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2022 aultimate plan

2022 ADDITIONAL INFORMATION
2022 PART D PRESCRIPTION DRUG COVERAGE INFORMATION
2022 ABRIDGED FORMULARY
2022
COMPREHENSIVE FORMULARY

2022 Plans - Aultimate

2022 PrimeTime Health Plan Aultimate (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 are a United States citizen or are lawfully present in the United States

PrimeTime Health Plan Aultimate (HMO-POS)

  • Plan Premium

    $0 per month
  • Primary Care Physician

    You pay a $5 copay for each Medicare-covered PCP visit.
    Telehealth available
    Teladoc® available
  • Specialist

    $40 copay for each Medicare-covered specialist visit Telehealth available
  • Urgent Care (Inside United States)

    $65 copay for Medicare-covered urgently-needed-care visits
  • Urgent Care (Outside United States)

    $90 copay for Medicare-covered urgently-needed-care visits
  • Emergency Care (Worldwide Coverage)

    $90 copay for Medicare-covered emergency room visits
  • Inpatient Hospital Coverage

    $310 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
  • Outpatient Surgery (Ambulatory/Outpatient Surgery)

    $350 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.
  • Ambulance Services

    $230 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

    Other Diabetic Supplies 20% of the cost for Medicare-covered diabetic supplies
  • Diagnostic Tests and Procedures

    $100 copay for Medicare-covered general diagnostic tests (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

    $100 copay for Medicare-covered X-ray services
  • Lab Services

    $0- $35 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 drugs
  • Part D Prescription Drug Coverage
  • $200 Deductible for drugs in Tiers 3, 4, or 5; excluding Select Insulins*.
    (To find Select Insulins, look for “SI” in the 2022 formulary.) 

    Initial Coverage Limit (up to $4,430 total drug cost):

    Retail - Preferred Pharmacy:

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

    • Tier 2: Generic - $15 copay / 30 day supply, $30 copay/ 60 day supply, $45 copay/ 90 day supply;

    • *Tier 3: Preferred Brand- $42 copay / 30 day supply, $84 copay/ 60 day supply, $126 copay/ 90 day supply;

    • Insulin Savings Program: $35 copay/ 30 day supply, $70 copay/60 day supply, $105 copay/90 day for Select Insulins*


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

    • *Tier 5: Specialty – You pay 29% of the total drug cost, 60 day and 90 day supply not available for Tier 5 drugs.

    _______________________________________________


    Retail Standard Pharmacy:

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

    • Tier 2: Generic -$20 copay / 30 day supply, $40 copay/ 60 day supply, $60 copay/ 90 day supply;

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

    • Insulin Savings Program: $35 copay/30 day supply, $70 copay/60 day supply, $105 copay/ 90 day supply for Select Insulins*


    • *Tier 4: Non-Preferred Drug - $100 copay / 30 day supply, $200 copay/ 60 day supply, $300 copay/ 90 day supply;

    • *Tier 5: Specialty – You pay 29% of the total drug cost, 60 day and 90 day supply not available for Tier 5 drugs.

    ______________________________________________

    Mail-Order Pharmacy:

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

    • Tier 2: Generic - $15 copay/ 30 day supply, $30 copay/ 60 day supply, $45 copay/ 90 day supply

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

    • Insulin Savings Program: $35 copay/30 day supply, $70 copay/60 day supply, $105 copay/ 90 day supply for Select Insulins*


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

    • *Tier 5: Specialty –You pay 29% of the total drug cost, 60 day and 90 day supply not available for Tier 5 drugs.


    Coverage Gap: 

    The Coverage Gap begins after the total yearly drug cost reaches $4,430. 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: 

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050, you pay the greater of:

    - 5% of the cost, or
    - $3.95 copay for generic (including brand drugs treated as generic) and an $9.85 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
  • $0 copay for the programs below:

    • 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 1-855-409-6448

    • 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 (OTC) Benefit

    Up to $50 per quarter on qualified OTC items. OTC Items must be purchased from our catalog or website (ShopFirstlineBenefits.com)
  • Supplemental Vision and Dental – Reimbursement up to $500 annually combined for non-Medicare covered dental and vision costs. 
  • Amplifon Hearing Healthcare Program (Hearing Aids)

    You pay a copayment of $595, $695, or $895 per hearing aid depending on the brand and model selected.
  • Out of Pocket Maximum (per calendar year)

    $4,500

    This is not a complete description of benefits. 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, non-Medicare covered dental and vision services, hearing exams and hearing aids. 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. For hearing exams and/or hearing aids, you can use the provider of your choice, but you may have a higher out-of-pocket cost for hearing aids purchased from non-Amplifon providers.

    *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.

    ENROLLMENT in Aultimate


    • Members may enroll in the plan only during specific times of the year. Contact PrimeTime Health Plan for more information

    2022 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, 2021, 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 Aultimate (HMO-POS)

    • $0 Monthly Premium
    • $0 Annual Deductible
    • $4,500 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 Aultimate 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 711. 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
    Morrow House
    2600 Sixth St SW
    Canton, Ohio 44710

    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
    Morrow House
    2600 Sixth St SW
    Canton, Ohio 44710

    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 711. 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: 09/07/2021
    Reviewed: 9/16/2021