San Francisco HICAP- Part D Intake 407 Sansome Street, 4th Floor
San Francisco, CA 94111 415-677-7520 (Phone) 415-296-0313 (Fax)
Name _______________________________________________________________________________
Address _____________________________________________________________________________
Phone Number ___________________ Language __________________ Male Female
Marital status
Single Married Divorced Separated Widowed
Medicare Claim # __________________________ Date of Birth __________________
Part A Effective Date ___________________ OR Part B Effective Date ___________________
HICAP Disclosure statement Please check box after reading
HICAP counseling services are provided by Counselors registered by the California Department of Aging who are acting in good faith to provide information about health insurance policies and benefits to you, the client. Any information shall not be construed to be legal advice, and the volunteer HICAP Counselor is generally not liable for acts and omissions in providing counseling to recipients of this service. (W&I Code, Section 9541(f).) If you choose a plan and have difficulty in completing the necessary forms or process for enrollment, the HICAP Counselor will assist you. However, you will be responsible for the actual plan contract. The HICAP Counselor will NOT choose your plan for you.
I do not have Part A.
Current Medicare Coverage (Check all that apply)
Medi-Cal Medi-Cal with Share of Cost Veterans Benefits
Original Medicare Medigap
Part D Medicare Advantage Plan (HMO/ PPO) You may qualify for Extra Help for Part D. Please ask HICAP if your monthly income is
Less than $1,369/month and have assets less than $13,070 (single) Less than $1,891/month and have assets less than $26,120 (married)
Enter your Prescription Drugs.
You may attach a drug list print-out from your pharmacy.
Generic alternatives may save money.
Drug Name Dosage (e.g. ml, mg)
Frequency (e.g. twice daily)
Monthly supply (e.g. 30, 60, 90)
Is there a pharmacy you prefer to use? No
Yes (if yes, please provide the name and address of your preferred pharmacy)
2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222
or 1-800-Medicare
Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov
Monthly Low Drug Plan
Organization Name Plan Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality
Enrollment Telephone Number Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating
Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan
Aetna Medicare Rx Plans CVS Pharmacy Plan $28.60 $325 $2 $5 $45 47% 25% No Yes Yes 3.5
800-832-2640 aetnamedicare.com Premier Plan $118.40 $0 $5 $33 $45 49% 33%Many Generics
Some BrandsYes 3.5
Anthem Blue Cross Standard $41.30 $325 $2 $6 $39 $85 25% No Yes 3.0
800-261-8667 Plus $76.80 $0 $2 $7 $45 $90 $95 / 33% Few Generics Yes 3.0
anthem.com/ca/medicare Gold $113.00 $0 $2 $7 $45 $90 $95 / 33%Many Generic
Some BrandsYes 3.0
Blue Shield Basic $53.40 $325 $4 $37 $76 25% 25% No Yes 4.0
800-488-8000 blueshieldca.com Enhanced $72.50 $0 $5 $45 $90 25% 33% No Yes 4.0
Cigna
800-735-1459 cignamedicarerx.com
Envision Silver Plan $29.10 $325 25% 25% 23% 28% 25% No No Yes 3.0
800-250-2005 envisionrxplus.com Gold Plan $54.00 $150 $2 or 1% $5 or 1% $25 or 1% 30% 29% Some Generics Yes 3.0
Express Scripts Value $61.00 $325 $4 $6 25% 27%-50% 25% No Yes 4.0
866-477-5704 express-scriptsmedicare.com Choice $91.60 $200 $8 $45 $95 28% 28% Many Generics Yes 4.0
First Health Value Plus $24.20 $0 $0 $35 $70 33% 33% No Yes 3.0
877-815-8163 Premier $47.90 $325 $1 $25 43% N/A N/A No Yes 3.0
myfirsthealthpland.com Premier Plus $102.40 $0 $0 $20 25% 43% 33%Some Generics
Some BrandsYes 3.5
HealthMarkets Medicare888-625-5531 hmic-medicare.com
