2013 Member Cost-Sharing and Benefit Limits
| Benefits | Central Health Medicare Plan (HMO) | Central Health Medicare Plan (HMO SNP) |
| Monthly Plan Premium | $0 | $29.90*
*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) | $6,700 limit | $6,700 limit |
| 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, $1.15, or $2.65 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, $1.15, or $2.65 copay
Depending on income and institutional status |
Tier 3
Preferred Brand Drugs | $25 copay 30-day supply
($50 copay 90-day mail order) | $0, $3.50, or $6.60 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, $3.50, or $6.60 copay
Depending on income and institutional status |
Tier 5
Specialty Brand Drugs | 33% coinsurance | $0, $3.50, or $6.60 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 | $2.65 copay for generic and $6.60 copay for all other drugs, or 5% coinsurance | $0 copay |
| Dental Benefit | $0 copay:
· oral exams
· 2 cleanings every year
· 2 fluoride treatments every year
· 1 dental x-ray every 6 months
Plan offers additional comprehensive dental benefits. | $0 copay:
· oral exams
· 2 cleanings every year
· 2 fluoride treatments every year
· 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
$2,000 allowance every year |
| Eye Glasses | $0 copay exam
$75 allowance every year | $0 copay exam
$300 allowance every year |
| Over-the-Counter Items | Not covered | $32 allowance every month |
| Select Benzodiazepines and Erectile Dysfunction Agents | Not covered | $300 allowance every year |
| Routine Transportation | Not covered | $0 copay
40 one-way trips to plan-approved locations every year |
| Acupuncture | Not covered | $0 copay
Up to 24 visits every year |
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). .