University Hospitals MA Red Plan by PTHP (HMO-POS)

Member Resources

2024 Medicare Plan Overview and Comparison

We believe that people choose University Hospitals Medicare Advantage Plan by PTHP because of our person-to-person service, affordability, and clinical care coordination team. Our members are like our family. Whether they call or stop by our offices, our team is always ready to talk with them and help them compare Medicare plans.

University Hospitals Medicare Advantage Plan by PTHP is available to Medicare-eligible individuals in the local communities we serve. Founded on the values of affordable pricing and service excellence. We serve Lake, Lorain and Cuyahoga counties.

Our Promise to You: When you call, someone will pick up. Your claims will be processed quickly. Your questions will be answered. And we’re always searching for the better way to do things for you and help you compare Medicare plans.

Learn more about our 5-Star Rating and Quality Recognition.

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2024 Enrollment Forms and Additional Information

Important Plan Documents

Important Pharmacy Documents

Summary of Benefits

Benefit category

University Hospitals MA Red Plan by PTHP (HMO-POS)

Plan Premium

$0 per month

Primary Care Physician

You pay a $5 copay for each Medicare-covered PCP visit.

Telehealth available

Specialist

$40 copay for each Medicare-covered specialist visit

Telehealth

Urgent Care (Inside United States)

$40 copay for Medicare-covered urgently-needed-care visits

Urgent Care (Outside United States)

$110 copay for Medicare-covered urgently-needed-care visits

Emergency Care (Worldwide Coverage)

$110 copay for Medicare-covered emergency room visits

Inpatient Hospital Coverage

$310 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays

Outpatient Surgery (Ambulatory/Outpatient Surgery)

$350 copay for each Medicare-covered surgical visit

Ambulance Services

$230 copay for Medicare-covered ambulance benefits

Durable Medical Equipment

20% of the cost for Medicare-covered durable medical equipment

Diabetic Testing Supplies (test strips, lancets, certain glucometers)

0% of cost for Medicare-covered diabetic testing supplies

Other Diabetic Supplies

20% of the cost for Medicare-covered supplies

Diagnostic Tests and Procedures

$100 copay for Medicare-covered general diagnostic tests (not including x-rays)

Diagnostic Radiology Services (MRI/CT/PET/Thallium Scans)

$190 copay for Medicare-covered complex diagnostic radiology services (not including X-rays)

Outpatient X-rays

$100 copay for Medicare-covered X-ray services

Lab Services

$0-$5 copay for Medicare-covered lab services.

Radiation Therapy

20% of the cost for Medicare-covered therapeutic radiology services

Part B Prescription and Chemotherapy Drugs

0%-20% of the cost for Medicare-covered Part B drugs

Preventive Services

$0 copay for all preventive services covered under Original Medicare at zero cost sharing.

Health & Wellness Education Programs

$0 copay for the programs below:

Tele-monitoring Services – Enrollees diagnosed with any of the conditions below may be eligible:
- Heart Failure
- Diabetes
- Chronic Obstructive Pulmonary Disease (COPD)
- Hypertension
Stroke Prevention Program – offered to members who have health conditions that put them at higher risk for stroke.
Behavioral Health Program - Provides support, education and resources for members with conditions such as depression, bipolar disorder, and substance use disorder.
In-Home Safety Assessment -evaluates your home for potential safety concerns. For example: proper lighting, fall hazards,and grab bars. The benefit is available in our service area with the plan's contracted network.
24 Hour Nursing Hotline 1-844-413-1194
The Silver&Fit® Exercise & Healthy Aging Program –offers members access to a fitness center membership at a participating fitness center or select YMCA at no additional cost.

Over-The-Counter (OTC) Benefit

Up to $50 per quarter on qualified OTC items. You will receive a debit card with funds deposited quarterly to spend on OTC items and the flexibility to use the debit card at over 55,000 approved retail locations or order via the app, phone or mail for delivery directly to your home.

Routine Vision

$0 copay annual routine exam

$300 allowance for non-Medicare covered eyewear

Routine Dental

$600 allowance for non-Medicare covered dental services

Amplifon Hearing Health Care Program (Hearing Aids)

You will pay $595 for a tier 1 hearing aid; $695 for a tier 2 hearing aid; $895 for a tier 3 hearing aid. If you purchase a higher tier hearing aid, your copay will be greater. Copays are per hearing aid. Contact Amplifon at 1-888-341-1629 to access these copayment rates.

Hearing aids purchased from non-Amplifon providers are eligible for reimbursement of $100 per hearing aid.

