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2022 MEDICARE ADVANTAGE PLANS

Benefits at a Glance

The following is intended to be only a summary of benefits for Medicare Advantage plans. For a complete list, including any limitations, exclusions, and plan restrictions, please review the  Evidence of Coverage for Medicare Advantage plans.

Coverage effective Jan 1, 2022 to Dec 31, 2022

 

Global Classic (HMO) Plans  

 

H6062-001

Global Classic

(HMO)

H6062-003

Global Classic

(HMO)

Monthly Plan Premium

(You must continue to pay your Part B premium)

$0

$0

Deductible

$0

$0

Maximum Out-of-Pocket (MOOP) Annually

(Does not include supplemental benefits or prescription drugs)

$3,400

$4,500

INPATIENT CARE

1 Prior Authorization Required

2 Referral Required

Inpatient Hospital Coverage1,2

$250 copay per day (Days 1-7);

$0 copay per day (Days 8-190)

$315 copay per day (Days 1-7);

$0 copay per day (Days 8-190)

Inpatient Mental Health Care1,2

$250 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)

OUTPATIENT CARE

1 Prior Authorization Required

2 Referral Required

Doctor Visits

• $0 copay per visit for PCP

• $30 copay per visit for specialists1,2

• $0 copay per visit for PCP

• $30 copay per visit for specialists1,2

Chiropractic Services

$20 copay per visit

$20 copay per visit

Podiatry Services1,2

$30 copay per visit

$30 copay per visit

Outpatient Mental Health Visit1,2

$30 copay per visit

$30 copay per visit

Ambulatory Surgery Center1,2

$200 copay per visit

$265 copay per visit

Outpatient Hospital Observation Services1,2

$250 copay per visit

$315 copay per visit

Outpatient Hospital Surgery1,2

$250 copay per visit

$315 copay per visit

Emergency 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)

• $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

$65 copay per visit

$65 copay per visit

Worldwide Urgent Care

(Does not accumulate to MOOP)

• $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

Outpatient1,2

Therapeutic Radiology

You pay 20% of the cost per visit

You pay 20% of the cost per visit

Outpatient1,2

Diagnostic Radiology (MRI, etc.)

• $175 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

• $315 outpatient hospital

Outpatient Rehabilitation Services1,2

(Physical, occupational, and/or speech therapy)

$30 copay per visit

$30 copay per visit

Acupuncture1,2

$30 copay per visit

$30 copay per visit

Ambulance

(One-way trip)

• $225 per occurrence for ground

• You pay 20% of the cost per occurrence for air

• $225 per occurrence for ground

• You pay 20% of the cost per occurrence for air

Home Health Services1,2

$0

$0

PREVENTIVE CARE

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

OUTPATIENT MEDICAL SUPPLIES

Durable Medical Equipment1

(e.g., Continuous glucose monitors (CGM), wheelchairs, oxygen)

You pay 20% of the cost

You pay 20% of the cost

Standard Diabetic Testing Supplies1

You pay 20% of the cost

You pay 20% of the cost

Prosthetics and Related Supplies1

(e.g., Braces, artificial limbs)

You pay 20% of the cost

You pay 20% of the cost

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 $500 for hearing aids per year

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

Vision Services

• $0 routine eye exam limited to 1 per year

• Our plan pays up to a total of $100 for all supplemental eyewear per year

• $0 routine eye exam limited to 1 per year

• Our plan pays up to a total of $100 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 6 one-way trips per year

• Limited to 50 miles per one-way trip

Over-the-Counter Benefit

(Includes nicotine replacement therapy)

Plan pays $50 per quarter

Plan pays $50 per quarter

Fitness

$0

$0

24/7 Nurse Line

$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

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-day supply). For more information on the additional pharmacies specific cost-shar­ing and the phases of the benefit, please call us or access the Evidence of Coverage.

Phase 1: Deductible

$0

$0

Phase 2: Initial Coverage Limit (ICL)

$4,430

$4,430

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

$5 copay per fill

$5 copay per fill

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

$15 copay per fill

$15 copay per fill

Tier 3: Preferred Brand* (Preferred Retail 30-Day Supply)

$42 copay per fill

$42 copay per fill

Tier 4: Non-Preferred Drug* (Preferred Retail 30-Day Supply)

$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

Tier 1: Preferred Retail & Mail Order

(100-Day Supply)

$10 copay per fill

$10 copay per fill

Tier 2: Preferred Retail & Mail Order

(100-Day Supply)

$30 copay per fill

$30 copay per fill

Tier 3: Preferred Retail & Mail Order

(100-Day Supply)

$84 copay per fill

$84 copay per fill

Tier 4: Preferred Retail & Mail Order

(100-Day Supply)

$270 copay per fill

$270 copay per fill

Phase 3: GAP Coverage Stage3

(After your prescription costs reach $4,430)

 

 

 

3 You stay in this stage until your year-to-year “out-of-pocket” (you payments) reach a total of $7,050. This amount and rules for counting costs toward this amount have been set by Medicare.

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.

 

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.

Phase 4: Catastrophic Coverage Stage (After your prescriptions reach $7,050)

You pay the greater 5% of the cost of the drug or $3.95 for generics/$9.85 for brand names.

