Area Agency On Aging - 2018 Medicare Advantage Plans · 2017-10-17 · A program of the Area Agency...

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2018 Medicare Advantage Plans

in Maricopa County

There are a variety of different types of Medicare Health Plans to choose from. The attached comparison sheets should be used as a guideline in selecting the type of health plan that meets your individual needs. Things to consider in choosing a plan include cost, choice of doctor, benefits, prescription coverage, flexibility and convenience. The following types of health plans are available to most individuals enrolled in Medicare living in Maricopa County: 1. Health Maintenance Organizations (HMO) Pg. 3 2. Preferred Provider Organizations (PPO) Pg. 35 And Private Fee for Service Plans

Most current revision: 10/10/2017

BENEFITS ASSISTANCE PROGRAM A State Health Insurance Assistance Program (SHIP) A program of the Area Agency on Aging, Region One 1366 East Thomas, Suite 108, Phoenix, AZ 85014 602-264-2255

This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Admin

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Health Maintenance Organizations (HMO) A group of doctors, hospitals, and other health care providers who agree to give health care to Medicare beneficiaries for a set amount of money from Medicare each month. In an HMO, you generally must get all your care and services from doctors or hospitals in the plan’s network (except emergency or urgent care). You generally must see a primary care doctor to get a referral before you see any other health care provider. If you get health care outside the plan’s network, you may have to pay the full cost. Plans with Prescription Drug Coverage: Page 1. AARP Medicare Complete Plan 1 3 2. AARP Medicare Complete Plan 2 5 3. Aetna Medicare Prime Plan 7 4. Aetna Medicare Platinum Platinum Plan 9 5. Allwell Medicare Essentials I 11 6. Allwell Medicare Essentials II 13 7. Allwell Medicare Premier 15 8. Blue Medicare Advantage Classic 17 9. Blue Medicare Advantage Plus 19 10. Bright Advantage 21 11. Bright Advantage Plus 23 12. CIGNA HealthSpring Preferred 25 13. Humana Gold Plus H2649-032 27 14. Humana Gold Plus H2649-063 29 15. Humana Gold Plus H2649-030 31 Plans WITHOUT Prescription Drug Coverage: 1. Allwell Medicare Complement 33 Preferred Provider Organizations (PPOs) begin on page 35

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AARP MedicareComplete Plan 1 (HMO) Plan Number H0609-026 STAR RATING = N/A

United Healthcare 1-800-555-5757

aarpmedicareplans.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $4,900.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 $285.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 51 $160.00 Co-pay per day for days 52 – 100 $0.00 Mental Health Outpatient Visits Co-pay per visit $30.00 to $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $30.00 to $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $230.00 Physician Services Co-pay for Primary Care Physician $10.00 Co-pay for Specialist $45.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 Routine Podiatry Service Co-pay per visit for exams and treatment $45.00 Co-pay per visit for routine foot care – 6 visits per year $45.00 Chiropractic Care Co-pay per visit – Limited servies $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $2.00 to 20% Outpatient Services Facility co-pay at hospital outpatient facility $285.00 Facility co-pay at ambulatory surgical center $285.00 Prescription Drugs See reverse side Home Health Care Visits $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Transportation Not Covered Routine Vision Services Vision exams, lenses, glasses Not Covered Hearing Services Co-pay for Medicare covered hearing exam $10.00 Co-pay for routine hearing exam $10.00 Hearing aid appliance $330.00 - $380.00 Dental Optional plan available

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AARP Medicare Complete Plan 1 (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network

Prescription drugs may be covered under Part A, Part B or Part D

Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of the hospital charges, with no copay. Part B drugs – Vaccinationssuchasflushots,pneumoniashots,andhepatitisB;transplantdrugs;drugsadministeredinadoctor’sofficeoroutpatientsetting,suchaschemotherapy,etc.,whichgenerallyhave20%coinsurance.

Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary.

