Summary of Benefits 2020

[Pages:13]Summary of Benefits 2020

Overview of your plan

AARP? Medicare Advantage Choice (PPO) H2406-009-000

Look inside to take advantage of the health services and drug coverages the plan provides. Call Customer Service or go online for more information about the plan.

Toll-free 1-844-723-6473, TTY 711

8 a.m. - 8 p.m. local time, 7 days a week



Y0066_SB_H2406_009_000_2020_M

Summary of Benefits

January 1st, 2020 - December 31st, 2020

The benefit information provided is a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. The Evidence of Coverage (EOC) provides a complete list of services we cover. You can see it online at or you can call Customer Service for help. When you enroll in the plan you will get information that tells you where you can go online to view your Evidence of Coverage.

About this plan.

AARP? Medicare Advantage Choice (PPO) is a Medicare Advantage PPO plan with a Medicare contract.

To join this plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, live within our service area listed below, and be a United States citizen or lawfully present in the United States.

Our service area includes these counties in:

Florida: Charlotte, Collier, Glades, Hendry, Lee, Manatee, Sarasota.

Use network providers and pharmacies.

AARP? Medicare Advantage Choice (PPO) has a network of doctors, hospitals, pharmacies, and other providers. With this plan, you have the freedom to enjoy nationwide access to care at innetwork costs when you visit any provider participating in the UnitedHealthcare? Medicare National Network (exclusions may apply). Plus, you have the flexibility to visit any provider nationwide who accepts Medicare. You may pay a higher copay or coinsurance when you see an out-of-network provider. When looking at the following charts you'll see the cost differences for network vs. out-ofnetwork care and services. If you use pharmacies that are not in our network, the plan may not pay for those drugs, or you may pay more than you pay at a network pharmacy.

You can go to to search for a network provider or pharmacy using the online directories. You can also view the plan Drug List (Formulary) to see what drugs are covered, and if there are any restrictions.

AARP? Medicare Advantage Choice (PPO)

Premiums and Benefits

Monthly Plan Premium

Annual Medical Deductible

Maximum Out-of-Pocket Amount (does not include prescription drugs)

In-Network

Out-of-Network

There is no monthly premium for this plan.

This plan does not have a deductible.

$4,900 annually for Medicare-covered services you receive from in-network providers.

$10,000 annually for Medicare-covered services you receive from any provider.

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 share of the cost for your Part D prescription drugs.

AARP? Medicare Advantage Choice (PPO)

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Benefits

In-Network

Out-of-Network

Inpatient Hospital2

$250 copay per day: for days 1-8 $0 copay per day: for days 9 and beyond

40% coinsurance per stay

Our plan covers an unlimited number of days for an inpatient hospital stay.

Outpatient Hospital Cost sharing for additional plan covered services will apply.

Doctor Visits

Preventive Care

Ambulatory Surgical Center (ASC)2

$0 copay for a diagnostic colonoscopy $175 copay otherwise (designated as Type 1 in the Provider Directory)

40% coinsurance

Outpatient Hospital, including surgery2

$0 copay for a diagnostic colonoscopy $250 copay otherwise (designated as Type 2 in the Provider Directory)

40% coinsurance

Outpatient Hospital Observation Services2

$250 copay

40% coinsurance

Primary

$10 copay

$45 copay

Specialists2

$35 copay

$70 copay

Virtual Medical Visits

Speak to network telehealth providers using your computer or mobile device. Visit to access virtual visits or if you are an existing Wellmed patient, contact your provider to access virtual visits.

Not covered

Medicare-covered $0 copay

$0 copay - 40% coinsurance (depending on the service)

Abdominal aortic aneurysm screening

Benefits

Routine physical Emergency Care Urgently Needed Services

In-Network

Out-of-Network

Alcohol misuse counseling Annual "Wellness" visit Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screening Cervical and vaginal cancer screening Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy) Depression screening Diabetes screenings and monitoring Hepatitis C screening HIV screening Lung cancer with low dose computed tomography (LDCT) screening Medical nutrition therapy services Medicare Diabetes Prevention Program (MDPP) Obesity screenings and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screenings 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)

Any additional preventive services approved by Medicare during the contract year will be covered. This plan covers preventive care screenings and annual physical exams at 100% when you use innetwork providers.

