 copay/day for days 1 – 6 $0 copay for days 7-90; annual benefit period Urgent Care 20% coinsurance; Part B deductible applies $40 copay $30 copay Emergency Care 20% coinsurance plus a specified copayment for the hospital visit; Part B deductible applies $75 copay $65 copay Ambulance Transport 20% coinsurance; Part B deductible applies $150 copay $100 copay Rx Copays (Preferred Generic) Part D prescription drugs not covered As low as $2 for a 30-day supply As low as $2 for a 30-day supply Vision Not covered (limited – 20% coinsurance ONLY after cataract surgery for standard eyeglasses or contacts); Part B deductible applies $100 allowance every two (2) years for eyeglass lenses, frames and contact lenses PLUS $10 annual routine eye exams $125 allowance every one (1) year for each benefit: eyeglass lenses, frames and contact lenses PLUS $10 annual routine eye exam Dental Limited Medicare-covered services; preventive and comprehensive dental not covered Preventive: (1) oral exam, (1) cleaning, and (1) x-ray per year $1,500 annual allowance (50% coinsurance), PLUS (1) oral exam, (1) cleaning, and (1) x-ray per year Over-the-Counter (OTC) Not covered $50 per quarter allowance at Walgreens, CVS and more $50 per quarter allowance at Walgreens, CVS and more Transportation Benefit Not covered 12 trips annually to plan-approved locations 12 trips annually to plan-approved locations Fitness Benefit Not covered $25 annual deductible $25 annual deductible 24-Hour Nurse Advice Line Not covered You pay nothing You pay nothing Wellness and Education Programs Restrictions may apply You pay nothing You pay nothing *Reflects 2015 benefits and costs; please consult Medicare & You 2016 for the most current information. Please review the Evidence of Coverage documents for complete details of all services.