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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
Generations Classic Choice (HMO-POS)
In-Network

H3706-021
Generations Classic Choice (HMO-POS)
Out-of-Network

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

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

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

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

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

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.

Phase 1: Deductible

$0

Not covered

$0

$0

Not covered

Phase 2: Initial Coverage Limit (ICL)

$4,430

$4,430

$4,430

Tier 1: Preferred Generics* (Preferred Retail 30-Day Supply)

$5 copay per fill

$3 copay per fill

$5 copay per fill

Tier 2: Generic* (Preferred Retail 30-Day Supply)

$15 copay per fill

$13 copay per fill

$15 copay per fill

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

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.

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.

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

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

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

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

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
(HMO-POS)

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 -
$45 copay

Out-of-Network - 30% coinsurance 

Preventative Care * You pay nothing You pay nothing You pay nothing

In-Network -
You pay nothing

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


$320 - Hospital

$250 copay - Ambulatory Surgery Center


$320 - Hospital

$250 copay - Ambulatory Surgery Center


$320 - Hospital

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 x-rays;
$50 copay for
therapeutic radiology;
$100 copay for sleep
studies in outpatient
facility

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 -
You pay nothing for labs and x-rays;
$50 copay for
therapeutic radiology;
$100 copay for sleep
studies in outpatient
facility

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 -
$90 copay

Out-of-Network - $90 copay

Urgent Care $15 copay $30 copay $25 copay

In-Network -
$30 copay

Out-of-Network - $30 copay

Chiropractic $20 copay $20 copay $20 copay

In-Network -
$20 copay

Out-of-Network - Not covered

Home Health You pay nothing You pay nothing You pay nothing

In-Network -
You pay nothing

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 -
You pay nothing for up to 1 visit per year

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 -
Plan pays up to a $200 calendar year maximum

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 -
Plan pays up to a $1,000 calendar year maximum for preventive and comprehensive services

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 -
$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.

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 -
You pay nothing at an in-network fitness facility or for up to 2 home fitness kits per year

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 -
You pay nothing for up to 1 visit per year

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 -
Plan pays up to a $500 calendar year maximum for hearing aids and fitting

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.