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Medicare Advantage Benefits at a Glance
Medicare Advantage Plans Member Materials
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2022 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, 2022 to Dec 31, 2022
Generations Classic (HMO), Generations Value (HMO), Generations Select (HMO),
Generations Classic Choice (HMO-POS) In-Network and Generations Classic Choice (HMO-POS) Out-of-Network
|
|
H3706-001 Generations Classic (HMO) |
H3706-009 Generations Value (HMO) |
H3706-018 Generations Select (HMO) |
H3706-021 |
H3706-021 |
|
Monthly Plan Premium (You must continue to pay your Part B premium) |
$0 |
$0 |
$29 |
$10 |
|
|
Deductible |
$0 |
$0 |
$0 |
$0 |
$0 |
|
Maximum Out-of-Pocket (MOOP) Annually (Does not include supplemental benefits or prescription drugs) |
$3,900 |
$3,000 |
$3,900 |
$3,900 |
$10,000 (Combined in-network and out-of-network) |
|
INPATIENT CARE 1 Prior Authorization Required 2 Referral Required |
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|
Inpatient Hospital Coverage 1,2 |
$395 copay per day (Days 1-5); $0 copay per day (Days 6-190) |
$400 copay per day (Days 1-5); $0 copay per day (Days 6-190) |
$325 copay per day (Days 1-5); $0 copay per day (Days 6-190) |
$395 copay per day (Days 1-5); $0 copay per day (Days 6-190) |
You pay 30% of the cost per visit |
|
Inpatient Mental Health Care1,2 |
$275 copay per day (Days 1-6); $0 copay per day (Days 7-90) |
$275 copay per day (Days 1-6); $0 copay per day (Days 7-90) |
$250 copay per day (Days 1-6); $0 copay per day (Days 7-90) |
$275 copay per day (Days 1-6); $0 copay per day (Days 7-90) |
You pay 30% of the cost per visit |
|
Skilled Nursing Facility (SNF)1,2 |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
You pay 30% of the cost per visit |
|
OUTPATIENT CARE 1 Prior Authorization Required 2 Referral Required |
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|
Doctor Visits |
• $0 copay per visit for PCP • $45 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $40 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $35 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $45 copay per visit for specialists1,2 |
• PCP visits not covered• You pay 30% of the cost per visit for specialists1,2 |
|
Chiropractic Services |
$20 copay per visit |
$20 copay per visit |
$20 copay per visit |
$20 copay per visit |
Not covered |
|
Podiatry Services1,2 |
$45 copay per visit |
$40 copay per visit |
$35 copay per visit |
$45 copay per visit |
You pay 30% of the cost per visit
|
|
Outpatient Mental Health Visit1,2 |
$0 copay per visit |
$0 copay per visit |
$0 copay per visit |
$0 copay per visit |
Not covered |
|
Ambulatory Surgery Center1,2 |
$250 copay per visit; waived if admitted to acute care |
$250 copay per visit; waived if admitted to acute care |
$250 copay per visit; waived if admitted to acute care |
$250 copay per visit; waived if admitted to acute care |
Not covered |
|
Outpatient Hospital Observation Services1,2 |
$300 copay per visit; waived if admitted to acute care |
$300 copay per visit; waived if admitted to acute care |
$150 copay per visit; waived if admitted to acute care |
$300 copay per visit; waived if admitted to acute care |
You pay 30% of the cost per visit |
|
Outpatient Hospital Surgery1,2 |
$320 copay per visit; waived if admitted to acute care |
$320 copay per visit; waived if admitted to acute care |
$320 copay per visit; waived if admitted to acute care |
$320 copay per visit; waived if admitted to acute care |
Not covered |
|
Emergency Care |
$90 copay per visit; waived if admitted to acute care |
$120 copay per visit; waived if admitted to acute care |
$85 copay per visit; waived if admitted to acute care |
$90 copay per visit; waived if admitted to acute care |
$90 copay per visit; waived if admitted to acute care |
|
Worldwide Emergency Care (Does not accumulate to MOOP) |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $120 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $85 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
