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Prescription Drug Coverage Information (Part D)
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PTHP Prime PPO |
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Disclaimer:
- The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan
- You must continue to pay your Medicare Part B premium
- Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, 2013
- You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week;
- The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or
- Your State Medicaid Office
With PrimeTime Health Plan Prime PPO there are no deductibles to pay. Instead, your cost-sharing consists of a monthly plan premium and copayments or coinsurances for the services that you receive.
To be eligible to enroll in PrimeTime Health Plan:
You must have Medicare Parts A and B.
You must live in the PrimeTime Health Plan service area, which is Carroll, Columbiana, Harrison, Holmes, Jefferson, Mahoning, Stark, Summit, Tuscarawas, and Wayne counties.
You cannot have end-stage Renal Disease at the time of enrollment, unless you do not need regular dialysis or have had a successful kidney transplant.
| PrimeTime Health Plan Prime PPO |
| Premium | $121 per month |
| Primary Care Physician |
$15 per visit / $30 per visit if out of network |
| Specialist |
$35 per visit / $60 per visit if out of network |
| Urgent Care |
$40 per visit |
| Emergency Care (worldwide) |
$50 per visit |
| Inpatient Hospital Coverage |
$210 per day (days 1–10) / $400 per day (days 1–10) if out of network |
| Prescription Drug |
In Network Only - Initial Coverage Limit (up to $2930 total drug cost):
Tier 1 - $7 / 30 day supply
Tier 2 - $45 / 30 day supply
Tier 3 - $80 / 30 day supply
Tier 4 – 33% of total drug cost
Gap Coverage:
During the coverage gap you pay 100% of prescription costs.
Catastrophic Coverage (after $4700 out of pocket):
Generic - $2.50 or 5% (whichever is greater)
All others - $6.30 or 5% (whichever is greater)
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| Outpatient Surgery |
20% of the cost (whichever is greater) / 40% of the cost if out of network |
| Home Health Care |
$0 / 40% per day if out of network |
| Ambulance Services |
$150 per service |
| Durable Medical Equipment |
20% of the cost / 40% if out of network |
| Diabetes Supplies |
20% of the cost / 40% if out of network |
| MRI/CT/PET/Thallium Scans |
$100 per scan / 40% if out of network |
| Lab & X-Ray |
$35 per visit / 40% if out of network |
| Radiation Therapy |
20% of the cost / 40% if out of network |
| HIV Screenings | $0 |
| Health Club Membership Reimbursement |
*Contact plan for more information |
| Out of Pocket Maximum (per calendar year) |
$3400 / $5100 if out of network |
| For coverage details and additional copayments/coinsurance please see the Summary of Benefits
. Conditions and limitations may apply. |
Last updated:
5/16/2012 12:00:00 AM
Copyright Aultman Health Foundation
AultCare Information Systems
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