Medicare Advantage Plan - City of Alexandria

88 Pages·2013·1.1 MB·English

Hello
sImplICITy
Important Information
about your new plan
CITY OF ALEXANDRIA
UUnniitteeddHHeeaalltthhccaarree®® GGrroouupp MMeeddiiccaarree AAddvvaannttaaggee (PPO)
EEffffeeccttiivvee January 1, 2014 through December 31, 2014
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Cover Letter ...............................................................3
Introduction ................................................................5
Benefit Highlights .......................................................6
Plan Information .........................................................8
The Plan Drug List
The plan Drug list
Drug List ..................................................................19
Additional Drug Coverage .........................................31
Getting Started
getting started
Statement of Understanding ......................................41

More Plan Information
Summary of Benefits .................................................45
Important Information ................................................87
more plan Information

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Hello
SIMPLICITY
Dear Retiree,
Welcome to UnitedHealthcare®. We’re excited to tell you 1 5
about what your new plan has to offer. This plan is easy to in

understand, and even easier to use.
Medicare
beneficiaries have
We give you all of the details.
UnitedHealthcare1
In this book you’ll find information about the costs, benefits,
services and programs included with your new plan.
How to enroll.
If you want to enroll in this plan, follow your plan sponsor’s instructions. They will forward your
enrollment information to UnitedHealthcare.
Something to note.
You can only have prescription drug coverage under one plan. If you enroll in a stand-alone
Medicare Part D prescription drug plan or another medical plan that includes prescription
drug coverage, it may cause you to be disenrolled from your current plan.
Coverage from a trusted leader.
UnitedHealthcare has been serving the needs of Medicare beneficiaries for more than 30 years.
We strive to give you the resources, tools and coverage you may need to have the best health care
experience possible.
Whether you’ve never felt better in your life, or you’re managing a chronic condition, UnitedHealthcare
is here for you. We look forward to welcoming you as a plan member.
One call does it all. Learn more today.
1-877-714-0178, TTY 711 www.UHCRetiree.com
8 a.m. – 8 p.m. local time, 7 days a week Learn more online
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UnitedHealthcare®
yoUr partner in HealtH
Choosing UnitedHealthcare means you’re
partnering with a national health care
coverage leader. Helping more than
9 million
We simplify Medicare by offering Medicare
Medicare members
Advantage plans. Also known as Medicare
Part C, this plan combines your Medicare Parts live healthier lives.1
A and B with Medicare Part D prescription
drug coverage — into one easy plan.
Here’s the helpful information you’ll find in this book:
Discover the benefits
Review some of the most commonly used benefits.
learn about your plan
Find out how your plan works, the programs included, which doctors and hospitals
you can use and prescription drug information.
review your drugs
Make sure your prescription drugs are covered.
Find out your next steps to living a healthier life
See what you can expect after you’re enrolled in the plan.
Named “MOST ADMIRED COMPANY” by Fortune magazine, 2013
We’re with you every step of the way.
Our Customer Service team has been specially trained on the details of your plan. They are happy to
answer any questions you have.
1-877-714-0178, TTY 711 www.UHCRetiree.com
8 a.m. – 8 p.m. local time, 7 days a week Learn more online
12012 UnitedHealth Group Annual Report
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Benefit highlights CITY OF ALEXANDRIA 12229
Effective January 1, 2014 to December 31, 2014
This is a short description of plan benefits. For complete information, please refer to your Summary of
Benefits or Evidence of Coverage.
Medical Benefits Your In-Network Cost Your Out-of-Network Cost
(Medicare-Covered) (unless otherwise noted) (unless otherwise noted)
Doctor Office Visits
Primary care physician (PCP) $15 copay $15 copay
Specialist $15 copay $15 copay
Preventive Care
Annual wellness visit $0 copay $0 copay
Prostate cancer screening $0 copay $0 copay
Breast cancer screening $0 copay $0 copay
Immunizations $0 copay $0 copay
Inpatient Care
Inpatient hospital care $100 copay per admission $100 copay per admission
Skilled Nursing Facility (SNF) care $0 copay per day up to 100 days $0 copay per day up to 100 days
Outpatient Services
Radiation therapy $15 copay $15 copay
Outpatient surgery $0 copay $0 copay
Outpatient rehabilitation services Up to $15 copay Up to $15 copay
Lab Services and Other Tests
Laboratory tests $0 copay $0 copay
X-rays $0 copay $0 copay
Diagnostic radiology services $0 copay $0 copay
Emergency Services
Ambulance services $0 copay $0 copay
Emergency room (worldwide) $50 copay $50 copay
Urgently needed care $15 copay $15 copay
Other Medicare-Covered Benefits
Chiropractic services $15 copay $15 copay
Podiatry services $15 copay $15 copay
Eye exam $15 copay $15 copay
Hearing exam $15 copay $15 copay
Annual out-of-pocket maximum
Your plan has an annual combined in-network and out-of-network
Annual out-of-pocket maximum
out-of-pocket maximum of $3,400 each plan year
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Medical Benefits Your In-Network Cost Your Out-of-Network Cost
(unless otherwise noted) (unless otherwise noted)
Additional Benefits and Programs Not Covered Under Medicare