|
Urgently Needed Services |
$30 copay per visit |
$15 copay per visit |
$25 copay per visit |
$30 copay per visit |
$30 copay per visit |
|
Worldwide Urgent Care (Does not accumulate to MOOP) |
• 90 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $120 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $85 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $90 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $90 copay per visit • Limited to $50,000 benefit combined with emergency care |
|
Outpatient Labs, X-Rays, Etc. |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
•$5 copay pervisit for labs •$0 - x-rays,ultrasounds, EKGs, and similar low-cost diagnostics
|
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
Not covered |
|
Outpatient1,2 Therapeutic Radiology |
$50 copay per visit |
$50 copay per visit |
$40 copay per visit |
$50 copay per visit |
Not covered |
|
Outpatient Diagnostic Radiology1,2 (MRI, etc.) |
•$180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility •$250 outpatient hospital |
•$180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility •$250 outpatient hospital |
•$180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility •$250 outpatient hospital |
•$180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility •$250 outpatient hospital |
Not covered |
|
Outpatient Rehabilitation Services1,2 (Physical, occupational, and/or speech therapy) |
$20 copay per visit |
$20 copay per visit |
$10 copay per visit |
$20 copay per visit |
Not covered |
|
Acupuncture1,2 |
$25 copay per visit |
$25 copay per visit |
$25 copay per visit |
$25 copay per visit |
Not covered |
|
Ambulance (One-way trip) |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $240 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
|
Home Health Services1,2 |
$0 |
$0 |
$0 |
$0 |
Not covered |
|
PREVENTIVE CARE |
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|
Preventive Services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
Not covered |
|
PART B DRUGS 1 Prior Authorization Required 2 Referral Required |
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|
Medicare Part B Drugs1,2 (Includes chemotherapy) |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
Not covered |
|
OUTPATIENT MEDICAL SUPPLIES 1 Prior Authorization Required |
|||||
|
Durable Medical Equipment1 (e.g., Continuous glucose monitors (CGM), wheelchairs, oxygen) |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
Not covered |
|
Standard Diabetic Testing Supplies1 |
$0 |
$0 |
$0 |
$0 |
Not covered |
|
Prosthetics and Related Supplies1 (e.g., Braces, artificial limbs) |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
Not covered |
|
SUPPLEMENTAL BENEFITS 1 Prior Authorization Required 2 Referral Required |
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|
Hearing Services |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $1,000 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
You pay 30% of the cost for Medicare-covered services
|
|
Dental Services |
• $0 preventive services - oral exams, x-rays, cleanings, and fluoride treatments • Our plan pays a total of $1,000 for comprehensive dental services per year • You pay 30% of the cost for some comprehensive services |
• $0 preventive services - oral exams, x-rays, cleanings, and fluoride treatments • Our plan pays a total of $1,500 for preventive and comprehensive dental services per year, including dentures |
• $0 preventive services - oral exams, x-rays, cleanings, and fluoride treatments • Our plan pays a total of $1,000 for preventive and comprehensive dental services per year, including dentures
|
• $0 preventive services - oral exams, x-rays, cleanings, and fluoride treatments • Our plan pays a total of $1,000 for comprehensive dental services per year • You pay 30% of the cost for some comprehensive services |
You pay 30% of the cost for Medicare-covered services
|
|
Vision Services |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $300 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
|
|
