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2015 Medicare Advantage Plan Benefit Details


Medicare Advantage Plan Benefit Details for:
Group Health Cooperative Optimal (HMO)

2015 Medicare Advantage Plan Details
Plan Name:Group Health Cooperative Optimal (HMO)
Location (County, State ZIP):Mason, Washington State
Plan ID:H5050 - 004     Click to see other plans

Click here for the Group Health Cooperative Optimal (HMO) enrollment options and to have a copy of this chart sent to your email. Enroll in Group Health Cooperative Optimal (HMO)

— Plan Features —
Monthly Premium:$253.00
Monthly Premium with Low-Income Subsidy:100%75%50%25%
$0.00$0.00$0.00$0.00
Annual Rx Deductible:$0
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit
for Parts A & B (MOOP):
$2,000
Gap Coverage:No Gap Coverage
Total Number of Formulary Drugs:5448    Browse Plan Formulary
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Cost-Sharing during
       initial coverage phase:
$4.00$21.00$45.00$95.0033%
  — Number of Drugs per Tier:17666234382232389
Plan’s Summary Star Rating: 5.00 out of 5 Stars.  
This plan qualifies for the 5-star rating Special Enrollment period. Read more.
   - Customer Service Rating: 3 out of 5 Stars.
   - Member Experience Rating: 5 out of 5 Stars.
   - Drug Cost Accuracy Rating: 5 out of 5 Stars.

— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$253 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $2 000 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
For up to 12 visit(s):  $10 copay
** Extra Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  20% of the cost
Other Part B drugs1:  20% of the cost
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
Tier 2 (Non-Preferred Generic)$21 copay$42 copay$63 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
Tier 2 (Non-Preferred Generic)$21 copay$42 copay$63 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$253 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $2 000 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
For up to 12 visit(s):  $10 copay
Ambulance Services
$0-100 copay depending on the service
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $10 copay
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  You pay nothing
Diabetes Supplies and Services
Diabetes monitoring supplies:  20% of the cost
Diabetes self-management training:  You pay nothing
Therapeutic shoes or inserts:  20% of the cost
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):  $25 copay
Diagnostic tests and procedures:  You pay nothing
Lab services:  You pay nothing
Outpatient x-rays:  You pay nothing
Therapeutic radiology services (such as radiation treatment for cancer):  20% of the cost
Doctor&rsuo;s Office Visits
Primary care physician visit:  $10 copay
Specialist visit:  $20 copay
Durable Medical Equipment (wheelchairs, oxygen, etc.)
20% of the cost
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
Emergency Care
$65 copay
If you are admitted to the hospital within 1 day you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
Foot Care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $20 copay
Hearing Services
Exam to diagnose and treat hearing and balance issues:  $10 copay
Routine hearing exam (for up to 1 every year):  $10 copay
Hearing aid fitting/evaluation (for up to 1 every year):  You pay nothing
Hearing aid:  You pay nothing
Our plan pays up to $500 every year for hearing aids.
Home Health Care
You pay nothing
Mental Health Care
Inpatient visit:
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
  • $100 copay per day for days 1 through 2
  • You pay nothing per day for days 3 through 90
  • Outpatient group therapy visit:  $10 copay
    Outpatient individual therapy visit:  $10 copay
    Outpatient Rehabilitation Services
    Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $10 copay
    Occupational therapy visit:  $10 copay
    Physical therapy and speech and language therapy visit:  $10 copay
    Outpatient Substance Abuse
    Group therapy visit:  $20 copay
    Individual therapy visit:  $20 copay
    Outpatient Surgery
    Ambulatory surgical center:  $100 copay
    Outpatient hospital:  $100 copay
    Over-the-Counter Items
    Not Covered
    Prosthetic Devices (braces, artificial limbs, etc.)
    Prosthetic devices:  20% of the cost
    Related medical supplies:  20% of the cost
    Renal Dialysis
    20% of the cost
    Transportation
      You pay nothing
    Urgently Needed Care
    $25 copay
    Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $10-20 copay depending on the service
    Routine eye exam (for up to 1 every year):  $10-20 copay depending on the service
    Contact lenses (for up to 1 every year):  You pay nothing
    Eyeglasses (frames and lenses) (for up to 1 every year):  You pay nothing
    Eyeglasses or contact lenses after cataract surgery:  You pay nothing
    Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses).
    ** Hospice **
    Hospice
    You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
    ** Preventive Care **
    Preventive Care
    You pay nothing
    Our plan covers many preventive services including:
    • Abdominal aortic aneurysm screening
    • Alcohol misuse counseling
    • Bone mass measurement
    • Breast cancer screening (mammogram)
    • Cardiovascular disease (behavioral therapy)
    • Cardiovascular screenings
    • Cervical and vaginal cancer screening
    • Colonoscopy
    • Colorectal cancer screenings
    • Depression screening
    • Diabetes screenings
    • Fecal occult blood test
    • Flexible sigmoidoscopy
    • HIV screening
    • Medical nutrition therapy services
    • Obesity screening and counseling
    • Prostate cancer screenings (PSA)
    • Sexually transmitted infections screening and counseling
    • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
    • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
    • "Welcome to Medicare" preventive visit (one-time)
    • Yearly "Wellness" visit
    Any additional preventive services approved by Medicare during the contract year will be covered.
    ** Inpatient Care **
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital stay.
    • $100 copay per day for days 1 through 2
    • You pay nothing per day for days 3 through 90
    • You pay nothing per day for days 91 and beyond
    • Inpatient Mental Health Care
      For inpatient mental health care see the "Mental Health Care" section.
      Skilled Nursing Facility (SNF)
      Our plan covers up to 100 days in a SNF.
      • You pay nothing per day for days 1 through 20
      • $25 copay per day for days 21 through 100
      • Outpatient Prescription Drugs
        For Part B drugs such as chemotherapy drugs1:  20% of the cost
        Other Part B drugs1:  20% of the cost
        You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
        You may get your drugs at network retail pharmacies and mail order pharmacies.
        Standard Retail Cost-Sharing
        TierOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
        Tier 2 (Non-Preferred Generic)$21 copay$42 copay$63 copay
        Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
        Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
        Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
        Standard Mail Order Cost-Sharing
        TierOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
        Tier 2 (Non-Preferred Generic)$21 copay$42 copay$63 copay
        Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
        Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
        Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
        If you reside in a long-term care facility you pay the same as at a retail pharmacy.
        You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
        Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