Health Spring877-357-1685 myhealthspring.com
Humana Wal Mart Plan $18.50 $325 $1 $3 20% 35% 25% No Yes Yes 3.5
800-706-0872 Enhancd $47.50 $0 $2 $5 $44 $90 33% No Yes 3.5
humana-medicare.com Complete $118.60 $0 $5 $37 $69 $33 33%Some Generics
Some BrandsYes 3.5
Yes 3.0No
Yes 2.5
No Yes new
No
$70 25%
$37 27% N/A
$28
25%Health Spring Drug Plan 46.90 $325 25% 25%
$325 $1 $2.50
Plan One 55.80 $325 $0 $8
25% 25%
Reader's Digest Value Plan $32.30
Rev.10/15/2012 Information subject to change.Contact plans to verify information. Tier 1 = Preferred GenericsTier 2 = Non Preferred GenericsTier 3 = Preferred BrandsTiers 4 = Non Preferred Brands Tier 5 = Specialty Drugs
2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222
or 1-800-Medicare
Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov
Monthly Low Drug Plan
Organization Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality
Enrollment Telephone Number Plan Name Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating
Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan
Silver Script Basic $30.60 $325 $2 21% 43% 25% N/A No Yes Yes 3.0
866-552-6106 Choice $29.10 $0 $0 $34 35% 33% N/A No Yes 3.0
silverscript.com Plus $113.10 $0 $0 $34 35% 33% N/AMany Generics
Some BrandsYes 3.0
Smart Rx Saver $31.40 $325 $0 $20 $32 $85 25% No Yes Yes new
855-976-2781 smartdrx.com Plus $73.00 $0 $0 $20 $32 $85 25% Some Generics Yes new
United American Select $36.50 $325 $1 $4 $37 $95 25% No Yes 3.5
866-524-4169 uamedicarepartd.com Enhanced $60.80 $80 $1 $7 $40 $95 29% No Yes 3.5
United Health Care - AARP MedicareRx Saver Plus $15.00 $325 $1 $2 $25 $45 25% No Yes Yes 3.0
888-867-5575 MedicareRx Preferred $47.90 $0 $3 $5 $40 $85 33% No Yes 3.0
aarpmedicarerx.com MedicareRx Enhanced $98.00 $0 $2 $5 $40 $76 33%Some Generics
Some BrandsYes 3.0
Well Care Classic $33.00 $0 $6 $45 $95 33% 33% No Yes 3.0
888-293-5151 wellcarepdp.com Extra $49.00 0 $0 25% 25% 50% 33% Many Generics Yes 3.0
Logo Here :-)
Used by permission from Council of Aging Orange County
San Francisco 2013 Medicare Advantage PlansPage 1 of 2
Care1st Chinese Com. Health Plan Health Net of California Humana Humana Kaiser Permanente
Plan Name Care1st AdvantageOptimum Plan (H5928-026) HMO Senior Program (H0571-001) HMO Health Net Healthy Heart (H0562-009) HMO Humana Gold Plus (H0108-028) HMO Humana Gold Plus (H0108-027) HMO Senior Advantage (H0524-032) HMO
Monthly Premium $28, MOOP $3400 $40, MOOP $3400 $89, MOOP $6700 $32, MOOP $5000 $62, MOOP $3400 $76, MOOP $3400
Phone Number 1-800-847-1222 Prospective Members 1-888-775-7888 ext. 3282 Prospective Members 1-800-977-6738 Prospective Members 1-800-833-2364 Prospective Members 1-800-833-2364 Prospective Members 1-800-777-1238 Prospective Members
1-800-544-0088 Current Members 1-888-775-7888 Current Members 1-800-275-4737 Current Members 1-800-457-4708 Current Members 1-800-457-4708 Current Members 1-800-443-0815 Current Members
Web Site Address www.care1st.com/ca/ www.cchphmo.com www.healthnet.com www.humana-medicare.com www.humana-medicare.com www.kp.org/medicare
Network Provider Brown and Toland Chinese Community Health Plan Physicians Brown and Toland; Hill Physicians Kaiser Network
Network Hospital CPMC CPMC, Chinese Hospital, St. Francis, St. Mary's CPMC, UCSF, St. Francis, St. Mary's CPMC CMPC Kaiser Permanente
Physician Visit $0 primary care. $10 specialist. $15 primary care, specialist, urgent care. $10 primary care, specialist or in-network urgent care. $0 primary care. $10 specialist. $0 primary care. $5 specialist. $25 primary care. $25 specialist.
Inpatient Hospital $100/day for days 1-5; $0 for days 6-90 and beyond.
Unlimited days each benefit period. Except in an
emergency, your doctor must notify plan of admission.