Transportation1 (To and from plan-approved locations) |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 24 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
Not covered |
|
Over-the-Counter Benefit (Includes nicotine replacement therapy) |
Plan pays $50 per quarter |
Plan pays $50 per quarter |
Plan pays $50 per quarter |
Plan pays $50 per quarter |
Not covered |
|
Fitness |
$0 |
$0 |
$0 |
$0 |
Not covered |
|
24/7 Nurse Line |
$0 |
$0 |
$0 |
$0 |
Not covered |
|
Post-Discharge Meal Delivery1 |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
Not covered |
|
PART D DRUGS *Cost-sharing may differ depending on the pharmacy’s status (e.g., preferred, non-preferred, mail-order, Long Term Care (LTC), or home infusion) or the supply (e.g., 30 or 100 days supply). For more information on the additional pharmacies specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. 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. |
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|
Phase 1: Deductible |
$0 |
Not covered |
$0 |
$0 |
Not covered |
|
Phase 2: Initial Coverage Limit (ICL) |
$4,430 |
$4,430 |
$4,430 |
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Tier 1: Preferred Generics* (Preferred Retail 30-Day Supply) |
$5 copay per fill |
$3 copay per fill |
$5 copay per fill |
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|
Tier 2: Generic* (Preferred Retail 30-Day Supply) |
$15 copay per fill |
$13 copay per fill |
$15 copay per fill |
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Tier 3: Preferred Brand* (Preferred Retail 30-Day Supply) |
$42 copay per fill |
$40 copay per fill |
$42 copay per fill |
||
|
Tier 4: Non-Preferred Drug* (Preferred Retail 30-Day Supply) |
You pay 40% of the cost per fill
|
You pay 40% of the cost per fill |
You pay 40% of the cost per fill |
||
|
Tier 5: Specialty Tier* (Preferred Retail 30-Day Supply) |
You pay 33% of the cost per fill |
You pay 33% of the cost per fill |
You pay 33% of the cost per fill |
||
|
Tier 1 & Tier 2: Preferred Retail & Mail Order* (100-Day Supply) |
$0 |
$0 |
$0 |
||
|
Tier 3: Preferred Retail & Mail Order* (100-Day Supply) |
$84 copay per fill |
$84 copay per fill |
$84 copay per fill |
||
|
Tier 4: Preferred Retail & Mail Order* (100-Day Supply) |
You pay 40% of the cost per fill |
You pay 40% of the cost per fill |
You pay 40% of the cost per fill |
||
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Phase 3 Coverage Gap Stage (After your prescription costs reach $4,430)4 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. 4 = You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $7,050. This amount and rules for counting costs toward this amount have been set by Medicare. |
Generic Drugs: • GlobalHealth members continue to pay the same amount as in the initial coverage stage for Tier 1 generic drugs or Tier 3 oral antidiabetics. • Members pay 25% of the cost for other generic drugs. Brand Name Drugs: • The Medicare Coverage Gap Discount Program of 70% is applied to the initial coverage stage copayment for Tier 1 brand drugs or for Tier 3 oral antidiabetics. • Members pay 25% of the cost of the drug plus a portion of the dispensing fee for other brand name drugs. |
Generic Drugs: • GlobalHealth members continue to pay the same amount as in the initial coverage stage for Tier 1 generic drugsor Tier 3 oral antidiabetics. • Members pay 25% of the cost for other generic drugs. Brand Name Drugs: • The Medicare Coverage Gap Discount Program of 70% is applied to the initial coverage stage copayment for Tier 1 brand drugs or for Tier 3 oral antidiabetics. • Members pay 25% of the cost of the drug plus a portion of the dispensing fee for other brand name drugs. |
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Phase 4: Catastrophic Coverage Stage (After you have paid $7,050 out-of-pocket) |
You pay the greater of 5% of the cost of the drug or $3.95 for generics/$9.85 for brand names. |
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Generations Classic Plus (HMO), Generations Special Care (HMO C-SNP) and Generations Special Care Savings (HMO C-SNP) plans