This plan’s Part D Deductible $230 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. No restricted network for this plan Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Heallthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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AARP MedicareComplete Plan 2 (HMO) Plan Number H0609-027 STAR RATING = N/A

United Healthcare 1-800-555-5757

aarpmedicareplans.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $4,000.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 –7 $225.00 Co-pay per day for days 8 – 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 45 $160.00 Co-pay per day for days 46 – 100 $0.00 Mental Health Outpatient Visits Co-pay per visit $30.00 to $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $30.00 to $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $150.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $30.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $30.00 Routine Podiatry Service Co-pay for exams and treatment $30.00 Copay for routine foot care – 6 visits per year $30.00 Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $2 to 20% Outpatient Services Co-pay at hospital outpatient facility $225.00 Co-pay at ambulatory surgical center $225.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Transportation Not covered Vision Services Vision exams, lenses, glasses Plan pays up to $70.00 $20.00 Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for routine fitting $0.00 Hearing aid appliance $330.00 to $380.00 Dental Optional plan available

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AARP Medicare Complete Plan 2 (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $ 0 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. No restricted network for this plan Hospitals: Abrazo Dignity Health West Campus (Goodyear) Arizona General Central Campus Chandler Regional Maryvale Mercy Gilbert Phoenix (PV-Bell) St Joseph’s Arrowhead St Joseph’s Westgate Honor Health St Luke’s Scottsdale Healthcare Osborn Tempe ScottsdaleHealthcare Shea Phoenix Scottsdale Healthcare Thompson Peak John C Lincoln Deer Valley John C Lincoln Phoenix

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Aetna Medicare Prime Plan (HMO) Plan Number H3931-092 STAR RATING = N/A

Aetna Medicare 1-855-338-7027

aetnamedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,000.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 $185.00 Co-pay per day for days 8 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.00 Mental Health Outpatient Visits Co-pay per visit $20.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $60.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $315.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $20.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $20.00 Routine Podiatry Service Co-pay per visit for exams and treatment $20.00 Co-pay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to 250.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $185.00 Co-pay at ambulatory surgical center $185.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit Not covered Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Transportation Not Covered Vision Services Vision exams, lenses, glasses One routine eye exam per year $0.00 Hearing Services Co-pay for Medicare covered diagnostic hearing exam $20.00 Co-pay for routine hearing exam $0.00 Hearing aid appliance Not Covered Dental Optional plan available

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Aetna Medicare Prime Plan (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network




This plan’s Part D Deductible $0 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Frys CVS Walgreens Osco Safeway Costco Walmart Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Hlthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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Aetna Medicare Platinum Plan (HMO) Plan Number H3931-130 STAR RATING = N/A


aetnamedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $26.00 (LIS $5.10) Maximum out-of-pocket limit $6,000.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $350.00 Co-pay per day for days 6 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.00 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $60.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $325.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $40.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 Routine Podiatry Service Co-pay per visit for exams and treatment $40.00 Co-pay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit– Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $10.00 to 20% Outpatient Services Co-pay at outpatient hospital facility $295.00 Co-pay at ambulatory surgical center $295.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses One routine eye exam per year $0.00 Transportation Not Covered Hearing Services Co-pay for Medicare covered diagnostic hearing exam $40.00 Co-pay for routine hearing exam Not Covered Hearing aid appliance Not Covered Dental Optional plan available

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Aetna Medicare Platinum Plan (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $95.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Frys CVS Walgreens Osco Safeway Costco Walmart Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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Allwell Medicare Essentials I (HMO) Plan Number H9287-004 STAR RATING = N/A

Allwell 1-800-333-3930

allwell.healthnetadvantage.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,950.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 6 $225.00 Co-pay per day for days 7 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 No hospital stay required $0.00 Co-pay per day for days 21 – 100 $120.00 Mental Health Outpatient Visits Co-pay per visit $35.00 Emergency/Urgent Care

Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $350.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $35.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $35.00 Routine Podiatry Service Co-pay per exams and treatment $35.00 Co-pay for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services (optional plan available) $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to $200.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $225.00 Co-pay at ambulatory surgical center $150.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $100.00 $0.00 Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $35.00 Co-pay for routine fitting Not Covered Hearing aid appliance Not Covered Dental Optional plan available