Learn more about Amplifon

Papa Pals Inc.

Papa Pals Program

$0 copay for up to 40 hours per year of help with Instrumental Activities of Daily Living provided by Papa Pals.

Out of Pocket Maximum (per calendar year)

$4,300

Part D Prescription Drug Coverage

Cost-sharing may change when you enter a new stage of the Part D benefit. For more information on the stages of the benefit, please contact the plan or view the Evidence of Coverage online at www.pthp.com/UH.

Phase 1: Deductible Stage: There is no deductible for this plan. You begin in the Initial Coverage Stage when you fill your first prescription of the year.

Phase 2: Initial Coverage Stage: The plan pays its share of the cost of your covered prescription drugs, and you pay your share (your copayment or coinsurance amount). Your share of the cost will vary depending on the drug and where you fill your prescription. You pay the following copays/coinsurance until your total yearly drug costs reach $5,030. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.

The below copays/coinsurance are for prescriptions purchased from network pharmacies. Costs will differ based on whether the prescriptions are filled at a preferred pharmacy, standard pharmacy, or mail-order pharmacy. Refer to your pharmacy directory for information on which pharmacies are preferred or standard. Cost will also differ based on the number of days’ supply. Long-Term Care (LTC) pharmacies can fill up to a 31-day supply at the 30-day copays/ coinsurance listed below.

Initial Coverage Limit (up to $5,030 total drug cost):

Preferred Pharmacy - Retail (up to a 90 day supply)	30 day	60 day	90 day
1 - Preferred Generic Drugs	$0 copay	$0 copay	$0 copay
2 - Generic Drugs	$15 copay	$30 copay	$45 copay
3 - Preferred Brand Drugs	$42 copay	$84 copay	$126 copay
Covered Insulins	$35 copay	$70 copay	$105 copay
4 - Non-preferred Drugs	$95 copay	$190 copay	$285 copay
5 - Specialty Drugs	33% of the cost	Not available	Not available

Standard Pharmacy - Retail (up to a 90 day supply)	30 day	60 day	90 day
1 - Preferred Generic Drugs	$10 copay	$20 copay	$30 copay
2 - Generic Drugs	$20 copay	$40 copay	$60 copay
3 - Preferred Brand Drugs	$47 copay	$94 copay	$141 copay
Covered Insulins	$35 copay	$70 copay	$105 copay
4 - Non-preferred Drugs	$100 copay	$200 copay	$300 copay
5 - Specialty Drugs	33% of the cost	Not available	Not available

Mail Order Pharmacy - Retail (up to a 90 day supply)	30 day	60 day	90 day
1 - Preferred Generic Drugs	$0 copay	$0 copay	$0 copay
2 - Generic Drugs	$15 copay	$30 copay	$45 copay
3 - Preferred Brand Drugs	$45 copay	$90 copay	$125 copay
Covered Insulins	$35 copay	$70 copay	$105 copay
4 - Non-preferred Drugs	$95 copay	$190 copay	$285 copay
5 - Specialty Drugs	33% of the cost	Not available	Not available

Coverage Gap: The Coverage Gap begins after the total yearly drug cost reaches $5,030. If you reach the coverage gap, for tier 1, tier 2 or covered insulins, you will continue to pay the same copay. For other drugs in tier 3, tier 4 or tier 5 the plan pays 75% of the price and you pay the remaining 25% of the price. Not everyone will enter the Coverage Gap.

Catastrophic Coverage:

You enter the Catastrophic Coverage Stage when your out-of-pocket costs have reached the $8,000 limit for the calendar year. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.

During this payment stage, the plan pays the full cost for your covered Part D drugs. You pay nothing.

This is not a complete description of benefits.

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 8 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 lab services, non-Medicare covered dental and vision services, hearing exams and hearing aids. For lab services, members may use the Medicare provider of their choice and services will be paid in-network. Molecular Diagnostics/Genetic testing requires prior authorization. For non-Medicare covered dental and vision services, members may use the provider of their choice and services will be reimbursed up to the plan annual maximum allowed. For hearing exams and/or hearing aids, you can use the provider of your choice, but you may have a higher out-of-pocket cost for hearing aids purchased from non-Amplifon providers.

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.

Learn More from Our Local Specialists.

We are here to help you.

Call us at 216-535-4014 | 1-833-954-0483 | (TTY 711)* from 8 a.m. to 8 p.m., Monday through Friday. Talk to a local specialist or schedule a 1-on-1 meeting to discuss your options.

Trisha

216-535-4014

Debbie

216-535-4014

Karen

216-535-4014