        After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

        After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
        • 5% of the cost or
        • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
        ** Outpatient Care **
        Diabetes Supplies and Services
        Diabetes monitoring supplies:  20% of the cost
        Diabetes self-management training:  You pay nothing
        Therapeutic shoes or inserts:  20% of the cost
        Foot Care (podiatry services)
        Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $20 copay
        Hearing Services
        Exam to diagnose and treat hearing and balance issues:  $10 copay
        Routine hearing exam (for up to 1 every year):  $10 copay
        Hearing aid fitting/evaluation (for up to 1 every year):  You pay nothing
        Hearing aid:  You pay nothing
        Our plan pays up to $500 every year for hearing aids.
        ** Outpatient Medical Services and Supplies **
        Outpatient Substance Abuse
        Group therapy visit:  $20 copay
        Individual therapy visit:  $20 copay
        Prosthetic Devices (braces, artificial limbs, etc.)
        Prosthetic devices:  20% of the cost
        Related medical supplies:  20% of the cost
        ** Additional Benefits **
        Inpatient Mental Health Care
        For inpatient mental health care see the "Mental Health Care" section.
        ** Cost **
        Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
        Package 1: Dental HMO
        Benefits include:
        • Preventive Dental
        • Comprehensive Dental
        Additional $51.00 per month. You must keep paying your Medicare Part B premium and your $253 monthly plan premium.
        $100 per year.
        Our plan pays up to $1500 every year.
        ** Important Information **
        Package 1: Dental HMO
        Benefits include:
        • Preventive Dental
        • Comprehensive Dental
        Additional $51.00 per month. You must keep paying your Medicare Part B premium and your $253 monthly plan premium.
        $100 per year.
        Our plan pays up to $1500 every year.

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