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.