$195-295/day for days 1-7;$0 for days 7-90 and
beyond. Unlimited days each benefit period. Except in
an emergency, your doctor must notify plan of
admission.
$320/day for days 1-5; $0 for days 6-90 and
beyond. Unlimited days each benefit period. Except in
an emergency, your doctor must notify plan of
admission.
$125/day for days 1-8; $0 for days 9-90 and beyond.
Unlimited days each benefit period. Except in an
emergency, your doctor must notify plan of admission.
$100/day for days 1-8; $0 for days 9-90 and beyond.
Unlimited days each benefit period. Except in an
emergency, your doctor must notify plan of admission.
$255/day for days 1-7; $0/day for days 8-90; $0 copay
for additional days. Except in emergency. Doctor must
tell the plan you are being admitted into a hospital.
Outpatient Surgery $20-$75 for each visit to outpatient surgical center.
$20-50 for each visit to outpatient hospital facility.
$195-295 for each visit to the surgical center or
outpatient hospital facility. Authorization rules may
apply.
$125 for each visit to outpatient surgical center.
$250 for each visit to outpatient hospital facility.
$150 for each visit to outpatient surgical center.
$10-$200 (or 20% of cost) for each visit to outpatient
hospital facility.
$50 for each visit to outpatient surgical center.
$5-$125 (or 20% of cost) for each visit to outpatient
hospital facility.
$250 for each outpatient surgical center visit.
$0-$250 for each visit to hospital facility.
Mental Health Inpatient : Days 1-8 $100/day; Days 9-90 $0/day,
except in an emergency, doctors must inform the plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$10; Partial hospitalized program $0.
Inpatient : Days 1-7 $250/day; Days 8-90 $0/day.
Additional days are $0 except, in emergency, doctor
must inform plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$25; Partial hospitalized program services $0.
Inpatient : Part of 190 lifetime days inpatient hospital
care; $900/day. In an emergency, doctor must inform
plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$25; Partial hospitalized program $0.
Inpatient : Days 1-8 $125/day; Days 9-90 $0/day,
except in an emergency, doctors must inform the plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$10; Partial hospitalized program $25.
Inpatient : Days 1-8 $100/day; Days 9-90 $0/day,
except in an emergency, doctors must inform the plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without $5;
Partial hospitalized program $25.
Inpatient : Days 1-7 $255/day; Days 8-90 $0/day.
Additional days are $0, except in an emergency,
doctors must inform the plan.
Outpatient : Individual therapy w/ psychiatrist and
without $25. Group therapy w/ psychiatrist and without
$12; Partial hospitalized program services $0.
Ambulance Service $100; if admitted into the hospital you pay $0. $175 for Medicare-covered ambulance services.
Authorization rules may apply.
$275 for Medicare-covered ambulance services.
Authorization rules may apply.
$150 for Medicare-covered ambulance services.
Authorization rules may apply.
$150 for Medicare-covered ambulance services.
Authorization rules may apply.
$200 for Medicare-covered ambulance visit.
Emergency Care $50; $25,000 plan coverage limit for supplemental
emergency services outside the U.S. every year; if
immediately admitted into the hospital you pay $0.
$65; waived if admitted within 24 hours for the same
condition. Worldwide coverage.
$65; waived if admitted immediately. Worldwide
coverage. Annual $50,000 limit for emergency
services outside the U.S.
$65; if immediately admitted into the hospital you pay
$0. Worldwide coverage.
$65; if immediately admitted into the hospital you pay
$0. Worldwide coverage.
$65; if immediately admitted into the hospital you pay
$0. Worldwide coverage.
Diagnostic Test, X-
Ray & Lab Service
$0 for Medicare-covered x-rays, clinical/ diagnostic lab
tests and diagnostic radiology services. 10% for
Medicare-covered therapeutic radiology services.
$0 for x-rays, clinical/ diagnostic lab tests and
therapeutic radiology service. $0-100 for diagnostic
radiology services.
$0 for x-rays, lab services & diagnostic procedures &
tests. $60 for diagnostic & therapeutic radiology
services, not including x-ray.
$0-$10 for lab services & diagnostic procedures &
tests. $0-$125 (or 20% cost) for diagnostic, not
including x-ray services. $0-$10 (or 10% cost) for x-
rays. $10 (or 20% cost) copay for therapeutic
radiology services.
