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2020 classic plan

2020 ADDITIONAL INFORMATION
2020 PART D PRESCRIPTION DRUG COVERAGE INFORMATION
2020 ABRIDGED FORMULARY
COMPREHENSIVE FORMULARY

2020 Plans - Classic

2020 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
  • $0 copay for each Medicare-covered primary care doctor visit
  • Specialist
  • $35 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
  • $280 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
  • Outpatient Surgery (Ambulatory/Outpatient Surgery)
  • $250 copay for each Medicare-covered surgical visit
  • Home Delivered Meal Benefit
  • $0 copay; Benefit is limited to 5 days, up to 10 meals, and following an inpatient hospital stay at a network facility, with a doctor’s order, and in our service area with a contracted provider.
  • Ambulance Services
  • $210 copay for Medicare-covered ambulance benefits
  • Durable Medical Equipment
  • 20% of the cost for Medicare-covered durable medical equipment
  • Diabetic Testing Supplies (test strips, lancets, certain glucometers) 0% of cost for Medicare-covered diabetic testing supplies
  • Diabetic Supplies 20% 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
  • $30 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)*
    *Tier 3, 4 and 5 copays apply after you have met the annual deductiblePhase

    Initial Coverage Limit (up to $4,020 total drug cost):

    Preferred Pharmacy (retail up to a 90 day supply):

    • Tier 1: Preferred Generic - Retail: $0 copay / 30 day supply, $0 copay/ 60 day supply, $0 copay/ 90 day supply;

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

    • *Tier 3: Preferred Brand- Retail: $42 copay / 30 day supply, $84 copay/ 60 day supply, $126 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;

    • *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

    _______________________________________________


    Standard Pharmacy (retail up to a 90 day supply):

    • Tier 1: Preferred Generic - Retail: $10 copay / 30 day supply, $20 copay/ 60 day supply, $30 copay/ 90 day supply;

    • Tier 2: Generic - Retail: $18 copay / 30 day supply, $36 copay/ 60 day supply, $54 copay/ 90 day supply;

    • *Tier 3: Preferred Brand- Retail: $47 copay / 30 day supply, $94 copay/ 60 day supply, $141 copay/ 90 day supply;

    • *Tier 4: Non-Preferred Drug - Retail: $100 copay / 30 day supply, $200 copay/ 60 day supply, $300 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

    ______________________________________________


    Mail-Order Pharmacy (retail up to a 90 day supply):

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

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

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

    • *Tier 4: Non-Preferred Drug - 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 (Phase 3):

    The Coverage Gap begins after the total yearly drug cost reaches $4,020. If you reach the coverage gap, the plan pays 75% of the price for drugs and you pay the remaining 25% of the price. Not everyone will enter the Coverage Gap.

    Catastrophic Coverage (Phase 4):

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,350, you pay the greater of:

    - 5% of the cost, or
    - $3.60 copay for generic (including brand drugs treated as generic) and an $8.95 copay for all other drugs.

    If you reach the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.
  • Preventive Services
  • $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
  • Health & Wellness Education Programs
  • • Tele-monitoring Services – Enrollees diagnosed with any of the conditions below may be eligible:
      ○ Heart Failure
      ○ Diabetes
      ○ Chronic Obstructive Pulmonary Disease (COPD)
      ○ Behavioral Health Conditions
    • Stroke Prevention Program – offered to members who have health conditions that put them at higher risk for stroke.
    • In-Home Safety Assessment -evaluates your home for potential safety concerns. For example: proper lighting, fall hazards,and grab bars. The benefit is available in our service area with the plan's contracted network.

    • 24 Hour Nursing Hotline (330) 363-7600 or 1-800-686-9373

    • The Silver&Fit® Exercise & Healthy Aging Program –offers members access to a fitness center membership at a participating fitness center or select YMCA at no additional cost.
  • Over-The-Counter Medicine (OTC) Benefit
  • Up to $50 per quarter on qualified OTC items. OTC Items must be purchased from our catalog or website (www.PTHPOTC.com)
    • You must use your full benefit amount in one order.
    • Unused benefits will not roll over into the next quarter.
    • Your order total may not exceed your benefit amount. Cash, checks, credit cards or money orders are not accepted under this OTC benefit.
    • OTC items are available for home delivery only.
    • Products may not be purchased at a local retail pharmacy or through any source other than the catalog or website.
  • Dental
  • In-network: You pay a $35 copay for a Medicare covered medical exam.

    Reimbursement for non-Medicare covered dental services up to a maximum of $250 annually combined with non-Medicare covered vision. For routine dental services, you may use any qualified dental provider.
  • Vision
  • In-network: You pay a $35 copay for a Medicare covered medical exam. Exam to diagnose and treat diseases and conditions of the eye (including annual diabetic retinopathy exam). Eyeglasses or contact lenses after cataract surgery - You pay 20% of the cost.

    Reimbursement for non-Medicare covered services up to a maximum of $250 annually combined with non-Medicare covered dental. For routine vision services, you may use any qualified vision provider.
  • Hearing Services
  • In-network $5 copay for Medicare covered Medical Exam to diagnose and treat hearing and balance issues. Routine exam - you pay $5 copay (one routine hearing exam every three (3) years)
  • Amplifon Hearing Healthcare Program
  • Amplifon Information:

    You pay a copayment of $595, $695, or $895 per hearing aid depending on the brand and model selected. 2 hearing aids every 3 years.  Call 1-866-921-2299 to access Amplifon's discounted hearing aid rates.  Hearing aid copays do not count towards your out-of-pocket limit.
  • Out of Pocket Maximum (per calendar year)
  • $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 lab services, and non-Medicare covered dental and vision services. For lab services, members may use the Medicare provider of their choice and services will be paid in-network. Molecular Diagnostics/Genetic testing requires prior authorization. For non-Medicare covered dental and vision services, members may use the provider of their choice and services will be reimbursed up to the plan annual maximum allowed.

    *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.

    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

    2020 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, 2019, 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
    • $3,900 Annual Out-of-Pocket Max

    By completing this enrollment form, you are sending an actual enrollment election to 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 on 10-15-2019

    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

    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: 10/15/2019