2018 Plans


Value D Plan 2017

Jul 25, 2017, 16:32 PM
Copayment Plan Name : 2017 Value D
Exam : No
This plan includes prescription drug coverage.
$0
$5,900

Primary Care: $0 copay/per visit

Specialist: $50 copay/visit

In-network: $30 copay/visit

Out-of-network: $60 copay/visit

$75 copay/visit
You pay 20%.

Days 1-4: $355 copay/day

Days 5 and beyond: $0

Days 1-20: $0

Days 21 -100: $135 copay/day

Exam: $50 copay

Eyewear: $100 for frames, lenses and upgrades

Hearing exam: $15 copay

Hearing Aids: $699-$999 copay per aid

Limit: 1 per ear/year

Hospital: $250 copay

Ambulatory Surgical Center: $150 copay

Covered in full.
This plan includes Part D coverage.
Learn more here.
  • $250 (applies to Tiers 3, 4 and 5)

After you pay your yearly deductible of $250 costs (brand name drugs in Tier 3, Tier 4 or Tier 5 only), you pay the following until your total yearly drug costs reach $3,700. 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.

Mail Order Pharmacy copayment amounts are also noted below

  • Tier 1 - (Preferred Generic) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $3 copay
    • Three-month (90 day) supply - $9 copay

    Mail Order Pharmacy

    • Three-month (90-day) supply - $7
     
  • Tier 2 - (Generic) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $12 copay
    • Three-month (90 day) supply - $36 copay

    Mail Order Pharmacy

    • Three month (90 day) supply - $30

     

  • Tier 3 - (Preferred Brand) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $47 copay
    • Three-month (90 day) supply - $141 copay

    Mail Order Pharmacy

    • Three month (90 day) supply - $118

     

  • Tier 4 - (Non-Preferred Drug) Coinsurance Amounts
    Retail Pharmacy
    • One-month (30 day) supply -You pay 40% of the cost.
    • Three-month (90 day) supply -You pay 40% of the cost.

    Mail Order Pharmacy

    • Three month (90 day) supply - You pay 40% of the cost.

     

  • Tier 5 - (Specialty Medications) Coinsurance Amounts
    Retail Pharmacies
    • One-month (30 day) supply - You pay 28% of the cost.
    • We do not cover three-month (90 day) supplies of Tier 5 medications at retail pharmacies.

    Mail Order Pharmacy

    • One-month (30 day) supply - You pay 28% of the cost.
    • We do not cover three-month (90 day) supplies of Tier 5 medications through Mail Order Pharmacy.

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, but you may pay more than you pay in an in-network pharmacy.

After your total yearly drug costs (paid by both you and Senior Preferred) reach $3,700, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 40% for the plan's costs for brand name drugs and 51% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,950.

After your yearly out-of-pocket drug costs reach $4,950 you pay the greater of 5% of the cost or $3.30 copay for generic (including brand drugs treated as generic) and $8.25 for all other drugs

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2017 Plans


Value D Plan 2017

Jul 25, 2017, 16:32 PM
Copayment Plan Name : 2017 Value D
Exam : No
This plan includes prescription drug coverage.
$0
$5,900

Primary Care: $0 copay/per visit

Specialist: $50 copay/visit

In-network: $30 copay/visit

Out-of-network: $60 copay/visit

$75 copay/visit
You pay 20%.

Days 1-4: $355 copay/day

Days 5 and beyond: $0

Days 1-20: $0

Days 21 -100: $135 copay/day

Exam: $50 copay

Eyewear: $100 for frames, lenses and upgrades

Hearing exam: $15 copay

Hearing Aids: $699-$999 copay per aid

Limit: 1 per ear/year

Hospital: $250 copay

Ambulatory Surgical Center: $150 copay

Covered in full.
This plan includes Part D coverage.
Learn more here.
  • $250 (applies to Tiers 3, 4 and 5)

After you pay your yearly deductible of $250 costs (brand name drugs in Tier 3, Tier 4 or Tier 5 only), you pay the following until your total yearly drug costs reach $3,700. 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.