$0-$5 for lab services. $0-$10 for x-rays, diagnostic
procedures & tests. $0-$125 for diagnostic services,
not including x-rays. $5 (or 20% cost) copay for
therapeutic radiology services.
$0-$30 for lab services, diagnostic procedures and
tests. $30 for x-rays. $145 copay diagnostic radiology
services, not including x-ray.
Prescription Drugs
Copay
Tier 1: Preferred generic $0/ 30 day supply
Tier 2: Non-preferred generic $5/ 30 day supply
Tier 3: Preferred generic $30 /30 day supply
Tier 4: Non-preferred generic $50 /30 day supply
Tier 5: Specialty 30% coinsurance /30 day supply
Tier 1: Generic $10 /30 day supply
Tier 2: Brand name $40 /30 day supply
Tier 3: Specialty 20% coinsurance /30 day supply
Tier 1: Preferred generic $3 /30 day supply
Tier 2: Non-preferred generic $12 /30 day supply
Tier 3: Preferred Brand $45 /30 day supply
Tier 4: Non-preferred brand $95 /30 day supply
Tier 5: 33% coinsurance /30 day supply
Tier 1: Preferred generic $5 /30 day supply
Tier 2: Non-Preferred generic $10 /30 day supply
Tier 3: Preferred brand $45 /30 day supply
Tier 4: Non-Preferred brand $45 /30 day supply
Tier 5: Specialty Tier 33% coinsurance /30 day supply
Tier 1: Preferred Generic $0/ 30 day supply
Tier 2: Non-Preferred generic $10 /30 day supply
Tier 3: Preferred brand $45 /30 day supply
Tier 4: Non-preferred brand $95 /30 day supply
Tier 5: Specialty Tier 33% coinsurance /30 day supply
Tier 1: Preferred generic $5 /30 day supply
Tier 2: Generic $10 /30 day-supply
Tier 3: Preferred brand name $45 /30 day supply
Tier 4: Non-Preferred brand name $65 /30 day supply
Tier 5: 25% coinsurance /30 day supply
Tier 6: Injectable Part D vaccines /no charge
Dental $0 copay for 1 cleaning every six months and 1 dental
x-ray every 2 years. $0-$570 copay for Medicare-
covered dental benefits. $5 copay for 1 fluoride
treatment a year.
Optional Supplemental Package: $14.60 monthly
premium includes preventive and comprehensive
dental.
3 Optional Supplemental Packages: $10-$28 monthly
premium includes eye exam, eye wear, preventative
dental, comprehensive dental.
3 Optional Supplemental Packages: $10-$28 monthly
premium includes eye exam, eye wear, preventative
dental, comprehensive dental.
Vision $0 copay for 1 pair of Medicare-covered eyeglasses or
contact lenses after cataract surgery. $0 copay for
Medicare-covered eye exams to look at eye condition.
$5 copay for up to 1 supplemental routine eye exams
every year.
No additional rider. 3 Optional Supplemental Packages: $10-$28 monthly
premium includes eye exam, eye wear, preventative
dental, comprehensive dental.
3 Optional Supplemental Packages: $10-$28 monthly
premium includes eye exam, eye wear, preventative
dental, comprehensive dental.
Two Optional Supplemental Packages:
$19 or $29 monthly premium includes preventive and
comprehensive dental, chiropractic, acupuncture, eye
wear, and education and wellness programs.
Optional Supplemental Package:
Advantage Plus - $20 monthly premium
includes preventive and comprehensive
dental, eye wear, and hearing aids.
For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012
San Francisco 2013 Medicare Advantage PlansPage 2 of 2
SCAN Health Plan SCAN Health Plan United Healthcare Health Net of California Anthem Blue Cross
Plan Name Plus (H5425-041) HMO Classic (H5425-019) HMO AARP Medicare Complete (H0543-085) HMO Health Net Seniority Plus Green (H0562-045) HMO Anthem Medicare Preferred Standard (H8522-008-0) PPO
Monthly Premium $27.50, MOOP $3000 $49, MOOP $3400 $0, MOOP $6700 **NO Part D. $99, MOOP $3400 $85, MOOP $3800
Phone Number 1-800-915-7226 Prospective Members 1-800-915-7226 Prospective Members 1-800-547-5514 Prospective Members 1-800-977-6738 Prospective Members 1-800-797-96439 Prospective Members
1-800-559-3500 Current Members 1-800-559-3500 Current Members 1-800-950-9355 Current Members 1-800-275-4737 Current Members 1-877-811-3107 Current Members
Web Site Address www.scanhealthplan.com www.scanhealthplan.com www.aarpmedicareplans.com www.healthnet.com www.anthem.com/ca/medicare
Network Provider Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Lower copayments for in-network providers than for out-of-network providers. You may go to any doctor,
specialist or hospital out-of-network.
