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2018 plus plan

2018 ADDITIONAL INFORMATION
2018 PART D PRESCRIPTION DRUG COVERAGE INFORMATION
2018 ABRIDGED FORMULARY
COMPREHENSIVE FORMULARY -
EFFECTIVE NOVEMBER 1, 2018

2018 Plans - Plus

Disclaimers:

• PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal.

• This information is not a complete description of benefits. Contact the plan for more information.

• Limitations, co-payments, and restrictions may apply.

• Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.

• You must continue to pay your Medicare Part B premium.

• The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

2018 PrimeTime Health Plan Plus (HMO-POS) Eligibility Requirements: 

You are eligible for membership in our plan as long as:

• You live in our service area
(Carroll, Columbiana, Harrison, Holmes, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas, and Wayne Counties)

• --and-- you have both Medicare Part A and Medicare Part B
(When you enroll in a Medicare Advantage Plan, you continue to pay your Medicare Part B premium.)

• --and--you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.

PrimeTime Health Plan PLUS (HMO-POS)

  • Plan Premium
  • Primary Care Physician
  • Specialist
  • Urgent Care (Inside United States)
  • Urgent Care (Outside United States)
  • Emergency Care (Worldwide Coverage)
  • Inpatient Hospital Coverage
  • Outpatient Surgery (Ambulatory/Outpatient Surgery)
  • Home Health Care
  • Ambulance Services
  • Durable Medical Equipment
  • Diabetes Supplies
  • Diagnostic Tests and Procedures
  • Complex Diagnostic Radiology Services (MRI/CT/PET/Thallium Scans)
  • X-rays
  • Lab Services
  • Radiation Therapy
  • Part B Prescription and Chemotherapy Drugs
  • Part D Prescription Drug Coverage
  • Preventive Services
  • Silver&Fit Exercise & Healthy Aging Program
  • Routine Vision
  • Routine Dental
  • Out of Pocket Maximum (per calendar year)
  • $89 per month*
  • $0 copay for each Medicare-covered primary care doctor visit
  • $40 copay for each Medicare-covered specialist visit
  • $65 copay for Medicare-covered urgently-needed-care visits
  • $75 copay for Medicare-covered urgently-needed-care visits
  • $65 copay for Medicare-covered emergency room visits
  • $275 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
  • 25% of the cost for each Medicare-covered surgical visit
  • $0 copay for each Medicare-covered home health visit
  • $200 copay for Medicare-covered ambulance benefits
  • 20% of the cost for Medicare-covered durable medical equipment
  • 20% of the cost for Medicare-covered diabetic supplies
  • $60 copay for Medicare-covered general diagnostic tests and radiology services (not including x-rays)
  • $175 copay for Medicare-covered complex diagnostic radiology services (not including X-rays)
  • $60 copay for Medicare-covered X-ray services
  • $35 copay for Medicare-covered Medicare-covered lab services
  • 20% of the cost for Medicare-covered therapeutic radiology services
  • 20% of the cost for Medicare-covered Part B prescription and chemotherapy drugs
  • $100 Deductible for brand name drugs (Tiers 3, 4, and 5)* 

    Initial Coverage Limit (up to $3,750 total drug cost):

    • Tier 1: Preferred Generic - $0 copay / 30 day supply

    • Tier 2: Generic - $6 copay / 30 day supply

    • *Tier 3: Preferred Brand - $45 copay / 30 day supply

    • *Tier 4: Non-Preferred Brand - $95 copay / 30 day supply

    • *Tier 5: Specialty – 31% co-insurance of the total drug cost

    60-day and 90-day supplies are also available. Contact the plan for details. 

    Coverage Gap: 

    After your total yearly drug costs reach $3,750, you receive limited coverage by the plan on certain drugs. You will receive a discount on brand name drugs and generally pay no more than 35% of the plan’s costs for covered brand name drugs and 44% of the plan’s cost for covered generic drugs until your yearly out-of-pocket drug costs reach $5,000. 

    Catastrophic Coverage: 

    After your yearly out-of-pocket costs reach $5,000, you pay the greater of:

    • 5% coinsurance, or
    • $3.35 copay for generic (including brand drugs treated as generic) and a
    • $8.35 copay for all other drugs
  • $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
  • Offers members access to participating fitness facilities and instructor led classes. Alternatively, members have the option to receive up to 2 Home Fitness Kits per year. Members may also choose to receive health information, track their fitness activity, participate in health challenges, and earn rewards.
  • No Coverage
  • No Coverage
  • $3,900

For coverage details and additional co-payments/co-insurance please see the Summary of Benefits. Conditions and limitations may apply.

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. 

You must receive your care from a network provider. 

In most cases, care you receive from an out-of-network provider (a provider who is not part of plan’s network) will not be covered. There are four exceptions:

• The plan covers emergency care or urgently needed services that you get from an out-of-network provider.

• If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider with our prior approval. In this situation with our approval, you will pay the same as you would pay if you got the care from a network provider.

• The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

• Our plan offers a Point of Service (POS) option for services associated with routine eyewear. For lenses and frames or contacts (except after cataract surgery), you may use a qualified provider of your choice.

*The late enrollment penalty is an amount that is added to your Part D premium. You may owe a monthly late enrollment penalty if at any time after your initial enrollment period is over, there is a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. If you get "Extra Help" you do not pay a late enrollment penalty.

Last updated: 09/10/2018

ELIGIBILITY AND ENROLLMENT in PLUS

To be eligible for our HMO-POS PLAN Options:

• Must have Medicare Part A & B
• Must reside in one of the following counties within Ohio
  • Stark
  • Carroll
  • Columbiana
  • Holmes
  • Harrison
  • Mahoning
  • Medina
  • Portage
  • Summit
  • Trumbull
  • Tuscarawas
  • Wayne

• Only pre-existing ESRD not eligible to join PrimeTime Health Plan
• Members may enroll in the plan only during specific times of the year. Contact PrimeTime Health Plan for more information

Return to All Plan Descriptions

Medicare beneficiaries may also enroll with PrimeTime Health Plan through the CMS Medicare Online Enrollment Center located at Medicare.gov

CONTACT INFORMATION

If you have questions or require language assistance, please call Customer Service at 330-363-7407 or 1-800-577-5084. For people who are hearing impaired, please call our TTY line at 330-363-7460 or 1-800-617-7446. Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

Last updated: 09/25/2018