Medicare Advantage Benefits at a Glance
2021 MEDICARE ADVANTAGE PLANS
Benefits at a Glance
The following is intended to be only a summary of benefits for Generations Medicare Advantage plans. For a complete list, including any limitations, exclusions, and plan restrictions, please review the GlobalHealth Evidence of Coverage for Generations Medicare Advantage plans.
Coverage effective Jan 1, 2021 to Dec 31, 2021
| MA-Only | MAPD | |||
|---|---|---|---|---|
| GENERATIONS VALUE (HMO) | GENERATIONS CLASSIC (HMO) | GENERATIONS SELECT (HMO) |
GENERATIONS CLASSIC CHOICE |
|
| BENEFIT | YOU PAY | |||
| Premium | $0 | $0 | $29 |
$10 |
| Deductible | $0 | $0 | $0 |
$0 |
| MOOP | $3,000 | $3,900 | $3,900 |
In-Network - $3,900 Combined In-Network and Out-of-Network - $10,000 |
| Primary Care Physician | $0 | $0 | $0 |
In-Network - $0 Out-of-Network - Not covered |
| Specialist | $40 copay | $45 copay | $35 copay |
In-Network - Out-of-Network - 30% coinsurance |
| Preventative Care * | You pay nothing | You pay nothing | You pay nothing |
In-Network - Out-of-Network - Not covered |
| Inpatient Hospital Care | $400 copay per day (Days 1–5) You pay nothing per day (Days 6–190) | $395 copay per day (Days 1–5) You pay nothing per day (Days 6–190) | $325 copay per day (Days 1–5) You pay nothing per day (Days 6–190) |
In-Network - $395 copay per day (Days 1–5) You pay nothing per day (Days 6–190) Out-of-Network - 30% coinsurance |
| Outpatient Surgery and Hospital Service |
$250 copay - Ambulatory Surgery Center
|
$250 copay - Ambulatory Surgery Center
|
$250 copay - Ambulatory Surgery Center
|
In-Network - $250 copay - Ambulatory Surgery Center $320 - Hospital Out-of-Network - 30% coinsurance |
| Diagnostic Tests, X-rays, Lab Services and Radiology |
$5 copay for labs; |
You pay nothing for labs and x-rays; $50 copay for therapeutic radiology; $100 copay for sleep studies in outpatient facility |
You pay nothing for labs and x-rays; $40 copay for therapeutic radiology; $100 copay for sleep studies in outpatient facility |
In-Network - Out-of-Network - Not covered |
| MRI, PET, CT Scan |
$180 copay in PCP, specialist, urgent care, or free-standing radiology facility; $250 copay in outpatient hospital |
$180 copay in PCP, specialist, urgent care, or free-standing radiology facility; $250 copay in outpatient hospital | $180 copay in PCP, specialist, urgent care, or free-standing radiology facility; $250 copay in outpatient hospital |
In-Network - $180 copay in PCP, specialist, urgent care, or free-standing radiology facility; $250 copay in outpatient hospital Out-of-Network - Not covered |
| Ambulance Service | $250 copay | $250 copay | $250 copay |
In-Network - $250 copay Out-of-Network - 30% coinsurance |
| Emergency Room | $120 copay | $90 copay | $85 copay |
In-Network - Out-of-Network - $90 copay |
| Urgent Care | $15 copay | $30 copay | $25 copay |
In-Network - Out-of-Network - $30 copay |
| Chiropractic | $20 copay | $20 copay | $20 copay |
In-Network - Out-of-Network - Not covered |
| Home Health | You pay nothing | You pay nothing | You pay nothing |
In-Network - Out-of-Network - Not covered |
| Standard Diabetic Testing Supplies | You pay nothing | You pay nothing | You pay nothing |
In-Network - You pay nothing Out-of-Network - Not covered |
All cost shares for treatment of COVID-19 are waived even if the public health emergency is lifted. Those services include: Emergency services, inpatient hospital care, Medicare Part B prescription drugs, observation services, specialist visits, skilled nursing facility, and urgently needed services.