Network Hospital CPMC, St. Francis, St. Mary's CPMC, St. Francis, St. Mary's CPMC, St. Mary's, UCSF, UCSF Cancer Center CPMC, UCSF, St. Francis, St. Mary's
Physician Visit 20% of the cost for each Medicare-covered primary
care visit, specialist visit, urgent care.
$5 primary care. $10 specialist. $5 primary care. $10 specialist. $10 primary care or specialist. In-Network : $15 primary care. $45 for specialist.
Out-of-Network : $35 primary care. $55 for specialist.
Inpatient Hospital 1-90 days covered each benefit period. Will not be
charged additional sharing for professional services. In
an emergency, doctor must tell plan you will be
admitted into the hospital.
$125 for days 1-8; $0 for days 9-90 . $0 copay for
additional days, except in emergency. Doctor must tell
the plan you are being admitted into a hospital.
$395/day for days 1-4. $0 for days 5-90. Unlimited
days each benefit period. Except in an emergency,
your doctor must notify plan of admission.
$275/day for days 1-7; $0 for days 8-90 and beyond.
Unlimited days each benefit period. Except in an
emergency, your doctor must notify plan of admission.
In-Network : $695 copay for each Medicare-covered stay.
Out-of-Network : 15% of the cost of each stay. Unlimited days each benefit period. Except in an
emergency, your doctor must authorize.
Outpatient Surgery 20% for each visit to outpatient surgical center or
outpatient hospital facility.
$175 for each visit to outpatient surgical center.
$200 for each visit to outpatient hospital facility.
20% for each visit to outpatient surgical center or
outpatient hospital facility.
$125 for each visit to outpatient surgical center.
$275 for each visit to outpatient hospital facility.
In-Network : 15% of cost for each Medicare-covered ambulatory surgical center visit; $0- $45 copay (or
15% of the cost) for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply.
Out-of Network : 25% of cost for each ambulatory surgical center or outpatient hospital facility visit.
Mental Health Inpatient : Inpatient psychiatric services count toward
190-day lifetime inpatient psychiatric hospital care in a
lifetime.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
35% of cost. Partial hospitalized program services
20% of cost.
Inpatient : Days 1-8 $125/day; Days 9-90 $0/day.
Additional days are $0 except in an emergency,
doctors must inform plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$25. Partial hospitalized program services $25.
Inpatient : Days 1-7 $255/day; Days 8-90 $0/day;
Additional days are $0; except in emergency, doctor
must inform plan.
Outpatient : Individual therapy w/ psychiatrist & without
$25. Group Therapy w/ psychiatrist and without $12;
Partial hospitalized Medicare program services $60.
Inpatient : Part of 190 lifetime days inpatient hospital
care; $900/day; in an emergency, doctor must inform
plan.
Outpatient : Individual therapy w/ psychiatrist and
without & group therapy w/ psychiatrist and without
$25; Partial hospitalized program $0.
Inpatient: In-Network: Up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count
toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services
furnished in a general hospital. $695 copay for each hospital stay. Except in an emergency, your doctor must tell the plan that you are
going to be admitted to the hospital.
Out-of-Network : 15% of the cost for each hospital stay.
Outpatient: In-Network : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $40.
Out-of-Network : 30% of the cost for Mental Health visits w/ psychiatrist and without. 30% of the cost for partial hospitalization program
services.
Ambulance Service 20% of Medicare-approved cost. $150 for Medicare-covered ambulance benefits. $200 for Medicare-covered ambulance service. $125 for Medicare-covered ambulance services.
Authorization rules may apply.
In- or Out-of-Network : $200 for Medicare-covered ambulance service. Authorization rules may apply.
Emergency Care 20% of the cost (up to $65). $65; if immediately admitted into the hospital you pay
$0.
$65; waive if admitted within 24 hours for same
condition. Worldwide coverage.