 

 

 

Global Special Care (HMO C-SNP) and Global Special Care Savings (HMO C-SNP) Plans 

 

H6062-005

Global Special Care

(HMO C-SNP)

H6062-006

Global Special Care Savings

(HMO C-SNP)

Monthly Plan Premium

(You must continue to pay your Part B premium)

$0

$0

Deductible

$0

$0

Part B Premium Buydown

$0 per month

$50 per month

Maximum Out-of-Pocket (MOOP) Annually

(Does not include supplemental benefits or prescription drugs)

$2,900

$3,400

Healthy Benefits Grocery Card Redeemable at Walmart®

Plan pays $25 per month

Plan pays $25 per month

INPATIENT CARE

1 Prior Authorization Required

2 Referral Required

Inpatient Hospital Coverage1,2

$195 copay per day (Days 1-7);

$0 copay per day (Days 8-190)

$250 copay per day (Days 1-7);

$0 copay per day (Days 8-190)

Inpatient Mental Health Care1,2

$195 copay per day (Days 1-7);

$0 copay per day (Days 8-90)

$250 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)

OUTPATIENT CARE

1 Prior Authorization Required

2 Referral Required

Doctor Visits

• $0 copay per visit for PCP

• $20 copay per visit for specialists1,2

• $0 copay per visit for PCP

• $30 copay per visit for specialists1,2

Chiropractic Services

$20 copay per visit

$20 copay per visit

Podiatry Services1,2

$20 copay per visit

$30 copay per visit

Outpatient Mental Health Visit1,2

$20 copay per visit

$30 copay per visit

Ambulatory Surgery Center1,2

$145 copay per visit

$175 copay per visit

Outpatient Hospital Observation Services1,2

$195 copay per visit

$225 copay per visit

Outpatient Hospital Surgery1,2

$195 copay per visit

$225 copay per visit

Emergency Care

$120 copay per visit; waived if admitted to acute care

$120 copay per visit; waived if admitted to acute care

Worldwide Emergency Care

(Does not accumulate to MOOP)

• $120 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

Urgently Needed Services

$65 copay per visit

$65 copay per visit

Worldwide Urgent Care

(Does not accumulate to MOOP)

• $120 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

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

Outpatient1,2

Therapeutic Radiology

You pay 20% of the cost per visit

You pay 20% of the cost per visit

Outpatient1,2

Diagnostic Radiology (MRI, etc.)

• $145 copay per visit in PCP, specialist, urgent care, freestanding radiological facility

• $195 outpatient hospital

• $175 copay per visit in PCP, specialist, urgent care, freestanding radiological facility

• $225 outpatient hospital

Outpatient Rehabilitation Services1,2

(Physical, occupational, and/or speech therapy)

$20 copay per visit

$30 copay per visit

Acupuncture1,2

$20 copay per visit

$30 copay per visit

Ambulance

(One-way trip)

• $225 per occurrence for ground

• You pay 20% of the cost per occurrence for air

• $200 per occurrence for ground

• You pay 20% of the cost per occurrence for air

Home Health Services1,2

$0

$0

PREVENTIVE CARE

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

OUTPATIENT MEDICAL SUPPLIES

Durable Medical Equipment1

(e.g., Continuous glucose monitors (CGM), wheelchairs, oxygen)

You pay 20% of the cost

You pay 20% of the cost

Standard Diabetic Testing Supplies1

$0

$0

Prosthetics and Related Supplies1

(e.g., Braces, artificial limbs)

You pay 20% of the cost

You pay 20% of the cost

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 $500 for hearing aids per year

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 (Does not accumulate to MOOP)

• $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 (Does not accumulate to MOOP)

Vision Services

• $0 routine eye exam limited to 1 per year

• Our plan pays up to a total of $100 for all supplemental eyewear per year

• $0 routine eye exam limited to 1 per year

• Our plan pays up to a total of $100 for all supplemental eyewear per year

Transportation1

(To and from plan-approved locations)

• $0 per trip

• Limited to 18 one-way trips per year

• Limited to 50 miles per one-way trip

• $0 per trip

• Limited to 18 one-way trips per year

• Limited to 50 miles per one-way trip

Routine Foot Care1,2

• $20 copay per visit

• Limited to 6 visits per year

• $30 copay per visit

• Limited to 6 visits per year

Over-the-Counter Benefit

(Includes nicotine replacement therapy)

Plan pays $25 per month

Plan pays $25 per month

Fitness

$0

$0

24/7 Nurse Line

$0

$0

Post-Discharge Meal Delivery1

• $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

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-day supply). For more information on the additional pharmacies specific cost-shar­ing and the phases of the benefit, please call us or access the Evidence of Coverage.

Phase 1: Deductible

$0

$0

Phase 2: Initial Coverage Limit (ICL)

$4,430

$4,430

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

$0 copay per fill

$0 copay per fill

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

$5 copay per fill

$5 copay per fill

Tier 3: Preferred Brand* (Preferred Retail 30-Day Supply)

• $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)

$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

Tier 1: Preferred Retail & Mail Order

(100-Day Supply)

$0 copay per fill

$0 copay per fill

Tier 2: Preferred Retail & Mail Order

(100-Day Supply)

$10 copay per fill

$10 copay per fill

Tier 3: Preferred Retail & Mail Order

(100-Day Supply)

• $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)

$270 copay per fill

$270 copay per fill

Phase 3: GAP Coverage Stage3

(After your prescription costs reach $4,430)

 

 

 

3 You stay in this stage until your year-to-year “out-of-pocket” (you payments) reach a total of $7,050. This amount and rules for counting costs toward this amount have been set by Medicare.

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.

 

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 your prescriptions reach $7,050)

You pay the greater 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.