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IMPORTANT INFORMATION
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Original Medicare
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2010
Senior Preferred EliteD
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Premium and Other Important Information
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You pay the Medicare Part B premium of $96.40 or $110.50 per month.
Most people will pay the standard monthly Part B premium. However, starting January 1, 2007, some people are required to pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information on Part B premiums based on income, call Social Security at (800) 772-1213. TTY users should call (800) 325-0778.
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You pay $113.60 each month for Senior Preferred EliteD benefits and no additional premium for your Medicare Part D prescription benefits.
You pay the Medicare Part B premium of $96.40 or $110.50 per month.
There is a $2,500.00 maximum out-of-pocket limit every year for Medicare covered services when received in-network only.
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Doctor and Hospital Choice
(For more information, see Emergency and Urgently Needed Care
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You may go to any doctor, specialist or hospital that accepts Medicare.
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You must go to network doctors, specialists, and hospitals. You do NOT need a referral to go to network doctors, specialists, and hospitals.
A separate doctor office visit copayment may apply for certain services.
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INPATIENT CARE
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Inpatient Hospital Care
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You pay for each benefit period (3):
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Days 1–60: an initial deductible of $1,100.
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Days 61–90: $275 each day.
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Days 91–150: $550 each lifetime reserve days (4)
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Day 151 and beyond: you are responsible for all costs.
Please call 1-800-MEDICARE
(1-800-633-4227) for information about lifetime reserve days.
(4)
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If you receive inpatient care at a non-plan hospital and choose not to return to the network after your emergency condition is stabilized, you may be responsible for payment.
There is no copayment for inpatient hospital services received at a network hospital.
You are covered for unlimited days each benefit period based on medical necessity.
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Inpatient Mental Health Care
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You pay the same deductible and copayments as inpatient hospital care (above) except Medicare beneficiaries may only receive 190 days in a Psychiatric Hospital in a lifetime.
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There is no copayment for services received at a network hospital based on medical necessity.
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Skilled Nursing Facility
Covered services include, but are not limited to, the following:
• Semiprivate room (or a private room if medically necessary).
• Meals, including special diets.
• Regular nursing services.
• Physical therapy, occupational therapy, and speech therapy.
• Drugs (This includes substances that are naturally present in the body, such as blood clotting factors).
• Blood - including storage and administration.
• Medical and surgical supplies.
• Laboratory tests.
• X-rays and other radiology services.
• Use of appliances such as wheelchairs.
• Physician services.
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You pay for each benefit period (3), following at least a 3-day covered hospital stay:
There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period. (3)
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You pay:
No prior hospital stay is required.
There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period based on medical necessity and skilled nursing needs.
Prior Authorization is required.
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Swing Bed
Facility charges and costs associated with an approved swing bed stay when meeting the following criteria:
• Your physician must certify your stay as medically necessary and daily skilled needs are identified;
• You must be confined and receive treatment for which you were hospitalized;
• Intensity and frequency of services requires 24-hour nursing intervention;
• Frequent or daily physician monitoring is needed;
• Services will likely be for a short term period and may not exceed seven days; and
• There is likely no further need for skilled nursing services post discharge.
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You pay for each benefit period (3), following at least a 3-day covered hospital stay:
- Days 1–20: $0 for each day.
- Days 21–100: $137.50 for each day.
There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period. (3)
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You pay:
No prior hospital stay is required.
There is a combined limit (Skilled Nursing Facility and Swing Bed) of 100 days for each benefit period based on medical necessity and skilled nursing needs.
Prior Authorization is required.
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Home Health Care
(Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)
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There is no copayment for all covered home health visits.
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There is no copayment for covered home health visits.
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Hospice Care
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You pay part of the cost for outpatient drugs and inpatient respite care.
You must receive care from a Medicare-certified hospice.
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When you enroll in a Medicare certified Hospice program, your hospice services are paid for by Medicare, not our Plan.
You pay $15 for the consultation service.
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DOCTOR SERVICES/ OUTPATIENT CARE
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Doctor Office Visits
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You pay 20% of Medicare-approved amounts. (1)(2)
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You pay $15 for each primary care physician office visit for covered services.
You pay $15 for each specialist visit for covered services.
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Chiropractic Services
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You pay 20% of Medicare-approved amounts. (1)(2)
You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers.
You pay 100% for routine care.
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You pay $15 for each covered visit.
There is no copayment for lab and x-ray.
Coverage does not include maintenance therapy.
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Podiatry Services
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You pay 20% of Medicare-approved amounts. (1)(2)
You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs.
You pay 100% for routine care.
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You pay $15 for each covered visit (medically necessary foot care).
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Outpatient Mental Health Care
(Including partial hospitalization services).
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You pay 50% of Medicare-approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. (1)(2)
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For covered Mental Health services, you pay $15 for each individual/group therapy visit.
There is no copayment for covered partial hospitalization services.
Coverage does not include maintenance or activity therapy.