$50; waived if admitted immediately. Worldwide
coverage. Yearly $50,000 limit for emergency services
outside the U.S.
$65 for Medicare-covered ER visits; waived if admitted within 72 hours for same condition. Worldwide
coverage.
Diagnostic Test, X-
Ray & Lab Service
20% of cost for diagnostic tests, x-rays and lab
services.
$0 for lab services, diagnostic procedures and tests.
20% of costs for x-rays.
$13 for lab tests. $15 for x-rays. 20% for diagnostic
procedures & tests, including therapeutic radiology
services.
$0 for x-rays, lab services & diagnostic procedures &
tests. $60 for diagnostic, not including x-ray &
therapeutic radiology services.
In-network : $0 copay for Medicare-covered lab services. $65- $200 copay for Medicare-covered diagnostic
radiology services (not including x-rays). 20% of the cost for Medicare-covered therapeutic radiology services.
$0- $200 copay for Medicare-covere diagnostic procedures and tests. $65 copay for Medicare-covered x-rays.
Out-of-Network : 30% of the cost for Medicare-covered therapeutic radiology services, Medicare-covered
outpatient x-rays, Medicare-covered diagnostic radiology services, Medicare-covered diagnostic procedures,
tests, and lab services.
Prescription Drugs
Copay
Tier 1: Preferred Generic $0 /31 day supply
Tier 2: Non- Preferred Generic $0 /31 day supply
Tier 3: Preferred brand 25% of cost /31 day supply
Tier 4: Non- Preferred brand 25% of cost /31 day
supply
Tier 5: Specialty 25% coinsurance /31 day supply
Tier 6: Select Care $10 /31 day supply
Tier 1: Preferred generic drugs $5 /31 day supply
Tier 2: Non-Preferred generic drugs $10 /31 day
supply
Tier 3: Preferred brand drugs $45 /31 day supply
Tier 4: Non-Preferred brand drugs $75 /31 day supply
Tier 5: Specialty drugs 33% of cost /31 day supply
Tier 6: Select care drugs $10 /31 day supply
Tier 1: Preferred Generic $5 /31 day supply
Tier 2: Non-Preferred Generic $8 /31 day supply
Tier 3: Preferred brand $45 /31 day supply
Tier 4: Non-Preferred brand $95 /31 day supply
Tier 5: Specialty Tier 33% coinsurance /31 day supply
This plan does not offer prescription drug coverage.
Note: You cannot enroll in a Part D, in addition to this
plan.
20% of cost for Part B-covered drugs.
In-Network: $90 deductible on all drugs, except Tiers 1, 5, and 6.
Tier 1: Preferred Generic $4 /30 day supply
Tier 2: Non-preferred Generic $8 /30 day supply
Tier 3: Preferred Brand: $40 /30 day supply
Tier 4: Non-preferred Brand: $90 /30 day supply
Tier 5: Injectable Drugs: 33% coinsurance /30 day supply
Tier 6: Specialty: 33% coinsurance /30 day supply
20% of cost for Part B-covered drugs for in-network and out-of-network.
Dental Optional Supplemental Package: $15 monthly
premium in addition to the monthly plan premium.
Includes preventative dental.
Optional Supplemental Benefits:
#1: Basic Options- $8 monthly premium includes
preventive dental.
#2: High Option- $15 monthly premium includes
preventative dental.
2 Optional Supplemental Packages: $19 or $29
monthly premium includes preventive and
comprehensive dental, chiropractic, acupuncture, eye
wear, and education and wellness programs.
Vision No additional rider. 2 Optional Supplemental Packages: $19 or $29
monthly premium includes preventive and
comprehensive dental, chiropractic, acupuncture, eye
wear, and education and wellness programs.
Two Optional Supplemental Packages:
#1: Deluxe Rider- $37 monthly premium includes
preventive and comprehensive, dental, vision &
hearing aids.
#2: Dental 467 Rider- $15 monthly premium includes
preventive dental.
3 Optional Supplemental Packages:
#1: Preventive Dental - $12 monthly premium includes preventive dental.
#2: Comprehensive Dental & Vision - $31 monthly premium includes preventive and comprehensive dental,
eye exams, eye wear.
#3: Combination Package - $36 monthly premium includes preventive and comprehensive dental, eye
exams, eye wear, chiropractic, and acupuncture.
For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012
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