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How Much You Pay 2015 

2015 Member Cost-Sharing and Benefit Limits

BenefitsCentral Health Medicare Plan (HMO)Central Health Medicare Plan (HMO SNP)Central Health Premier Plan (HMO)Central Health Focus Plan (HMO)
Medicare onlyMedicare and Full Medi-Cal
EligibilityMedicare Part A and Part BMedicare Part A and Part B
Medi-Cal (Medicaid)
Medicare Part A and Part BMedicare Part A and Part BMedicare Part A and Part B
Diabetes Mellitus
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
Los Angeles County
Partial Orange County
Partial San Bernardino County
Los Angeles County
Partial Orange County
Partial San Bernardino County
Plan Premium$0$0*$28.80*$0*$0
Deductible$0$0$147$0$0
Out-of-Pocket Limit$3,400$0$6,700 $3,400
Hospital Stays$0$0Days 1-60: $1,260 deductible
Days 61-90: $315 coinsurance per day
Days 91-150: $630 coinsurance per lifetime reserve days
$0$0
Skilled Nursing Facility (SNF)Days 1–20: $0/day
Days 21–65: $75/day
Days 66–100: $0/day
$0Days 1–20: $0 for each benefit period
Days 21–100: $157.50 coinsurance per day
$0Days 1–20: $0/day
Days 21–65: $75/day
Days 66–100: $0/day
Doctor Office Visits$0$020%$0$0
Annual Wellness Exam$0$0$0$0$0
Chiropractic Services$0$0$0$0$0
Podiatry Services$0$0$0$0$0
Diagnostic Tests, X-Rays, Lab Services$0$020%$0$0
Outpatient Surgery$0$020%$0$0
Durable Medical Equipment (DME)0%-20%$020%$00%-20%
Diabetic Supplies$0$020%$0$0
Ambulance$50$020%$0$50
Emergency Room$50$020%$0$50
Urgent Care$0$020%$0$0

2015 Prescription Drug Benefits

Coverage StageCentral Health Medicare Plan (HMO)Central Health Medicare Plan (HMO SNP)Central Health Premier Plan (HMO)Central Health Focus Plan (HMO)
Without LISWith LIS
Deductible Stage$0$0$320 for Tiers 3-5$0$0
Initial
Coverage
Stage
Tier 1$0$0$0$0$0
Tier 2$5$5
Tier 3$25$0, $3.60, or $6.60 based on LIS level25% $0, $3.60, or $6.60 based on LIS level$25
Tier 4$50$50
Tier 533% coinsurance$0, $1.20, $2.65, $3.60 or $6.60 based on LIS level$0, $1.20, $2.65, $3.60 or $6.60 based on LIS level33% coinsurance
Tier 6$10$0, $3.60 or $6.60 based on LIS level15%$0, $3.60 or $6.60 based on LIS level$0
Coverage
Gap
Stage
Coverage BeginsAfter total drug costs reaches $2,960, the coverage gap stage begins
Tier 1$0$0$0$0$0
Tier 2$50, $1.20, $2.65 based on LIS level$5
Tier 3Generally no more than 45% of the plan’s costs for brand name drugs and no more than 65% of the plan’s costs for generic drugs$0, $3.60, or $6.60 based on LIS levelGenerally no more than 45% of the plan’s costs for brand name drugs and no more than 65% of the plan’s costs for generic drugs$0, $3.60, or $6.60 based on LIS levelGenerally no more than 45% of the plan’s costs for brand name drugs and no more than 65% of the plan’s costs for generic drugs
Tier 4
Tier 5$0, $1.20, $2.65, $3.60 or $6.60 based on LIS level$0, $1.20, $2.65, $3.60 or $6.60 based on LIS level
Tier 6$0, $3.60 or $6.60 based on LIS level$0, $3.60 or $6.60 based on LIS level$0
Catastrophic
Coverage
Stage
Coverage BeginsAfter yearly out-of-pocket drug costs reaches $4,700, the catastrophic coverage stage begins
Tier 1Generic: $2.65 copay or 5% coinsurance, whichever is greater$0 based on LISGeneric: $2.65 copay or 5% coinsurance, whichever is greater$0 based on LISGeneric: $2.65 copay or 5% coinsurance, whichever is greater
Tier 2
Tier 3
Tier 4Brand: $6.60 copay or 5% coinsurance, whichever is greaterBrand: $6.60 copay or 5% coinsurance, whichever is greaterBrand: $6.60 copay or 5% coinsurance, whichever is greater
Tier 5
Tier 6

* If you receive Extra Help for Drugs, the Extra Help for Drugs program will pay all or part of your monthly plan premium ($28.80)

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.

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, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.

Central Health Medi-Medi Plan (HMO SNP) is available to anyone who has both medical Assistance from the State and Medicare.

Central Health Focus Plan (HMO SNP) is available to anyone who has been diagnosed with Diabetes Mellitus.

Central Health Medi-Medi (HMO SNP) and Central Health Focus Plan (HMO SNP) have been approved by the National Committee for Quality Assuarnace (NCQA) to operate as a Special Needs Plan (SNP) until 2017 based on a review of Central Health Medi-Medi Plan's and Central Health Focus Plan's Model of Care.

Central Health Medicare Plan is an HMO plan with a Medicare contract. Enrollment in Central Health Medicare Plan depends on contract renewal.

This information is available for free in other languages. Please call 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 es disponible gratuitamente en otros lenguajes. Favor de ponerse en contacto con nuestro numero de servicio al cliente al 1-866-314-2427, TTY/TDD 1-888-205-7671, los 7 días a la semana, 8:00 AM a 8:00 PM (Tiempo Pacífico).