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Outpatient Substance Abuse Services
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You pay 20% of Medicare-approved amounts. (1)(2)
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For covered services you pay $15 for each individual/group visit.
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Outpatient Services/Surgery
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You pay 20% of Medicare-approved amounts for the doctor.
(1)(2)
You pay 20% of outpatient facility charges. (1)(2)
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There is no copayment for each covered visit to an ambulatory surgical center.
There is no copayment for each covered visit to an outpatient hospital facility.
Prior authorization may be required.
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Ambulance Services
(Medically necessary ambulance services)
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You pay 20% of Medicare-approved amounts or applicable fee schedule charge. (1)(2)
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There is no copayment for covered ambulance services.
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Emergency Care
(You may go to any emergency room if you reasonably believe you need emergency care.)
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You pay 20% of the facility charge or applicable Copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. (1)(2)
You pay 20% of doctor charges.
(1)(2)
NOT covered outside the U.S. except under limited circumstances.
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You pay $50 for each covered emergency room visit; You do not pay this amount if you are admitted to the hospital within the next three days for the same condition.
* Worldwide Coverage
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Urgently Needed Care
(This is NOT emergency care, and in most cases, is out of the service area.)
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You pay 20% of Medicare-approved amounts or applicable Copayment. (1)(2)
NOT covered outside the U.S. except under limited circumstances.
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You pay $15 for each covered urgently needed care visit.
* Worldwide Coverage
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Outpatient Rehabilitation Services
(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Cardiac or Pulmonary Rehabilitation Therapy)
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You pay 20% of Medicare-approved amounts. (1)(2)
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You pay $15 daily for each covered Occupational, Physical and/or Speech/Language Therapy visit.
You pay $10 for each covered Cardiac or Pulmonary Rehabilitation Therapy visit.
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Durable Medical Equipment
(Includes Wheelchairs, oxygen, etc.)
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You pay 20% of Medicare-approved amounts (1)(2)
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You pay 10% of the cost for each covered item.
Prior Authorization is required for purchases and repairs over $1,000, and all rentals.
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Prosthetic Devices
(Include braces, artificial limbs and eyes, etc.)
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You pay 20% of Medicare-approved amounts. (1)(2)
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You pay 10% of the cost for each covered item.
Prior Authorization is required for purchases and repairs over $1,000, and all rentals.
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Diabetes Self-Monitoring, Training and Supplies
(Includes coverage for glucose monitors, test strips, lancets, screening tests and self-management training.)
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You pay 20% of Medicare-approved amounts. (1)(2)
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You pay $15 for covered Diabetes self-monitoring training.
You pay 5% of the cost for each covered Diabetic testing supply item. Non-preferred blood glucose monitors and blood glucose test strips require a Prior Authorization. If approved, you will pay 25% of the cost for each covered Diabetic supply item.
There is no copayment for covered diabetic screening tests.
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Medical Nutrition Therapy
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You pay 20% of Medicare approved amounts. (1)(2)
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You pay $15 for each covered Medical Nutrition Therapy visit.
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Diagnostic Tests, X-Rays and Lab Services
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You pay 20% of Medicare-approved amounts, except for approved lab services. (1)(2)
There is no copayment for Medicare-approved lab services.
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There is no copayment for covered services.
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PREVENTIVE CARE AND SCREENING TESTS
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Abdominal Aorta Ultrasound Screening
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You pay 20% of Medicare-approved amounts. (1)(2)
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There is no copayment for one screening Abdominal Aorta Ultrasound per lifetime.
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Bone-Mass Measurements
(For People with Medicare who are at risk.)
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You pay 20% of Medicare approved amounts. (1)(2)
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There is no copayment for each covered Bone Mass Measurement.
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Colorectal Screening
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You pay 20% of Medicare approved amounts. (1)(2)
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There is no copayment for covered colorectal screening exams.
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Immunizations
(Flu Vaccine, Hepatitis B Vaccine – for people with Medicare who are at risk, Pneumonia Vaccine).
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There is no copayment for the Pneumonia and Flu vaccines.
You pay 20% of Medicare-approved amounts for the Hepatitis B vaccine. (1)(2)
You may only need the Pneumonia vaccine once in your lifetime.
Please contact your doctor for further details.
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There is no copayment for the Pneumonia and Flu vaccines.
Flu and Pneumonia vaccines by any qualified practitioner are covered.
There is no copayment for the Hepatitis B vaccine.
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Mammography Screening
(Annual Screening)
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You pay 20% of Medicare-approved amounts. (2)
No referral necessary for Medicare covered screenings.
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There is no copayment for one screening mammogram every calendar year.
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Pap Smears, Pelvic Exams and Clinical Breast Exams
(For women with Medicare)
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There is no copayment for a pap smear once every 2 years, annually for beneficiaries at high risk. (2)
You pay 20% of Medicare approved amounts for Pelvic Exams. (2)
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There is no copayment for one screening pap smear, pelvic exam and clinical breast exam every calendar year.