Prescription Drug Coverage
Effective January 1, 2021 - December 31, 2021
Generations Classic (HMO), Generations Select (HMO), Generations Classic Choice (HMO-POS)
Deductible: $0
Note: Generations Value (HMO) does not include Prescription Drug Coverage
| 30-Day Preferred Retail and Mail Order | |||
|---|---|---|---|
| Drug Type | GENERATIONS CLASSIC (HMO) | GENERATIONS SELECT (HMO) | GENERATIONS CLASSIC CHOICE (HMO-POS) |
| Tier 1 - Preferred Generics | $5 | $3 |
$5
|
| Tier 2 - Generics | $15 | $13 |
$15 |
| Tier 3 - Preferred Brand Name | $42 | $40 |
$42 |
| Tier 4 - Non-Preferred | 40% | 40% |
40% |
| Tier 5 - Specialty | 33% | 33% |
33% |
| 90-Day Preferred Retail and Mail Order | |||
|---|---|---|---|
| Drug Type | GENERATIONS CLASSIC (HMO) | GENERATIONS SELECT (HMO) | GENERATIONS CLASSIC CHOICE (HMO-POS) |
| Tier 1 - Preferred Generics | $0 |
$0 |
$0 |
| Tier 2 - Generics | $0 | $0 |
$0 |
| Tier 3 - Preferred Brand Name | $84 | $80 |
$84 |
| Tier 4 - Non-Preferred | 40% | 40% |
40% |
|
Coverage Gap Stage After your prescription costs reach $4,130 |
Your costs will be no more than 25% of the cost for generic drugs. You pay 25% of the cost of brand name drugs plus a portion of the dispensing fee. | ||
| Catastrophic Coverage Stage After you have paid $6,550 out-of-pocket | You pay the greater of 5% of the cost of the drug or $3.90 for generics/$9.20 for brand names. | ||
| Gap Coverage | You have additional gap coverage for Tier 1 drugs and Tier 3 oral anti-diabetic drugs. See the Evidence of Coverage for benefits and limitations. |
PLEASE NOTE: Please visit our website for the most up-to-date drug formulary. The formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Costs are higher at a Standard Pharmacy.
Additional Benefits Not Covered Under Original Medicare
Effective January 1, 2021 - December 31, 2021
| MA-Only | MAPD | |||
|---|---|---|---|---|
| GENERATIONS VALUE (HMO) | GENERATIONS CLASSIC (HMO) | GENERATIONS SELECT (HMO) | GENERATIONS CLASSIC CHOICE (HMO-POS) | |
| BENEFIT | YOU PAY | |||
| Routine Vision Exam |
You pay nothing for up to 1 visit per year |
You pay nothing for up to 1 visit per year |
You pay nothing for up to 1 visit per year |
In-Network - Out-of-Network - Not covered |
| Routine Supplemental Eyewear Benefit |
Plan pays up to a $300 calendar year maximum |
Plan pays up to a $200 calendar year maximum |
Plan pays up to a $200 calendar year maximum |
In-Network - Out-of-Network - Plan pays up to a $200 calendar year maximum |
| Dental |
Plan pays up to a $1,500 calendar year maximum for preventive and comprehensive services |
Plan pays up to a $1,000 calendar year maximum for preventive and comprehensive services | Plan pays up to a $1,000 calendar year maximum for preventive and comprehensive services |
In-Network - Out-of-Network - Not covered |
| Over-the-Counter Benefit |
$50 quarterly benefit for over-the-counter (OTC) health and wellness products available through our mail order service. If $50 is not used in a quarter, the balance does not carry over. Prices include shipping, handling, and sales tax. |
$50 quarterly benefit for over-the-counter (OTC) health and wellness products available through our mail order service. If $50 is not used in a quarter, the balance does not carry over. Prices include shipping, handling, and sales tax. | $50 quarterly benefit for over-the-counter (OTC) health and wellness products available through our mail order service. If $50 is not used in a quarter, the balance does not carry over. Prices include shipping, handling, and sales tax. |
In-Network - Out-of-Network - Not covered |
| Fitness Benefit |
You pay nothing at an in-network fitness facility or for up to 2 home fitness kits per year |
You pay nothing at an in-network fitness facility or for up to 2 home fitness kits per year | You pay nothing at an in-network fitness facility or for up to 2 home fitness kits per year |
In-Network - Out-of-Network - Not covered |
|
Routine Hearing Exam - for hearing aid evaluation |
You pay nothing for up to 1 visit per year | You pay nothing for up to 1 visit per year | You pay nothing for up to 1 visit per year |
In-Network - Out-of-Network - Not covered |
| Hearing Aids |
Plan pays up to a $1,000 calendar year maximum for hearing aids and fitting |
Plan pays up to a $500 calendar year maximum for hearing aids and fitting | Plan pays up to a $500 calendar year maximum for hearing aids and fitting |
In-Network - Out-of-Network - Not covered |
* 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.