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Allwell Medicare Essentials I (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $0.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Costco CVS Frys Osco Safeway Sams Walmart Hospitals: Abrazo St. Lukes Banner Arizona Heart Hospital Tempe Baywood Arrowhead Phoenix Boswell Central Campus Del Webb Maryvale Desert Phoenix (PV-Bell) Estrella Scottsdale Campus Gateway West Campus (Goodyear) Goldfield (Apache Junction) University Medical Center Ironwood Thunderbird Maricopa Medical Center

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Allwell Medicare Essentials II (HMO) Plan Number H0351-049-1 STAR RATING = N/A

Allwell 1-800-333-3930

allwell.healthnetadvantage.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $4,000.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 -6 $195.00 Co-pay per day for days 7 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 No hospital stay required $0 Co-pay per day for days 21 – 100 $150.00 Mental Health Outpatient Visit Co-pay per visit $25.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $275.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $25.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $20.00 Routine Podiatry Service Co-pay per visit for exams and treatment $25.00 Co-pay per visit for routine care Not Covered Chiropractic Care Co-pay per visit – Limited services (optional plan available) $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to $200.00 Outpatient Services Co-pay at outpatient hospital facility $150.00 Co-pay at ambulatory surgical center $100.00 Prescription Drugs See reverse side Home Health Care Visits $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses and glasses Plan pays up to $100.00 Not covered Transportation Up to 8 one-way trips per year $0.00 Hearing Services Co-pay for Medicare covered hearing exam $25.00 Co-pay for annual hearing exam $ 0.00 Hearing aid appliance (every 3 years) $ 0.00 Dental Optional plan available

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Allwell Medicare Essentials II (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network




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Allwell Medicare Premier (HMO) Plan Number H0351-043 STAR RATING = N/A

Allwell 1-800-333-3930

allwell.healthnetadvantage.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $59.00 (LIS $26.10) Maximum out-of-pocket limit $3,800.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $100.00 Co-pay per day for days 6 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 No hospital stay required $0 Co-pay per day for days 21 – 100 $100.00 Mental Health Outpatient Visits Co-pay per visit $15.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $125.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $15.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $10.00 Routine Podiatry Service Co-pay per visit for exams and treatment $15.00 Co-pay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services (optional plan available) $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to $200.00 or 20% Outpatient Services Co-pay at hospital outpatient facility $75.00 Co-pay at ambulatory surgical center $50.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME)

Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses and glasses Plan pays up $100.00 $0.00 Transportation Up to 8 one-way trips Not Covered Hearing Services Co-pay for Medicare covered hearing exam $15.00 Co-pay for routine fitting $0.00 Hearing aid appliance ($2,000.00 every 3 years) $0.00 Dental Optional plan available

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Allwell Medicare Premier (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network




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Blue Medicare Advantage Classic (HMO) Plan Number H0302-006 STAR RATING = N/A

Blue Cross Blue Shield 1-888-274-0367

azbluemedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,400.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 Maximum out of pocket $1,750.00 $250.00 Co-pay per day for days 8 – 364 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 No hospital stay required $20.00 Co-pay per day for days 21 – 100 $165.00 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $100.00 Co-pay per visit for urgent care $25.00 Foreign Travel Emergency Coverage Not covered Ambulance Services Co-pay per trip $200.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $40.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 Routine Podiatry Service Co-pay per visit for exams and treatment $40.00 Co-pay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $40.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab, and imaging $0.00 to $300.00 (or 20%) Outpatient Services Co-pay at outpatient hospital facility $295.00 Co-pay at ambulatory surgical center $200.00 Prescription Drugs See reverse side

Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Transportation Not Covered Vision Services Vision exams, lenses and glasses Not Covered Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for routine hearing exam $45.00 Hearing aid appliance $699.00 - $999.00 Dental Not Covered

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Blue Medicare Advantage Classic (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $195.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs.