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Prostate Cancer Screening Exams
(For men with Medicare age 50 and older).
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There is no copayment for approved lab services and a copayment of 20% of Medicare-approved amounts for other related services. (1)(2)
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There is no copayment for one screening Prostate Cancer exam every calendar year.
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Cardiovascular Screening
Blood Tests for the early detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease).
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You pay 20% of Medicare-approved amounts for cholesterol and other lipid or triglyceride levels. (1)(2)
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There is no copayment for covered tests.
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Physical Exams
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If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage.
This will not include laboratory tests. Please contact your plan for further details.
You pay 20% of the Medicare approved amount. (1)(2)
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There is no copayment for routine physical exams. If the exam is for the treatment of a suspected or existing condition, $15 office copay may apply.
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Tobacco/Smoking Cessation
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You pay 20% of Medicare-approved amounts. (1)(2)
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You pay a $15 copayment for each tobacco counseling session.
Reimbursement of approved smoking cessation program up to a maximum of $75.00 upon receipt of your program completion certificate and proof of payment. Limited to 2 programs per calendar year.
-Medications for tobacco/smoking cessation that require a prescription, limited to 180 days per calendar year.
-Nicotine inhalation system or nasal spray that requires a prescription is covered for 90 days, per calendar year. An additional 90 days may be covered, upon submission of your smoking cessation program completion certificate.
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Dental Services
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In general, you pay 100% for preventive dental services.
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In general, you pay 100% for preventive dental services.
You pay $15 for each covered dental exam.
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Hearing Services
(You pay 100% for Hearing Aids).
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You pay 100% for routine hearing exams and hearing aids.
You pay 20% of Medicare-approved amounts for diagnostic hearing exams. (1)(2)
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There is no copayment for the following services:
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Vision Care
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You are covered for one pair of eye glasses or contact lenses after each cataract surgery. (1)(2)
For people with Medicare who are at risk, you are covered for annual glaucoma screenings. (1)(2)
You pay 20% of Medicare approved amounts for diagnosis and treatment of diseases and conditions of the eye. (1)(2)
You pay 100% for routine eye exams and glasses.
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There is no copayment for the following items:
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Covered eyewear (one pair of eyeglasses or contact lenses after each cataract surgery and a $300.00 limit for routine eyewear every year (for frames, lenses, and eyewear upgrades at participating network providers).
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First Routine Eye Exam each calendar year.
You pay:
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Any amount over the allowable amount for frames.
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$15 for each covered eye exam (diagnosis and treatment for diseases and conditions of the eye).
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$15 for each annual glaucoma exam.
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Health and Wellness Education
The following is available to you at no cost:
• Health Education Classes
• Newsletter
• Nurse Advisor Line
• Disease Management
• Case Management
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You pay 100%.
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There is no copayment for these services.
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PART D DRUG BENEFIT
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Prescription Drugs
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You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program.
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This plan uses a formulary. A formulary is a list of drugs covered by us to meet our member’s needs. We may periodically add, remove, make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at www.glhealthplan.org.
People who have limited incomes, who live in long term care facilities, or who have access to Indian/Tribal/ Urban (Indian Health Service) facilities may have different out-of-pocket drug costs. Contact Gundersen Lutheran Health Plan at 800/897-1923 or 608/775-8007 (TTY/TDD 800-947-3529) for details.
There is no deductible.
Before the total yearly drug costs (paid by both you and Senior Preferred EliteD) reach $2,830, you pay the following for prescription drugs:
• $9 for a one-month (30 day) supply of Generic (Tier 1).
• $24 for a one-month (30) day supply of Formulary Preferred Brand Drugs (Tier 2).
• $80 for a one-month (30 day) supply of Formulary Non-Preferred Brand Drugs (Tier 3).
• 33% coinsurance for a one-month (30 day) supply of Specialty High Cost Drugs (Tier 4).
• $27 for a three-month (90 day) supply of Generic Drugs.
• $72 for a three-month (90 day) supply of Formulary Preferred Brand Drugs.
• $240 for a three-month (90 day) supply of Formulary Non-Preferred Brand Drugs.
After the total yearly drug costs (paid by both you and Senior Preferred EliteD) reach $2,830, you pay 100% of your prescription drug costs until your yearly out-of pocket drug costs reach $4,550.
After your yearly out-of-pocket drug costs reach $4,550 you pay the greater of:
• $2.50 for generic (including brand drugs treated as generic) and
• $6.30 for all other drugs, or
• 5% coinsurance.
In some cases, Senior Preferred EliteD requires you to first try one drug to treat your medical condition before we will cover another drug for that condition.
Certain prescription drugs will have maximum quantity limits. Your provider must get prior authorization from Senior Preferred EliteD for certain prescription drugs. Covered Part D drugs are available at out-of-network pharmacies in special circumstances including illness while traveling outside of our service area where there is no network pharmacy. You may also incur an additional cost for drugs received at an out-of-network pharmacy. Please contact Gundersen Lutheran Health Plan for details.
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