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2019 classic plan

2019 ADDITIONAL INFORMATION
2019 PART D PRESCRIPTION DRUG COVERAGE INFORMATION
2019 ABRIDGED FORMULARY
2019 COMPREHENSIVE FORMULARY

2019 Plans - Classic

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.  Call 330-363-7407 or 1-800-577-5084 (TTY users 330-363-7460 or 1-800-617-7446) for more information.  Our Call Center is open Monday through Friday, from 8:00 a.m. to 8:00 p.m.  From October 1 through March 31, the Call Center is open seven days a week, from 8:00 a.m. to 8:00 p.m.

2019 PrimeTime Health Plan Classic (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 CLASSIC (HMO-POS)

  • Plan Premium
  • $39 per month*
  • Primary Care Physician
  • $5 copay for each Medicare-covered primary care doctor visit
  • Specialist
  • $45 copay for each Medicare-covered specialist visit
  • Urgent Care (Inside United States)
  • $65 copay for Medicare-covered urgently-needed-care visits
  • Urgent Care (Outside United States)
  • $85 copay for Medicare-covered urgently-needed-care visits
  • Emergency Care (Worldwide Coverage)
  • $85 copay for Medicare-covered emergency room visits
  • Inpatient Hospital Coverage
  • $290 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
  • Outpatient Surgery (Ambulatory/Outpatient Surgery)
  • $300 copay for each Medicare-covered surgical visit
  • Home Health Care
  • $0 copay for each Medicare-covered home health visit
  • Ambulance Services
  • $210 copay for Medicare-covered ambulance benefits
  • Durable Medical Equipment
  • 20% of the cost for Medicare-covered durable medical equipment
  • Diabetes Supplies (test strips, lancets, glucometer)
  • 0% of the cost for Medicare-covered diabetic supplies
  • Diagnostic Tests and Procedures
  • $80 copay for Medicare-covered general diagnostic tests and radiology services (not including x-rays)
  • Diagnostic Radiology Services (MRI/CT/PET/Thallium Scans)
  • $190 copay for Medicare-covered complex diagnostic radiology services (not including X-rays)
  • Outpatient X-rays
  • $80 copay for Medicare-covered X-ray services
  • Lab Services
  • $45 copay for Medicare-covered lab services
  • Radiation Therapy
  • 20% of the cost for Medicare-covered therapeutic radiology services
  • Part B Prescription and Chemotherapy Drugs
  • 20% of the cost for Medicare-covered Part B prescription and chemotherapy drugs
  • Part D Prescription Drug Coverage
  • $150 Deductible for brand name drugs (Tiers 3, 4, and 5)* 

    Initial Coverage Limit (up to $3,820 total drug cost):

    • Tier 1: Preferred Generic - Retail: $2 copay / 30 day supply, $4 copay/ 60 day supply, $6 copay/ 90 day supply; Mail Order: $2 copay/ 30 day supply, $4 copay/ 60 day supply, $6 copay/ 90 day supply

    • Tier 2: Generic - Retail: $8 copay / 30 day supply, $16 copay/ 60 day supply, $24 copay/ 90 day supply; Mail Order: $8 copay/ 30 day supply, $16 copay/ 60 day supply, $20 copay/ 90 day supply

    • *Tier 3: Preferred Brand- Retail: $45 copay / 30 day supply, $90 copay/ 60 day supply, $135 copay/ 90 day supply; Mail Order: $45 copay/ 30 day supply, $90 copay/ 60 day supply, $125 copay/ 90 day supply

    • *Tier 4: Non-Preferred Drug - Retail: $95 copay / 30 day supply, $190 copay/ 60 day supply, $285 copay/ 90 day supply; Mail Order: $95 copay/ 30 day supply, $190 copay/ 60 day supply, $275 copay/ 90 day supply

    • *Tier 5: Specialty – 30% co-insurance of the total drug cost, 60 day supply not available for Tier 5, 90 day supply not available for Tier 5

    Coverage Gap: 

    After your total yearly drug costs reach $3,820, 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 25% of the plan’s costs for covered brand name drugs and 37% of the plan’s cost for covered generic drugs until your yearly out-of-pocket drug costs reach $5,100. 