No restricted network for this plan Hospitals: Banner Honor Health Baywood Scottsdale Healthcare Osborn Boswell Scottsdale Healthcare Shea Del Webb Scottsdale Healthcare Thompson Peak Desert John C Lincoln Deer Valley Estrella John C Lincoln Phoenix Gateway Goldfield (Apache Junction) University Medical Center Ironwood Thunderbird

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Blue Medicare Advantage Plus (HMO) Plan Number H0302-001 STAR RATING = N/A

Blue Cross Blue Shield 1-888-274-0367

azbluemedicare.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $35.00 (LIS $3.00) Maximum out-of-pocket limit $3,200.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 Maximum out of pocket $1,575.00 $225.00 Co-pay per day for days 8 – 365 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 10 $0.00 Co-pay per day for days 11 – 20 $20.00 Co-pay per day for days 21-100 $100.00 Mental Health Outpatient Visits Co-pay per visit $20.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $100.00 Co-pay per visit for urgent care $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $125.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $20.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $20.00 Routine Podiatry Service Co-pay per visit for exams and treatment $20.00 Co-pay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to $275.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $225.00 Co-pay at ambulatory surgical center $160.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses and glasses Not Covered Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for routine exam $45.00 Hearing aid appliance $699.00 - $999.00 Dental (cleaning, x-ray, oral exam annually) Covers up to $500.00

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Blue Medicare Advantage Plus (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network


Part A drugs – Drugs administered during an inpatient hospital stay are covered as part of the hospital charges, with no copay.

Part B drugs – Vaccinationssuchasflushots,pneumoniashots,andhepatitisB;transplantdrugs;drugsadministeredinadoctor’sofficeoroutpatientsetting,suchaschemotherapy,etc.,whichgenerallyhave20%coinsurance.


This plan’s Part D Deductible $100.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. No restricted network for this plan Hospitals: Banner Honor Health Baywood Scottsdale Healthcare Osborn Boswell Scottsdale Healthcare Shea Del Webb Scottsdale Thompson Peak Desert John C Lincoln Deer Valley Estrella John C Lincoln Phoenix Gateway Goldfield (Apache Junction) University Medical Center Ironwood Thunderbird

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Bright Advantage (HMO) Plan Number H4853-001 STAR RATING = N/A

Bright Health 1-844-679-2028

brighthealthplan.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,750.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 $185.00 Co-pay per day for days 8 – 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $145.00 Mental Health Outpatient Visits Co-pay per visit $10.00 - $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $30.00 Foreign Travel Emergency Coverage No coverage Ambulance Services Co-pay per trip $200.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $30.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per visit for exams and treatment $25.00 Co-pay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $10.00 - 20% Outpatient Services Co-pay at outpatient hospital facility $250.00 Co-pay at ambulatory surgical center $175.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses (1 routine exam every 12 months) Optional plan available Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance ($2,000.00 every 3 years) $0.00 Dental (Comprehensive dental coverage – there may be limits) $0.00

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Bright Advantage (HMO)

Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $0.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. No restricted network for this plan Hospitals: Abrazo Dignity Health Arizona Heart Hospital Arizona General Hospital Arrowhead Chandler Regional Medical Center Central Campus Mercy Gilbert Medical Center Maryvale St Joseph’s Hospital and Medical Center Phoenix (PV-Bell) St Joseph’s Westgate Medical Center Scottsdale Campus West Campus (Goodyear)

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Bright Advantage Plus (HMO) Plan Number H4853-002 STAR RATING = N/A

Bright Health 1-844-679-2028

Bbrighthealthplan.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $28.00 (LIS $0.00) Maximum out-of-pocket limit $3,500.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $170.00 Co-pay per day for days 6 - beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21-100 $155.00 Mental Health Outpatient Visits Co-pay per visit $10.00 - $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $75.00 Co-pay per visit for urgent care $30.00 Foreign Travel Emergency Coverage No coverage Ambulance Services Co-pay per trip $200.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $20.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service

Co-pay per visit for exams and treatment $25.00 Copay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services

Radiolog tests, lab and imaging $10.00 to 20% Outpatient Services Co-pay at outpatient hospital facility $250.00 Co-pay at ambulatory surgical center $150.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $130.00 $25.00 Hearing Services Co-pay for Medicare covered hearing exam $0.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance ($2,000.00 every 3 years) $0.00 Dental (Comprehensive dental coverage – there may be limits) $0.00

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Bright Advantage Plus (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network




