Retiree.innovomn.com
PEIP Retiree Health Group UCare for SeniorsJanuary 1, 2017 through December 31, 2017Group UCare for Seniors High Option$332.00 monthlyGroup UCare for Seniors Core Option$155.00 monthlyGroup UCare for Seniors Basic Option$65.00 monthlyNetworkMust choose a primary care clinic, however, you do not need a referral to see a specialist within the networkUCare’s Provider network includes Allina, CentraCare, Essentia, Fairview, HealthEast, HCMC, Mayo, North Memorial, Park Nicollet, U of M, and many more.MedicareMust have Parts A and B of MedicareResidency RequirementsMust reside within the service area which consists of the entire State of Minnesota and 26 Western Wisconsin counties.Service AreaService area includes: All of Minnesota and the following 26 counties in Western Wisconsin: Ashland, Barron, Bayfield, Buffalo, Burnett, Chippewa, Crawford, Douglas, Dunn, Eau Claire, Grant, Iowa, Jackson, Juneau, La Crosse, Monroe, Pepin, Pierce, Polk, Richland, St. Croix, Sauk, Sawyer, Trempealeau, Vernon and Washburn.Prescription Drugs(30-day supply, formulary)$50 annual deductible$10 copay - Generic Rx$40 copay - Preferred Brand Rx$80 copay - Brand Rx32% coinsurance – SpecialtyMail order only: 2 copays for 90-day supply.No Coverage Gap (donut hole). Medicare catastrophic begins once the out-of-pocket of $4,950 is met.$100 annual deductible$15 copay - Generic Rx$45 copay - Preferred Brand Rx$90 copay - Brand Rx31% coinsurance – SpecialtyMail order only: 2 copays for 90-day supply.Once total yearly Rx costs reach $3,700, you pay $15 copay for generic & 40% for Brand Name drugs until the out of pocket cost of $4,950 is met. Catastrophic coverage begins at that time.$200 annual deductible$15 copay - Generic Rx$45 copay - Preferred Brand Rx$90 copay - Brand Rx29% coinsurance – SpecialtyMail order only: 2 copays for 90-day supply.Once total yearly Rx costs reach $3,700, you pay 51% for generic & 40% for Brand Name drugs until the out of pocket cost of $4,950 is met. Catastrophic coverage begins at that time.Medicare Part B Medications80%80%80%Preventive Care(Routine physicals, cancer screenings, eye and hearing exams, immunizations).100% CoverageGroup UCare for Seniors High Option$332.00 monthlyGroup UCare for Seniors Core Option$155.00 monthlyGroup UCare for Seniors Basic Option$65.00 monthlyEyewear & Hearing AidsEyewear - $75 annual allowance – High and Core options only.Hearing Aid Benefit - $500 every 36 months – High & Core Options only.Office VisitsPrimary - $15 copaySpecialist - $15 copayPrimary - $15 copaySpecialist - $30 copayPrimary - $15 copaySpecialist - $40 copayLab & X-rays100% coverage100% coverage10% coinsuranceInpatient Hospital100% after $100 copay per admission100% after $200 copay per admission$300/day copay for days 1-5; then 100%Outpatient Surgery100% after a $200 copay100% after a $250 copay100% after a $250 copayEmergency Care (Worldwide)$50 copay per hospital emergency$75 copay per hospital emergency$75 copay per hospital emergencySNF100% coverage for days 1 -20$100 copay per day for days 21 -100No 3 day inpatient hospital stay required for coverage.Out of Pocket Maximum$3400 per calendar year for Part A and B Services.DentalPreventive Dental – 100% coverage; 2 exams, 3 cleanings plus annual bite-wing x-rays at participating providers. Classic Choice dental may be added for $22/mo.Travel Benefit OptionMay live outside of the service area for up to 6 months a year. Coverage for non-emergencies outside the UCare for Seniors network is 80%.FitnessSilverSneakers? Fitness Program – Members get free and flexible membership to health classes at Community Centers, the YMCA, LA Fitness, Anytime Fitness and many more including 13,000 nationwide clubs to use when you travel. Check out .UCare Health Club Savings Program – Receive up to a $20 reimbursement for membership in participating clubs such as Lifetime Fitness.This is a brief summary of benefits. Not all covered services, exclusions, and limitations are shown here. Please call the UCare benefit team at 612-676-6900 or1-877-598-6574 for specific information, or visit . ................
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