$0 copay; 1 per year*

40% coinsurance; 1 per year*

$90 copay (worldwide) per visit If you are admitted to the hospital within 24 hours, you pay the inpatient hospital copay instead of the Emergency copay. See the "Inpatient Hospital Care" section of this booklet for other costs.

$30 - $40 copay

Benefits

Diagnostic Tests, Lab and Radiology Services, and XRays

Diagnostic radiology services (e.g. MRI)2

Lab services2

In-Network

$0 copay for each diagnostic mammogram $110 copay per service otherwise

$0 copay

Diagnostic tests and procedures2

$20 copay

Therapeutic Radiology2

$60 copay per service

Outpatient Xrays2

$14 copay per service

Hearing Services

Exam to diagnose and treat hearing and balance issues2

$0 copay

Routine hearing exam

$0 copay; 1 per year*

Hearing aid2

$375 - $2,075 copay for each hearing aid provided through UnitedHealthcare Hearing, up to 2 hearing aids every 2 years.*

Routine Dental Services

Preventive

$0 copay for exams cleanings, and x-rays*

Out-of-Network

40% coinsurance

$0 copay 40% coinsurance

40% coinsurance

$21 copay per service

$70 copay

$70 copay; 1 per year*

Hearing aids available nationwide through mail order from UnitedHealthcare Hearing.*

$40 copay for exams cleanings, and x-rays*

Vision Services

Exam to diagnose and treat diseases and conditions of the eye2

$0 copay

Eyewear after cataract surgery

$0 copay

Routine eye exam $0 copay; 1 every year*

$70 copay

40% coinsurance $70 copay; 1 every year*

Benefits

Mental Health

Inpatient visit2

Outpatient group therapy visit2

Outpatient individual therapy visit2

Skilled Nursing Facility (SNF)2

Physical therapy and speech and language therapy visit2

Ambulance2

Your provider must obtain prior authorization for non-emergency transportation.

Routine Transportation

Medicare Part B Chemotherapy

Drugs

drugs2

Part B Drugs may be subject to Step Therapy. See Evidence of Coverage for details.

Other Part B drugs2

In-Network

$250 copay per day: for days 1-7 $0 copay per day: for days 8-90

Out-of-Network

40% coinsurance per stay

Our plan covers 90 days for an inpatient hospital stay.

$30 copay

$35 copay

$40 copay

$45 copay

$0 copay per day: for days 1-20 $160 copay per day: for days 21-51 $0 copay per day: for days 52-100

$195 copay per day: for days 1-52 $0 copay per day: for days 53-100

Our plan covers up to 100 days in a SNF.

$35 copay

$70 copay

$250 copay for ground $250 copay for air

$250 copay for ground $250 copay for air

Not covered 20% coinsurance

20% coinsurance

50% coinsurance 50% coinsurance

Prescription Drugs

If you reside in a long-term care facility, you pay the same for a 31-day supply as a 30-day supply at a retail pharmacy.

Stage 1: Annual Prescription Deductible

$0 per year for Tier 1 and Tier 2; $150 for Tier 3, Tier 4 and Tier 5 Part D prescription drugs.

Stage 2: Initial Coverage (After you pay your deductible, if applicable)

Retail

Standard 30-day supply

90-day supply

Mail Order

Preferred 90-day supply

Standard 90-day supply

Tier 1: Preferred Generic Drugs

$3 copay

$9 copay

$0 copay

$9 copay

Tier 2: Generic Drugs

$10 copay

$30 copay

$0 copay

$30 copay

Tier 3: Preferred Brand Drugs

$45 copay

$135 copay

$125 copay

$135 copay

Tier 4: Non-Preferred Drugs

$95 copay

$285 copay

$275 copay

$285 copay

Tier 5: Specialty Tier Drugs

30% coinsurance

30% coinsurance

30% coinsurance

30% coinsurance

Stage 3: Coverage Gap Stage

After your total drug costs reach $4,020, you will pay no more than 25% coinsurance for generic drugs or 25% coinsurance for brand name drugs, for any drug tier during the coverage gap.

Stage 4: Catastrophic Coverage

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% coinsurance, or ? $3.60 copay for generic (including brand drugs treated as generic) and

a $8.95 copay for all other drugs.

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