This plan’s Part D Deductible $0.00 Pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. No restricted network for this plan Hospitals: Abrazo Dignity Health Arizona Heart Hospital Arizona General Hospital Arrowhead Chandler Regional Medical Center Central Campus Mercy Gilbert Medical Center Maryvale St Joseph’s Hospital and Medical Center Phoenix (PV-Bell) St Joseph’s Westgate Medical Center Scottsdale Campus West Campus (Goodyear)

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CIGNA HealthSpring Preferred (HMO) Plan Number H0354-001 STAR RATING = N/A

CIGNA 1-855-561-3811

cignahealthspring.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,950.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 $200.00 Co-pay per day for days 8 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21-100 $167.00 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $25.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $250.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $30.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $30.00 Routine Podiatry Service Co-pay per visit for exams and treatment $30.00 Copay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited coverage plus 12 routine visits per year $20.00 Diagnostic Tests, X-Rays, and Lab Services

Radiolog tests, lab and imaging $0.00 - $150.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $325.00 Co-pay at ambulatory surgical center $150.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Not Covered Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $30.00 Co-pay for annual hearing exam $30.00 Hearing aid appliance Not Covered Dental Not Covered

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CIGNA Healthspring Preferred (HMO) Prescription Drug Coverage, Pharmacy and Hospital Network




This plan’s Part D Deductible $200.00

Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Cigna Medical Gp Frys Osco Safeway Sams Walgreens Walmart Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix Maricopa Integrated Health

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Humana Gold Plus (HMO) H2649-032 Plan Number H2649-032 STAR RATING = N/A

Humana 1-800-833-2364

humana.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $5,500.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 7 $225.00 Co-pay per day for days 8 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21-100 $167.50 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $35.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $0.00 Co-pay for Specialist $35.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $35.00 Routine Podiatry Service Co-pay per visit for exams and treatment $35.00 Copay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services

Radiolog tests, lab and imaging $0.00 - $200.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $200.00 Co-pay ambulatory surgical center $175.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 – 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $200.00 Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $35.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance $699.00 - $999.00 Dental (cleaning, x-ray, oral exam annually) Optional plan available

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Humana Gold Plus (HMO) H2649-032

Prescription Drug Coverage, Pharmacy and Hospital Network Prescription drugs may be covered under Part A, Part B or Part D



This plan’s part D Deductible $225.00

Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Bashas Costco CVS Frys Osco Safeway Sams Walmart Walgreens Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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Humana 1-800-833-2364

humana.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $0.00 Maximum out-of-pocket limit $3,200.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $175.00 Co-pay per day for days 6 - beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21-100 $167.50 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $0.00 - $35.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $0.00 - $20.00 Co-pay for Specialist $25.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per visit for exams and treatment $25.00 Copay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services

Radiolog tests, lab and imaging $0.00 - $150.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $150.00 Co-pay at ambulatory surgical center $125.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit (includes respite care) $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 - 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $200.00 Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $25.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance $399.00 - $699.00 Dental (cleaning, x-ray, oral exam annually) Optional plan available

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Humana Gold Plus (HMO) H2649-063 Prescription Drug Coverage, Pharmacy and Hospital Network




This plan’s Part D Deductible $0.00

Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Bashas Costco CVS Frys Osco Safeway Sams Walmart Walgreens Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Hlthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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Humana 1-800-833-2364

humana.com/medicare Out-of-Network Services No coverage Additional Monthly Premium for this plan $83.00 (LIS $83.00) Maximum out-of-pocket limit $4,900.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 6 $289.00 Co-pay per day for days - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21-100 $167.50 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $45.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 - $45.00 Routine Podiatry Service Co-pay per visit for exams and treatment $45.00 Copay per visit for routine foot care Not Covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services

Radiolog tests, lab and imaging $0.00 - $264.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $264.00 Co-pay at ambulatory surgical center $239.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit (includes respite care) $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 - 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $200.00 Transportation 12 one-way trips $0.00 Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for annual hearing exam $0.00 Hearing aid appliance $699.00 - $999.00 Dental (cleaning, x-ray, oral exam annually) Optional plan available

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Humana Gold Plus (HMO) H2649-030 Prescription Drug Coverage, Pharmacy and Hospital Network






