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How Much You Pay 2014 

2014 Member Cost-Sharing and Benefit Limits

BenefitsCentral Health Medicare Plan (HMO)Central Health Medicare Plan (HMO SNP)Central Health Premier Plan (HMO)
EligibilityMedicare Part A and Part BMedicare Part A and Part B
Medi-Cal (Medicaid)*
Medicare Part A and Part B
Service AreaLos Angeles County
Partial Orange County
Partial San Bernardino County
Los Angeles County
Partial San Bernardino County
Los Angeles County
Partial Orange County
Partial San Bernardino County
Plan Premium$0$0**$0**
Deductible$0$0$500*
*For some members, this may be paid for in full or in part by Medicaid or another third party
Out-of-Pocket Limit$3,400$0$6,700
Hospital Stays$0$02013 Amounts:
Days 1 - 60: $1,184 deductible*
Days 61 - 90: $296 per day*
Days 91 - 150: $592 per lifetime reserve day*
These amounts may change for 2014
*For some membe
Skilled Nursing Facility (SNF)Days 1–20: $0/day
Days 21–65: $75/day
Days 66–100: $0/day
$02013 Amounts:
Days 1–20: $0/day
Days 21–65: $148/day*
Days 66–100: $0/day
These amounts may change for 2014
*For some members, this may be paid for in full or in part by
Doctor Office Visits$0$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Annual Wellness Exam$0$0$0
Chiropractic Services$0$0$0
Podiatry Services$0$0$0
Diagnostic Tests, X-Rays, Lab Services$0$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Outpatient Surgery$0$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Durable Medical Equipment (DME)0% - 20%***$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Diabetic Supplies$0$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Ambulance$50$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Emergency Room$50$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.
Urgent Care$0$020%*
*For some members, this may be paid for in full or in part by Medicaid or another third party.

2014 Prescription Drug Benefits

Coverage StageCentral Health Medicare Plan (HMO)Central Health Medicare Plan (HMO SNP)Central Health Premier Plan (HMO)
Deductible StageCoverage Begins$0$0 with LIS or $310 for Tiers 3-5 without LIS $0 with LIS or $310 for Tiers 3-5 without LIS
Initial
Coverage
Stage
Tier 1$0$0$0
Tier 2$5
Tier 3$25$0, $3.60, or $6.35Based on LISor 25% coinsurance without LIS$0, $3.60, or $6.35Based on LISor 25% coinsurance without LIS
Tier 4$50
Tier 533% coinsurance
Coverage
Gap
Stage
Coverage BeginsAfter total drug costs reaches $2,850, the coverage gap stage begins
Tier 1$0$0$0
Tier 2$5$0, $1.20, or $2.55Based on LISor generally no more than 72% (of the plan’s costs for brand drugs) without LIS$0, $1.20, or $2.55Based on LISor generally no more than 72% (of the plan’s costs for generic drugs) without LIS
Tier 3Generally no more than 47.5% of the plan’s costs for brand name drugs and no more than 72% of the plan’s costs for generic drugs.$0, $3.60, or $6.35 based on LIS or generally no more than 47.5% of the plan’s costs for brand name drugs and no more than 72% of the plan’s costs for generic drugs without LIS.$0, $3.60, or $6.35 based on LIS or generally no more than 47.5% of the plan’s costs for brand name drugs and no more than 72% of the plan’s costs for generic drugs without LIS.
Tier 4Generally no more than 47.5% of the plan’s costs for brand name drugs and no more than 72% of the plan’s costs for generic drugs.
Tier 5Generally no more than 47.5% of the plan’s costs for brand name drugs and no more than 72% of the plan’s costs for generic drugs.
Catastrophic
Coverage
Stage
Coverage BeginsAfter yearly out-of-pocket drug costs reaches $4,550, the catastrophic coverage stage begins
Tier 1
Tier 2
$2.55 copay or 5% coinsurance, whichever is greater$0 with LISor $2.55 copay or 5% coinsurance whichever is greater, without LIS$0 with LISor $2.55 copay or 5% coinsurance whichever is greater, without LIS
Tier 3
Tier 4
Tier 5
$6.35 copay or 5% coinsurance, whichever is greater$0 with LISor $6.35 copay or 5% coinsurance whichever is greater, without LIS$0 with LISor $6.35 copay or 5% coinsurance, whichever is greater, without LIS

Central Health Medicare Plan (HMO) is a HMO plan with a Medicare contract. Central Health Medi-Medi Plan (HMO SNP) is a Coordinated Care plan with a Medicare contract and a contract with the California Medicaid program.


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


You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. .


This information is available for free in other languages. Please contact our customer service number at 1-866-314-2427, TTY/TDD 1-888-205-7671, 7 days a week, 8:00 AM to 8:00 PM (PT). .


Esta información está disponible gratuitamente en otros lenguajes. Favor de ponerse en contacto con nuestro número de servicio al cliente al 1-866-314-2427, TTY/TDD 1-888-205-7671, los 7 días de la semana, 8:00 AM a 8:00 PM (Tiempo Pacifico). .