|
|
H3706-022 Generations Classic Plus (HMO) |
H3706-023 Generations Classic Plus (HMO) |
H3706-024 Generations Special Care (HMO C-SNP) |
H3706-025 Generations Special Care Savings (HMO C-SNP) |
|
Monthly Plan Premium (You must continue to pay your Part B premium) |
$0 |
$0 |
$0 |
$0 |
|
Deductible |
$0 |
$0 |
$0 |
$0 |
|
Medicare Part B Premium Buydown |
$0 per month
|
$0 per month |
$0 per month |
$25 per month |
|
Maximum Out-of-Pocket (MOOP) Annually (Does not include supplemental benefits or prescription drugs) |
$3,900 |
$3,900 |
$3,450 |
$3,900 |
|
Healthy Benefits Grocery Card redeemable at Walmart®
|
Not covered
|
Not covered
|
Plan pays $25 per month
|
Plan pays $25 per month
|
|
INPATIENT CARE 1 Prior Authorization Required 2 Referral Required |
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|
Inpatient Hospital Coverage1,2 |
$275 copay per day (Days 1-7); $0 copay per day (Days 8-190) |
$275 copay per day (Days 1-7); $0 copay per day (Days 8-190) |
$225 copay per day (Days 1-7); $0 copay per day (Days 8-190) |
$275 copay per day (Days 1-7); $0 copay per day (Days 8-190) |
|
Inpatient Mental Health Care1,2 |
$265 copay per day (Days 1-7); $0 copay per day (Days 8-90) |
$265 copay per day (Days 1-7); $0 copay per day (Days 8-90) |
$225 copay per day (Days 1-7); $0 copay per day (Days 8-90) |
$265 copay per day (Days 1-7); $0 copay per day (Days 8-90) |
|
Skilled Nursing Facility (SNF)1,2 |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
$0 copay per day (Days 1-20); $184 copay per day (Days 21-100) |
|
OUTPATIENT CARE 1 Prior Authorization Required 2 Referral Required |
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|
Doctor Visits |
• $0 copay per visit for PCP • $35 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $40 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $20 copay per visit for specialists1,2 |
• $0 copay per visit for PCP • $35 copay per visit for specialists1,2 |
|
Chiropractic Services |
$20 copay per visit |
$20 copay per visit |
$20 copay per visit |
$20 copay per visit |
|
Podiatry Services1,2 |
$35 copay per visit |
$40 copay per visit |
$20 copay per visit |
$35 copay per visit |
|
Outpatient Mental Health Visit1,2 |
$35 copay per visit
|
$40 copay per visit
|
$20 copay per visit
|
$35 copay per visit
|
|
Ambulatory Surgery Center1,2 |
$225 copay per visit; waived if admitted to acute care |
$225 copay per visit; waived if admitted to acute care |
$175 copay per visit; waived if admitted to acute care |
$225 copay per visit; waived if admitted to acute care |
|
Outpatient Hospital Observation Services1,2 |
$275 copay per visit; waived if admitted to acute care |
$275 copay per visit; waived if admitted to acute care |
$225 copay per visit; waived if admitted to acute care |
$275 copay per visit; waived if admitted to acute care |
|
Outpatient Hospital Surgery1,2 |
$275 copay per visit; waived if admitted to acute care
|
$275 copay per visit; waived if admitted to acute care
|
$225 copay per visit; waived if admitted to acute care
|
$275 copay per visit; waived if admitted to acute care
|
|
Emergency Care |
$90 copay per visit; waived if admitted to acute care |
$90 copay per visit; waived if admitted to acute care |
$120 copay per visit; waived if admitted to acute care |
$90 copay per visit; waived if admitted to acute care |
|
Worldwide Emergency Care (Does not accumulate to MOOP) |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $120 copay per visit • Limited to $50,000 benefit combined with urgent care |
• $90 copay per visit • Limited to $50,000 benefit combined with urgent care |
|
Urgently Needed Services |
$30 copay per visit |
$30 copay per visit |
$20 copay per visit |
$40 copay per visit |
|
Worldwide Urgent Care (Does not accumulate to MOOP) |
• $90 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $90 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $120 copay per visit • Limited to $50,000 benefit combined with emergency care |
• $90 copay per visit • Limited to $50,000 benefit combined with emergency care |