- 33 -

Allwell Medicare Complement (HMO) Plan Number H0351-030 STAR RATING = N/A

Allwell 1-800-333-3930

allwell.healthnetadvantage.com Out-of-Network Services No coverage Additional Monthly Premium for this plan $83.00 Maximum out-of-pocket limit $6,700.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 8 $195.00 Co-pay per day for days 9 - 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 No hospital stay required $0.00 Co-pay per day for days 21 – 100 $100.00 Mental Health Outpatient Visits Co-pay per visit $35.00 Emergency/Urgent Care

Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $20.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $300.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $35.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $25.00 Routine Podiatry Service Co-pay per exams and treatment $35.00 Co-pay for routine foot care Not Covered Chiropractic Care Co-pay per visit - Limited services (optional plan available) $20.00 Diagnostic Tests, X-Rays, and Lab Services Radiology tests, lab and imaging $0.00 to $200.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $175.00 Co-pay at ambulatory surgical center $125.00 Prescription Drugs No Coverage Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME)

Co-pay per item for Diabetic supplies $0.00 Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Optional plan available Transportation Not Covered Hearing Services Co-pay for Medicare covered hearing exam $15.00 Co-pay for routine fitting Not covered Hearing aid appliance (every 3 years) Not covered Dental Optional plan available

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Allwell Medicare Complement (HMO)

Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –ThisplandoesnotcoverPartDdrugs Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Not applicable Hospitals: Abrazo St. Lukes Banner West Campus (Goodyear) Tempe Baywood Central Campus Phoenix Boswell Maryvale Del Webb Phoenix (PV-Bell) Desert Arrowhead Estrella Gateway Goldfield (Apache Junction) Maricopa Medical University Medical Center Ironwood Thunderbird

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Preferred Provider Organizations (PPO)

A health care plan in which you use doctors, hospitals, and providers that belong to the network. You can receive services outside of the network for an additional cost. You do not need a referral from a primary care physician to see a specialist. Plans with Prescription Drug Coverage: Local PPO (Maricopa county-wide only) Page 1. Aetna Medicare Prime Plan (MAPD) 37 2. Aetna Medicare Platinum Plan (MAPD) 39 Select Counties PPO (Maricopa, Pima, Pinal & Santa Cruz county-wide) 3. Humana Choice PPO (MAPD) 41 Regional PPO (provider network is state-wide) 4. Humana Choice Regional PPO (MAPD) 43 Plans WITHOUT Prescription Drug Coverage: 5. Humana Choice Regional PPO (MA) 45

Private Fee For Service PFFS

Private Fee For Service (nationwide coverage w/o a network or contracts)

1. Humana Gold Choice (PFFS) 47

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Aetna Medicare Prime Plan (PPO) Plan Number H5521-100 STAR RATING = N/A


aetnamedicare.com Out-of-Network Services Up to 40% Additional Monthly Premium for this plan $66.00 (LIS $33.10) Maximum out-of-pocket limit in-network/out-of-network $6,700.00/$10,000 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $269.00 Co-pay per day for days 6 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.00 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $60.00 Foreign Travel Emergency Coverage $80.00 Ambulance Services Co-pay per trip $325.00 Physician Services Co-pay for Primary Care Physician $10.00 Co-pay for Specialist $35.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $30.00 Routine Podiatry Service Co-pay per visit for exams and treatment $35.00 Co-pay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0-$40.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $275.00 Co-pay at ambulatory surgical center $275.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $125.00 Hearing Services Co-pay for Medicare covered diagnostic hearing exam $35.00 Co-pay for routine annual hearing exam $0.00 Hearing aid appliance benefit Plan pays up to $500 Transportation Not covered Dental (preventive & comprehensive dental services) Plan pays up to $500

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Aetna Medicare Prime Plan (PPO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $150.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Frys CVS Walgreens Osco Safeway Costco Walmart Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley

