How Much You Pay

2012 Member Cost-Sharing and Benefit Limits

Benefits	Central Health Medicare Plan (HMO)	Central Health Medicare Plan (HMO SNP)
Monthly Plan Premium	$0	$30.86* *Paid on your behalf by Medicare’s “Extra Help” program.
Yearly Plan Deductible	No deductible	No deductible
Maximum Out-of-Pocket (Part A + Part B)	$3,400 limit	Not applicable
Primary Care Physician Visit	$0 copay	$0 copay
Specialty Care Physician Visit	$0 copay	$0 copay
Inpatient Hospital Care	$0 copay Unlimited days	$0 copay Unlimited days
Chiropractic Services	$0 copay	$0 copay
Podiatry	$0 copay	$0 copay
Outpatient Services / Surgery	$0 copay	$0 copay
Ambulance Services	$50 copay	$0 copay
Emergency Care	$65 copay Waived if admitted to hospital	$0 copay
Worldwide Emergency Coverage	$50,000 limit per year Urgent & Emergent Services only	$50,000 limit per year Urgent & Emergent Services only
Urgently Needed Care	$0 copay	$0 copay
Diagnostic Lab Services	$0 copay	$0 copay
Diagnostic X-Rays	$0 copay	$0 copay
Part D Prescription Drugs Initial Coverage Stage
Tier 1 Preferred Generic Drugs	$0 copay 30-day supply ($0 copay 90-day mail order)	$0, $1.10, or $2.60 copay Depending on income and institutional status
Tier 2 Non-Preferred Generic Drugs	$5 copay 30-day supply ($10 copay 90-day mail order)	$0, $1.10, or $2.60 copay Depending on income and institutional status
Tier 3 Preferred Brand Drugs	$25 copay 30-day supply ($50 copay 90-day mail order)	$0, $3.30, or $6.50 copay Depending on income and institutional status
Tier 4 Non-Preferred Brand Drugs	$50 copay 30-day supply ($100 copay 90-day mail order)	$0, $3.30, or $6.50 copay Depending on income and institutional status
Tier 5 Specialty Brand Drugs	33% coinsurance	$0, $3.30, or $6.50 copay Depending on income and institutional status
Part D Prescription Drugs Coverage Gap Stage	Tier 1 Preferred Generics Tier 2 Non-Preferred Generics	Same as Initial Coverage Stage
Part D Prescription Drugs Catastrophic Coverage Stage	$2.60 copay for generic and $6.50 copay for all other drugs, or 5% coinsurance	$0 copay
Dental Benefit	$0 copay: · 1 oral exam every 6 months · 1 cleaning every 6 months · 1 fluoride treatment every 6 months · 1 dental x-ray every 6 months Plan offers additional comprehensive dental benefits.	$0 copay: · 1 oral exam every 6 months · 1 cleaning every 6 months · 1 fluoride treatment every 6 months · 1 dental x-ray every 6 months Plan offers additional comprehensive dental benefits.
Hearing Aid	$0 copay exam $500 allowance every year	$0 copay exam $1,000 allowance every year
Eye Glasses	$0 copay exam $300 allowance every year	$0 copay exam $300 allowance every year
Over-the-Counter Items	$8 allowance every month	$25 allowance every month
Select Benzodiazepines and Erectile Dysfunction Agents	$150 allowance every year	$150 allowance every year
Routine Transportation	Not covered	$0 copay 40 one-way trips to plan-approved locations every year
Acupuncture	$10 copay Up to 6 visits every year	$0 copay Up to 24 visits every year

Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1, 2013. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact the plan.

You must have Part A and Part B to enroll in the plan. You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply.

You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis or other services. If you obtain routine care from out-of-network providers neither Medicare nor Central Health Medicare Plan will be responsible for the costs.

Premiums, co-pays, and co-insurance may vary based on the level of Extra Help you receive. For more information contact the plan.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or Your State Medicaid Office.

People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048.