Mail Order Pharmacy copayment amounts are also noted below

  • Tier 1 - (Preferred Generic) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $3 copay
    • Three-month (90 day) supply - $9 copay

    Mail Order Pharmacy

    • Three-month (90-day) supply - $7
     
  • Tier 2 - (Generic) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $12 copay
    • Three-month (90 day) supply - $36 copay

    Mail Order Pharmacy

    • Three month (90 day) supply - $30

     

  • Tier 3 - (Preferred Brand) Copayment Amounts
    Retail Pharmacy
    • One-month (30 day) supply - $47 copay
    • Three-month (90 day) supply - $141 copay

    Mail Order Pharmacy

    • Three month (90 day) supply - $118

     

  • Tier 4 - (Non-Preferred Drug) Coinsurance Amounts
    Retail Pharmacy
    • One-month (30 day) supply -You pay 40% of the cost.
    • Three-month (90 day) supply -You pay 40% of the cost.

    Mail Order Pharmacy

    • Three month (90 day) supply - You pay 40% of the cost.

     

  • Tier 5 - (Specialty Medications) Coinsurance Amounts
    Retail Pharmacies
    • One-month (30 day) supply - You pay 28% of the cost.
    • We do not cover three-month (90 day) supplies of Tier 5 medications at retail pharmacies.

    Mail Order Pharmacy

    • One-month (30 day) supply - You pay 28% of the cost.
    • We do not cover three-month (90 day) supplies of Tier 5 medications through Mail Order Pharmacy.

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, but you may pay more than you pay in an in-network pharmacy.

After your total yearly drug costs (paid by both you and Senior Preferred) reach $3,700, you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 40% for the plan's costs for brand name drugs and 51% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4,950.

After your yearly out-of-pocket drug costs reach $4,950 you pay the greater of 5% of the cost or $3.30 copay for generic (including brand drugs treated as generic) and $8.25 for all other drugs

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Out-of-network providers

In most cases, care you receive from an out-of-network provider (a provider who is not part of our plan’s network) will not be covered. These are three exceptions:

  1. The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 in the Evidence of Coverage (links to the Evidence of Coverage documents can be found above).
  2. 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. If your network provider suggests or recommends care out-of-network, a referral must be obtained in writing, and signed by the plan’s medical director prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a network provider.
  3. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

Using a pharmacy that is out of the network

There are special circumstances when our plan will cover prescriptions from out of network providers/pharmacies; they are as follows:

1. Drugs may be covered for an illness while members are travelling outside of the plan’s service area and where there are no network pharmacies.

2. Part D vaccines administered in a clinic or hospital setting which are considered out of network.

In the event you are unable to use an in network pharmacy and none of the above scenarios would apply; you must have prior authorization (advance approval) from our plan to get prescriptions from an out-of-network pharmacy provider. If you pay out-of-pocket for a prescription and you feel we should cover this expense, please contact us or send the bill to us for payment review. You can find more detailed information regarding how this is done in your Evidence of Coverage in Chapter 7, section 2.1.

Interpreter Services

Interpreter Services Information can be found here. We have interpreter services available to answer questions about our health and drug plan. To get an interpreter, call us at (800) 394‐5566. This is a free service.

Contact Information 

If you have questions or require language assistance, please call Customer Service at (608) 775-8077 or (800) 394-5566. For people who are deaf, hard of hearing, or speech impaired please call TTY/TDD 711 or toll free (800) 877-8973. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. You may also call through a video relay service company of your choice.  Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8 a.m. to 8 p.m. From October 1 through February 14 we are also available to assist you on Saturdays and Sundays from 8 a.m. to 8 p.m.

Disclaimers

Senior Preferred is an HMO plan with a Medicare contract. Enrollment in Senior Preferred depends on contract renewal. Medicare Advantage & Part D contracts are reviewed annually by The Centers for Medicare and Medicaid Services to determine renewal status of the plan. You must continue to pay your Medicare Part B premium. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  Members must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. For more information contact the plan.

Senior Preferred does not discriminate on the basis of race, color, national origin, disability, age, sex, gender identity, sexual orientation, or health status in the administration of the plan, including enrollment and benefit determinations.

This web page was updated on October 25, 2017.