John C Lincoln Phoenix

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Aetna Medicare Platinum Plan (PPO) Plan Number H5521-184 STAR RATING = N/A


aetnamedicare.com Out-of-Network Services Up to 40% Additional Monthly Premium for this plan $106.00 (LIS $77.30) Maximum out-of-pocket limit in-network/out-of-network $5,000.00/$8,200 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $295.00 Co-pay per day for days 6 – beyond $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.00 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $50.00 Foreign Travel Emergency Coverage $80.00 Ambulance Services Co-pay per trip $275.00 Physician Services Co-pay for Primary Care Physician $.00 Co-pay for Specialist $30.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $35.00 Routine Podiatry Service Co-pay per visit for exams and treatment $30.00 Copay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0-$30.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $240.00 Co-pay at ambulatorty surgical center $240.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exam, lenses, glasses Plan pays up to $150.00 Hearing Services Co-pay for Medicare covered diagnostic hearing exam $30.00 Co-pay for routine annual hearing exam $0.00 Hearing aid appliance benefit Plan pays up to $300 Transportation Not covered Dental (preventive & comprehensive dental services) Plan pays up to $750

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Aetna Medicare Platinum Plan (PPO) Prescription Drug Coverage, Pharmacy and Hospital Network



Part D drugs –allotherprescriptiondrugscoveredontheplan’sformulary. This plan’s Part D Deductible $250.00 Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Frys CVS Walgreens Osco Safeway Costco Walmart Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley

John C Lincoln Phoenix

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Humana Choice PPO (MAPD) Plan Number H5216-034 STAR RATING = N/A

Humana Health Plan 1-800-833-2364

humana-medicare.com Out-of- Network Services; contact plan for out-of-network costs Up to 40% Additional Monthly Premium for this plan $123.00 (LIS $94.10 ) Maximum out-of-pocket limit in network/out of network $6,700.00/$10,000 Inpatient Hospital (In-Network) See reverse side for network hospitals Co-pay per day for days 1-6 $289.00 Co-pay per day for days 7 - beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $5.00 Co-pay for Specialist $45.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 - $45.00 Routine Podiatry Service Co-pay per visit for exams and treatment $45.00 Co-pay for visit for routine foot care Not covered Chiropractic Care Co-pay per visit $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $264.00 (or 20%) Outpatient Services Co-pay at outpatient hospital facility $264.00 Co-pay at ambulatory surgical facility $239.00 Prescription Drugs See reverse side Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $40.00 Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for routine annual hearing exam $0.00 Hearing aid appliance $699.00 - $999.00 Transportation No coverage Dental (limited benefits) Optional plan available

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Humana Choice PPO (MAPD)

Prescription Drug Coverage, Pharmacy and Hospital Network Prescription drugs may be covered under Part A, Part B or Part D





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Humana Choice Regional PPO (MAPD) Plan Number R7220-002 STAR RATING = 3 STARS


humana-medicare.com

Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $164.00 (LIS $135.30) Maximum out-of-pocket limit in network/out of network $6,700.00 Inpatient Hospital (In-Network) See reverse side for network hospitals Co-pay per day for days 1-6 $289.00 Co-pay per day for days 7 – beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.50 Outpatient Mental Health Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $15.00 Co-pay for Specialist $45.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $30.00 to $45.00 Routine Podiatry Service Co-pay per visit for exams and treatment $45.00 Co-pay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0 to $264.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $264.00 Co-pay at ambulatory surgical center $239.00 Prescription Drugs Not Covered Home Health Care (In Network) Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses glasses Plan pays up to $40.00 Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for routine annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available

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Humana Choice Regional PPO (MAPD) Prescription Drug Coverage, Pharmacy and Hospital Network






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Humana Choice Regional PPO (MA) Plan Number R7220-001 STAR RATING = N/A


humana-medicare.com Out-of- Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan 0.00 Maximum out-of-pocket limit in network/out of network $6,700.00 Inpatient Hospital (In-Network) See reverse side for network hospitals Co-pay per day for days 1-6 $289.00 Co-pay per day for days 7 – beyond $0.00 Skilled Nursing Facility (In Network) Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.50 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $40.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $15.00 Co-pay for Specialist $40.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 Routine Podiatry Service Co-pay per visit for exams and treatment $40.00 Co-pay per visit for routine foot care Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 to $264.00 or 20% Outpatient Services Co-pay at outpatient hospital facility $264.00 Co-pay at ambulatory surgical center $239.00 Prescription Drugs Not Covered Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies $0.00 to 20% Co-pay per piece of equipment 15% Co-pay per prosthetic device 15% Vision Services Vision exams, lenses, glasses Plan pays up to $40.00 Hearing Services Co-pay for Medicare covered hearing exam $40.00 Co-pay for routine annual hearing No coverage Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available