    Catastrophic Coverage: 

    After your yearly out-of-pocket costs reach $5,100, you pay the greater of:

    • 5% coinsurance, or
    • $3.40 copay for generic (including brand drugs treated as generic) and an $8.50 copay for all other drugs
  • Preventive Services
  • $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
  • Silver&Fit Exercise & Healthy Aging Program
  • Offers members access to a membership at a participating fitness center or select YMCA at no additional cost. Alternatively, members have the option to receive up to 2 Home Fitness Kits per benefit year through the Silver&Fit Home Fitness program. Silver&Fit members can also access low-impact Silver&Fit classes (where available),Healthy Aging classes (online or DVD), a quarterly newsletter, and web tools.The Silver&Fit program is provided by American Specialty Health Fitness, Inc., a subsidiary of American Specialty health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH and used with permission herein.
  • Routine Vision
  • Reimbursement for non-Medicare covered dental and vision services up to a maximum of $150 annually combined.
  • Routine Dental
  • Reimbursement for non-Medicare covered dental and vision services up to a maximum of $150 annually combined.
  • Amplifon Hearing Healthcare Program
  • Amplifon Information:
    $100 allowance per hearing aid device per ear every 3 years. You pay any amount over this plan allowed amount. PrimeTime Health Plan members are able to access Amplifon's discounted hearing aid rates of $595, $695, and $895 per device after plan allowance.
  • Out of Pocket Maximum (per calendar year)
  • $4,200

    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: 09/08/2018

    ELIGIBILITY AND ENROLLMENT in CLASSIC

    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

    2019 Enrollment Forms
    • HMO-POS Enrollment Form
    • Electronic Funds Transfer (EFT) Form

    ENROLLMENT OPTIONS FOR PRIMETIME HEALTH PLAN

    THIS IS AN ACTUAL ENROLLMENT REQUEST. FILLING OUT THE FORM AND CLICKING “SUBMIT MY ENROLLMENT” WILL BEGIN THE PROCESS TO FORMALLY ENROLL YOU INTO THE PRIMETIME HEALTH PLAN OF YOUR CHOICE.

    ONLINE

    Beginning October 15, 2018, you can complete a secure online enrollment application by continuing with the green button below. I am aware that I am Enrolling in the PrimeTime Health Plan Classic (HMO-POS)

    • $39 Monthly Premium
    • $0 Annual Deductible
    • $4,200 Annual Out-of-Pocket Max

    By completing this enrollment form, you are sending an actual enrollment election to AultCare's PrimeTime Health Plan.

    You will get an enrollment packet in the mail from PrimeTime Health Plan within seven to ten calendar days of enrolling online.

    For more information, contact PrimeTime Health Plan on our Contact Us Page.

    Continue to Classic Online Enrollment

    IN PERSON

    You can visit us during our office hours Monday through Friday from 8:00 a.m. to 4:30 p.m. to drop off your completed enrollment application. Additionally, a PrimeTime Health Plan staff person is available to meet with you to discuss your plan options. You can complete an enrollment application during this appointment or take one with you to fill out and return. To schedule an appointment, please call 330-363-7407 or 1-800-577-5084. TTY users call 330-363-7460 or 1-800-617-7446. Our call center is available 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.).

    PrimeTime Health Plan
    214 Dartmouth Ave SW
    Canton, Ohio 44706

    Download your PDF Here

    BY MAIL

    You can also choose to print and complete an enrollment application. When completed, mail the enrollment application to our office at:

    PrimeTime Health Plan
    214 Dartmouth Ave SW
    Canton, Ohio 44706

    Download your PDF Here
    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