Aultimate

Disclaimers:

  • PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal.
  • This information is not a complete description of benefits. Contact the plan for more information.
  • Limitations, co-payments, and restrictions may apply.
  • Benefits, 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.
  • The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

2016 PrimeTime Health Plan Aultimate (HMO-POS)

With PrimeTime Health Plan Aultimate (HMO-POS) there are no deductibles to pay. Instead, your cost-sharing consists of co-payments or co-insurances for the services that you receive.

Eligibility Requirements:
You are eligible for membership in our plan as long as:

  • You live in our service area
    (Carroll, Columbiana, Harrison, Holmes, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas, and Wayne Counties)
  • --and-- you have both Medicare Part A and Medicare Part B
    (When you enroll in a Medicare Advantage Plan, you continue to pay your Medicare Part B premium.)
  • --and--you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.
PrimeTime Health Plan Aultimate (HMO-POS)
Plan Premium$0 per month*
Primary Care Physician $35 copay for each Medicare-covered primary care doctor visit
Specialist $45 copay for each Medicare-covered specialist visit
Urgent Care (Inside United States) $45 copay for Medicare-covered urgently-needed-care visits
Urgent Care (Outside United States) $75 copay for Medicare-covered urgently-needed-care visits
Emergency Care (Worldwide Coverage) $75 copay for Medicare-covered emergency room visits
Inpatient Hospital Coverage $295 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
Outpatient Surgery (Ambulatory/Outpatient Surgery) 25% of the cost for each Medicare-covered surgical visit
Home Health Care $0 copay for each Medicare-covered home health visit
Ambulance Services $230 copay for Medicare-covered ambulance benefits
Durable Medical Equipment 20% of the cost for Medicare-covered durable medical equipment
Diabetes Supplies 20% of the cost for Medicare-covered diabetic supplies
General Diagnostic Tests and Radiology Services $75 copay for Medicare-covered general diagnostic tests and radiology services (not including x-rays)
Complex Diagnostic Radiology Services (MRI/CT/PET/Thallium Scans) $200 copay for Medicare-covered complex diagnostic radiology services (not including X-rays)
X-rays $50 copay for Medicare-covered X-ray services
Lab $45 copay for Medicare-covered lab services
Radiation Therapy 20% of the cost for Medicare-covered therapeutic radiology services
Part B Prescription and Chemotherapy Drugs 20% of the cost for Medicare-covered Part B prescription and chemotherapy drugs
Part D Prescription Drug Coverage No Deductible

Initial Coverage Limit (up to $3,310 total drug cost):
  • Tier 1: Preferred Generic - $3 copay / 30 day supply
  • Tier 2: Generic - $15 copay / 30 day supply
  • Tier 3: Preferred Brand - $45 copay / 30 day supply
  • Tier 4: Non-Preferred Brand - $95 copay / 30 day supply
  • Tier 5: Specialty – 33% co-insurance of the total drug cost
60-day and 90-day supplies are also available. Contact the plan for details.

Coverage Gap:

After your total yearly drug costs reach $3,310, you receive limited coverage by the plan on certain drugs. You will receive a discount on brand name drugs and generally pay no more than 45% of the plan’s costs for covered brand name drugs and 58% of the plan’s cost for covered generic drugs until your yearly out-of-pocket drug costs reach $4,850.

Catastrophic Coverage

After your yearly out-of-pocket costs reach $4,850, you pay the greater of:
  • 5% coinsurance, or
  • $2.95 copay for generic and a $7.40 copay for all other drugs
Preventive Services $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
Silver&Fit Exercise & Healthy Aging Program Offers members access to participating fitness facilities and instructor led classes. Alternatively, members have the option to receive up to 2 Home Fitness Kits per year. Members may also choose to receive health information, track their fitness activity, participate in health challenges, and earn rewards.
Routine Vision Up to $50 coverage annually for glasses (frames and lenses) or contacts
Out of Pocket Maximum (per calendar year) $4,200
For coverage details and additional co-payments/co-insurance please see the Summary of Benefits. Conditions and limitations may apply.

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.

You must receive your care from a network provider.

In most cases, care you receive from an out-of-network provider (a provider who is not part of plan’s network) will not be covered. There are four exceptions:

  • The plan covers emergency care or urgently needed services that you get from an out-of-network provider.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider with our prior approval. In this situation with our approval, you will pay the same as you would pay if you got the care from a network provider.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
  • Our Plan offers a Point of Service (POS) option for services associated with glasses or contacts. For glasses or contacts you may see a qualified provider of your choice.

*The late enrollment penalty is an amount that is added to your Part D premium. You may owe a monthly late enrollment penalty if at any time after your initial enrollment period is over, there is a period of 63 or more days in a row when you don’t have Part D or other creditable prescription drug coverage. If you get "Extra Help" you do not pay a late enrollment penalty.

Last updated: 10/1/2015