|
Outpatient Labs, X-Rays, Etc. |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
$0 - labs, x-rays, ultrasounds, EKGs, and similar low-cost diagnostics |
|
Outpatient1,2 Therapeutic Radiology |
$50 copay per visit |
$50 copay per visit |
$50 copay per visit |
$50 copay per visit |
|
Outpatient Diagnostic Radiology1,2 (MRI, etc.) |
• $180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility • $275 outpatient hospital |
• $180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility • $275 outpatient hospital |
•$175 copay per visit in PCP, specialist, urgent care, freestanding radiological facility •$225 outpatient hospital |
• $180 copay per visit in PCP, specialist, urgent care, freestanding radiological facility • $275 outpatient hospital |
|
Outpatient Rehabilitation Services1,2 (Physical, occupational, and/or speech therapy) |
$35 copay per visit |
$40 copay per visit |
$20 copay per visit |
$35 copay per visit |
|
Acupuncture1,2 |
$35 copay per visit |
$40 copay per visit |
$20 copay per visit |
$35 copay per visit |
|
Ambulance (One-way trip) |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $250 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $240 per occurrence for ground • You pay 20% of the cost per occurrence for air |
• $240 per occurrence for ground • You pay 20% of the cost per occurrence for air |
|
Home Health Services1,2 |
$0 |
$0 |
$0 |
$0 |
|
PREVENTIVE CARE |
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|
Preventive Services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
$0 for Medicare-covered preventive services |
|
PART B DRUGS 1 Prior Authorization Required 2 Referral Required |
||||
|
Medicare Part B Drugs1,2 (Includes chemotherapy) |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
|
OUTPATIENT MEDICAL SUPPLIES 1 Prior Authorization Required |
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|
Durable Medical Equipment1 (e.g., Continuous glucose monitors (CGM), wheelchairs, oxygen) |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
You pay 20% of the cost |
|
Standard Diabetic Testing Supplies1 |
$0 |
$0 |
$0 |
$0 |
|
Prosthetics and Related Supplies1 (e.g., Braces, artificial limbs) |
• $0 for surgically implanted devices and medical supplies • You pay 20% of the cost for external devices and medical supplies |
• $0 for surgically implanted devices and medical supplies • You pay 20% of the cost for external devices and medical supplies |
• $0 for surgically implanted devices and medical supplies • You pay 20% of the cost for external devices and medical supplies |
• $0 for surgically implanted devices and medical supplies • You pay 20% of the cost for external devices and medical supplies |
|
Hearing Services |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
• $0 routine hearing exam limited to one per year • $0 routine hearing aid evaluation limited to one per year • Our plan pays up to a total of $500 for hearing aids per year |
|
Dental Services |
• Our plan pays a total of $1,000 for preventive and comprehensive dental services per year, including dentures • You pay 30% of the cost for some comprehensive services (Does not accumulate to MOOP) |
• Our plan pays a total of $1,000 for preventive and comprehensive dental services per year, including dentures • You pay 30% of the cost for some comprehensive services (Does not accumulate to MOOP) |
• Our plan pays a total of $1,000 for preventive and comprehensive dental services per year, including dentures • You pay 30% of the cost for some comprehensive services (Does not accumulate to MOOP) |
• Our plan pays a total of $1,000 for preventive and comprehensive dental services per year, including dentures • You pay 30% of the cost for some comprehensive services (Does not accumulate to MOOP) |
|
Vision Services |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $300 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
• $0 routine eye exam limited to 1 per year • Our plan pays up to a total of $200 for all supplemental eyewear per year |
|
