• Tier 1: Preferred Generic - $0 copay/ 30 day supply, $0 copay/ 60 day supply, $0 copay/ 90 day supply
• Tier 2: Generic - $8 copay/ 30 day supply, $16 copay/ 60 day supply, $20 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, $275 copay/ 90 day supply
• *Tier 5: Specialty – You pay 30% of the total drug cost, 60day and 90 day supplies not available for Tier 5 drugs.
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.
$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 $750 annually combined for non-Medicare covered dental and vision costs.
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 CLASSIC
• Members may enroll in the plan only during specific times of the year. Contact PrimeTime Health Plan for more information
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.
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 Classic (HMO-POS)
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
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
How to contact us:
The PrimeTime Health Plan team is here and ready to help you. We can answer your questions and help you get more from your Medicare plan.
Members can contact us by:
330-363-7407 TTY: 711
Long Distance Calls:
1-800-577-5084 TTY: 711
P.O. Box 6905 Canton, Ohio 44706
Morrow House 2600 Sixth St. SW Canton, Ohio 44710
Call Center Hours:
Monday through Friday 8:00 am-8:00 pm
Monday through Friday 8:00 am-8:00 pm
Extended Days & Hours:
October 1st - March 31st Seven Days a Week 8:00 am-8:00 pm
PrimeTime Health Plan is committed to providing our members timely resolutions for all questions, complaints, or concerns. If you ever have questions or issues with PrimeTime Health Plan, your benefits, or our providers, please let us know so we can help. Our representatives are available by phone to assist you Monday through Friday, 8:00 am-8:00 pm at 330-363-7407 or toll-free at 1-800-577-5084 (TTY: 711). From October 1st - March 31st, our representatives are available 7 days a week, 8 a.m. to 8 p.m. If you would like to meet with a customer service representative in person, you can visit us during our office hours, Monday through Friday. Our office hours are 8:00 a.m. to 4:30 p.m.
You can also submit a complaint directly to Medicare if you’d like by completing the Medicare Complaint Form. The office of the Medicare Ombudsman (OMO)helps you with complaints, grievance and information requests. Visit their website here.
SPECIAL COMMUNICATION NEEDS
If you or someone you know requires the assistance of a translator, please contact our Service Center at 330-363-7407 or toll-free at 1-800-577-5084 and we will gladly provide one for you. To access our TTY phone line, please dial 711 for the hearing impaired.
PRIMETIME HEALTH PLAN PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal. Every year, Medicare evaluates plans based on a 5-star rating system.
PrimeTime Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. PrimeTime Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. PrimeTime Health Plan provides free aids and services to people with disabilities to communicate effectively with us, such as Qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, other formats). PrimeTime Health Plan provides free language services to people whose primary language is not English, such as Qualified interpreters and information written in other languages. If you need these services, or if you believe that PrimeTime Health Plan has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can contact or file a grievance with the: PrimeTime Health Plan Civil Rights Coordinator, 2600 6th St. S.W. Canton, OH 44710, 330-363-7456, CivilRightsCoordinator@aultcare.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, our Civil Rights staff is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html