Routine podiatry services $15 copay $15 copay
(Up to 6 visits per plan year) (Up to 6 visits per plan year)
Routine hearing exams $0 copay $0 copay
(1 exam every 12 months) (1 exam every 12 months)
Hearing aids Plan pays up to $500 Plan pays up to $500
(every 3 years) (every 3 years)
Routine eye exam (refraction) $15 copay $15 copay
(1 exam every 12 months) (1 exam every 12 months)
Fitness program Stay active with a basic membership at a participating location at no
extra cost to you
NurseLineSM Speak with a registered nurse (RN) 24 hours a day, 7 days a week
Solutions for Caregivers** Provides support for caregivers
Behavioral/Mental Health** Get support during one-to-one calls with a behavioral health specialist
**The products and services described above are neither offered nor guaranteed under our contract with the
Medicare program. In addition, they are not subject to the Medicare appeals process. Any disputes regarding
these products and services may be subject to the UnitedHealthcare ® Group Medicare Advantage (PPO)
grievance process.
Prescription Drugs Your Cost
Initial coverage stage Network Pharmacy Mail Service Pharmacy
(30-day retail supply) (90-day supply)
Tier 1: Preferred generic $10 copay $10 copay
Tier 2: Preferred brand (includes $25 copay $10 copay
some generic)
Tier 3: Non-preferred brand $25 copay $10 copay
(includes some generic)
Tier 4: Specialty tier $25 copay $10 copay
Coverage gap stage (after The plan continues to pay its share of the cost of your drugs and you
prescription costs reach $2,850) pay your share of the cost
Catastrophic coverage stage The greater of $2.55 copay for generic, $6.35 copay for brand name,
(after you have paid $4,550 out- or 5% coinsurance
of-pocket)
Your plan sponsor has elected to offer additional coverage on some prescription drugs that are normally
excluded from coverage on your Formulary. Please see your Additional Drug Coverage document.
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract. Enrollment in UnitedHealthcare plans depends
on contract renewal.
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UnitedHealthcare®
GROUP MEDICARE ADVANTAGE (PPO)
One plan designed for convenience and value.
®
When you sign up for a UnitedHealthcare Group Medicare Advantage (PPO) plan, your health care
coverage is combined into a single plan. We combined Medicare Parts A, B and D so you don’t have to
manage separate plans with multiple member ID cards. You get coverage for hospital care, doctor care and
prescription drugs. All from one company, with one member ID card.
Medicare Part A Medicare Part B Medicare Part D Extra Programs
Hospital Doctor and outpatient Prescription drugs Beyond Original
Medicare
Make sure you are signed up for Medicare.
You must be enrolled in Medicare Part A and purchase Medicare Part B to be eligible to
enroll in this plan. If you’re not sure if you are enrolled, check with your local Social Security
office. You must continue paying your Medicare Part B premium to keep your coverage under
this group-sponsored plan. If you stop your payments, you may be disenrolled from this plan.
Are you enrolled in Medicare Part A?
Have you purchased Medicare Part B?
Keep paying your Medicare Part B premium.
Note: This plan includes prescription drug coverage. Medicare recipients may only be enrolled in one
Medicare Part D prescription drug plan. If you enroll in another Medicare Part D prescription drug plan
after you enroll in this plan, you may be disenrolled from your group-sponsored medical and/or prescription
drug coverage.
Give us a call if you have any questions.
1-877-714-0178, TTY 711 www.UHCRetiree.com
8 a.m. – 8 p.m. local time, 7 days a week Learn more online
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How your PPO plan works
Your plan is a Preferred Provider Organization (PPO) plan. With this plan, you have access to our
national network. Plus, you can see providers out-of-network at the same cost as in-network providers, as
long as they participate in Medicare and accept the plan.
In-Network Out-of-Network
Has the choice to
Will the doctor or hospital accept my plan? Yes accept plan (except
for emergencies).
What is my copay or coinsurance? Standard plan copay or coinsurance applies.
Do I need to choose a primary
No No
care physician (PCP)?
Do I need a referral to see a specialist? No No
Are emergency and urgently needed
Yes Yes
services covered?
Do I have to pay the full cost for all doctor
No, standard plan copay or coinsurance applies.
or hospital services?
Is there a limit on my total out-of-pocket
Yes Yes
spending for the year?
We’ll handle the paperwork.
Keeping track of bills and payments can be overwhelming. We take care of the payments
to doctors and hospitals, so you don’t have to. There are no health questions to answer
and you don’t need a physical to enroll in this plan. You can view your account activity and
plan details online.
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Visit the doctors you want
Our large network is made up of doctors, hospitals and other health care professionals across the country.
Together, they create one of the largest networks of health care professionals in the country focused on the
health care needs of Medicare beneficiaries.
Freedom to choose.
With this plan you have the flexibility to see doctors that are
out-of-network. Unlike most PPO plans, with this plan you pay
the same costs in and out-of-network.
Is your doctor in our network?
Use our online provider directory at www.UHCRetiree.com
to search for doctors and hospitals in our network.
Need help finding a doctor? Call or go online.
1-877-714-0178, TTY 711 www.UHCRetiree.com
8 a.m. – 8 p.m. local time, 7 days a week Learn more online
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