Transportation1 (To and from plan-approved locations) |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
• $0 per trip • Limited to 12 one-way trips per year • Limited to 50 miles per one-way trip |
|
Routine Foot Care1,2 |
Not covered |
Not covered |
• $20 copay per visit • Limited to 6 visits per year |
• $35 copay per visit • Limited to 6 visits per year |
|
Over-the-Counter Benefit (Includes nicotine replacement therapy) |
Plan pays $50 per quarter |
Plan pays $50 per quarter |
Plan pays $25 per month |
Plan pays $25 per month |
|
Fitness |
$0 |
$0 |
$0 |
$0 |
|
24/7 Nurse Line |
$0 |
$0 |
$0 |
$0 |
|
Post-Discharge Meal Delivery1 |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 10 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 14 meals following discharge • Limited to 4 times per year |
• $0 per meal • Limited to 14 meals following discharge • Limited to 4 times per year |
|
Phase 1: Deductible |
$0 |
$0 |
$0 |
$0 |
|
Phase 2: Initial Coverage Limit (ICL) |
$4,430 |
$4,430 |
$4,430 |
$4,430 |
|
Tier 1: Preferred Generics* (Preferred Retail 30-Day Supply) |
$5 copay per fill |
$5 copay per fill |
$0 copay per fill |
$0 copay per fill |
|
Tier 2: Generic* (Preferred Retail 30-Day Supply) |
$15 copay per fill |
$15 copay per fill |
$5 copay per fill |
$5 copay per fill |
|
Tier 3: Preferred Brand* (Preferred Retail 30-Day Supply) |
$42 copay per fill |
$42 copay per fill |
• $42 copay per fill • $35 copay per fill for select insulins |
• $42 copay per fill • $35 copay per fill for select insulins |
|
Tier 4: Non-Preferred Drug* (Preferred Retail 30-Day Supply) |
You pay 40% of the cost per fill
|
You pay 40% of the cost per fill
|
$90 copay per fill
|
$90 copay per fill
|
|
Tier 5: Specialty Tier* (Preferred Retail 30-Day Supply) |
You pay 33% of the cost per fill |
You pay 33% of the cost per fill
|
You pay 33% of the cost per fill |
You pay 33% of the cost per fill
|
|
Tier 1 & Tier 2: Preferred Retail & Mail Order* (100-Day Supply) |
$0 |
$0 |
$0 |
$0 |
|
Tier 3: Preferred Retail & Mail Order* (100-Day Supply) |
$84 copay per fill |
$84 copay per fill |
• $84 copay per fill • $84 copay per fill for select insulins |
• $84 copay per fill • $84 copay per fill for select insulins |
|
Tier 4: Preferred Retail & Mail Order* (100-Day Supply) |
You pay 40% of the cost per fill |
You pay 40% of the cost per fill |
$270 copay per fill
|
$270 copay per fill
|
|
Phase 3 Coverage Gap Stage (After your prescription costs reach $4,430)4 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. 4 = You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $7,050. This amount and rules for counting costs toward this amount have been set by Medicare. |
Generic Drugs: • GlobalHealth members continue to pay the same amount as in the initial coverage stage for Tier 1 generic drugs or Tier 3 oral antidiabetics. • Members pay 25% of the cost for other generic drugs. Brand Name Drugs: • The Medicare Coverage Gap Discount Program of 70% is applied to the initial coverage stage copayment for Tier 1 brand drugs or for Tier 3 oral antidiabetics. • Members pay 25% of the cost of the drug plus a portion of the dispensing fee for other brand name drugs. |
Generic Drugs: • GlobalHealth members continue to pay the same amount as in the initial coverage stage for Tier 1 generic drugs or Tier 3 oral antidiabetics. • Members pay 25% of the cost for other generic drugs. Brand Name Drugs: • The Medicare Coverage Gap Discount Program of 70% is applied to the initial coverage stage copayment for Tier 1 brand drugs or for Tier 3 oral antidiabetics. • Members pay 25% of the cost of the drug plus a portion of the dispensing fee for other brand name drugs. Insulin: • Members pay no more than $35 for a 30-day supply of select insulins. |
||
|
Phase 4: Catastrophic Coverage Stage (After you have paid $7,050 out-of-pocket) |
You pay the greater of 5% of the cost of the drug or $3.95 for generics/$9.85 for brand names.
|
|||
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.
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.