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Humana Choice Regional PPO (MA) Prescription Drug Coverage, Pharmacy and Hospital Network




This plan does not cover Part D drugs

Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Not applicable Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix

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Humana Gold Choice (PFFS) Plan Number H8145-103 STAR RATING = N/A

Humana Insurance 1-800-833-2364

humana-medicare.com Out-of-Network Services; contact plan for out-of-network costs Up to 50% Additional Monthly Premium for this plan $190.00 (LIS $159.90) Maximum out-of-pocket limit $6,700.00 Inpatient Hospital See reverse side for network hospitals Co-pay per day for days 1 – 5 $275.00 Co-pay per day for days 6 – 90 $0.00 Skilled Nursing Facility Co-pay per day for days 1 – 20 $0.00 Co-pay per day for days 21 – 100 $167.50 Mental Health Outpatient Visits Co-pay per visit $40.00 Emergency/Urgent Care Co-pay per hospital emergency room visit $80.00 Co-pay per visit for urgent care $45.00 Foreign Travel Emergency Coverage Check with plan Ambulance Services Co-pay per trip $265.00 Physician Services Co-pay for Primary Care Physician $20.00 Co-pay for Specialist $45.00 Rehabilitation Services - Physical, Occupational, Speech Therapy Co-pay per visit $40.00 - $45.00 Routine Podiatry Service Co-pay per visit for exams and treatment $45.00 Co-pay per visit for routine foot care Not covered Chiropractic Care Co-pay per visit – Limited services $20.00 Diagnostic Tests, X-Rays, and Lab Services Clinical/diagnostic lab service $0.00 - $250.00 or 20 - 25% Outpatient Services Co-pay at outpatient hospital facility $250.00 Co-pay at ambulatory surgical center $225.00 Prescription Drugs See reverse Home Health Care Co-pay per visit $0.00 Durable Medical Equipment (DME) Co-pay per item for Diabetic supplies 0% to 20% Co-pay per piece of equipment 20% Co-pay per prosthetic device 20% Vision Services Vision exams, lenses, glasses Plan pays up to $130.00 Hearing Services Co-pay for Medicare covered hearing exam $45.00 Co-pay for routine annual hearing exam No coverage Hearing aid appliance No coverage Transportation No coverage Dental Optional plan available

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Humana Gold Choice (PFFS) Prescription Drug Coverage, Pharmacy and Hospital Network





Preferred pharmacies: If your plan's network includes preferred cost sharing pharmacies, you may save money by using them. Your prescription drug costs (such as a copayment or coinsurance) may be less at a preferred cost sharing pharmacy because it has agreed with your plan to charge less on at least some drugs. Bashas Costco CVS Frys Osco Safeway Sams Walmart Walgreens Albertson’s Hospitals: Abrazo Dignity Health Banner West Campus (Goodyear) Arizona General Baywood Central Campus Chandler Regional Boswell Maryvale Mercy Gilbert Del Webb Phoenix (PV-Bell) St Joseph’s Desert Arrowhead St Joseph’s Westgate Estrella Gateway Honor Health St Luke’s Goldfield (Apache Junction) Scottsdale Healthcare Osborn Tempe University Medical Center Scottsdale Healthcare Shea Phoenix Ironwood Scottsdale Healthcare Thompson Peak Thunderbird John C Lincoln Deer Valley John C Lincoln Phoenix Programs/Benefits Assistance/Medicare Advantage/2017 Advantage Plans/2017 HMO PPO PFFS rev 10/5/2017

Area Agency On Aging - 2018 Medicare Advantage Plans · 2017-10-17 · A program of the Area Agency...

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Transcript of Area Agency On Aging - 2018 Medicare Advantage Plans · 2017-10-17 · A program of the Area Agency...