Platinum (HMO-POS)
Plan Overview
Choose this plan if you want:
- a plan with no co-pays for in-network
primary care doctor visits and specialist visits
- a plan with little to no cost sharing for network health care services
- a choice in using network or out-of-network providers. If you use out-of-network providers, deductible and co-insurance apply.
- a plan with $0 prescription deductibles
- a plan with supplemental vision and hearing benefits
Medical Coverage Overview
Please refer to the Evidence of Coverage and Summary of Benefits for Out-Of-Network
benefits.
- Monthly Premium: $149 (You must continue to pay Medicare Part B premium)
- Visits to primary care physician: $0
- Visits to a specialist: $0
- In-Patient Hospitalization: $0
- Out-Patient Surgery: $0
Drug Coverage Overview
Costs below apply until yearly drug cost totals reach $2,930. These are the basic
coverage rules. There are some exceptions, i.e. chemotherapy drugs.
|
Rx Category
|
Up to 30-Day Supply
|
Up to 90-Day Supply
|
|
Formulary Generics
|
$5 Co-pay
|
$15 Co-pay
|
|
Preferred Formulary Brands
|
$35 Co-pay
|
$105 Co-pay
|
|
Non-Preferred Generics and Non-Preferred Brand
|
$65 Co-pay
|
$195 Co-pay
|
|
Formulary Specialty Pharmaceuticals
|
33%
|
33%
|
Limitations
- $200 limit for eye glasses every year
- 1 pair of contacts every year
- 1 pair of lenses every year
- 1 frame every year
- 1 routine eye exam every year
- 1 routine hearing exam every year
- 1 hearing aid every two years
- $400 allowance for hearing aids every two years
More Information
The benefit information provided herein is a brief summary, not a comprehensive
description of available benefits. Additional information about benefits is available
to assist you in making a decision about your coverage. For full information on
Carilion Clinic Medicare Health Plan benefits, call our Customer Service Department
at 800-779-2285, TTY 877-225-3157, Monday through Friday, 8 am to 8 pm.
If you decide to switch to premium withhold or move from premium withhold to direct
bill, it could take up to three months for it to take effect and you will remain
responsible for those premiums.
This is an advertisement; for more information contact the plan.
You can also view additional plan documents in the Document
and Forms section below.
Plan Specific Contact Information
Call us toll-free at: 877-233-7057, Monday through Friday, 8 am to 5 pm
Plan Disclaimers
View Plan Disclaimers
The following documents provide detailed information on Carilion Clinic Medicare
Health Plan (Gold HMO-POS) benefits and plan design. Use the links below to view
Carilion Clinic Medicare Health Plan (Gold HMO-POS) documents directly from your
computer.
If you would like any of these documents mailed to you, please
Contact Us. You should receive the documents within two weeks of your request.
Comprehensive Formulary
- the open formulary for prescription drugs covered by Carilion Clinic Medicare
Health Plan (Gold HMO-POS).
Drugs That Require Prior Authorization
- you will need authorization by your Carilion Clinic Medicare Health Plan (Gold
HMO-POS) before filling prescriptions for the drugs shown in this chart.
Drugs That Require Step Therapy
Drugs with Quantity Limits
Evidence of Coverage with Annual Notice of Changes
- provides information about your benefits, membership, covered and non-covered
services, member rights and responsibilities and other important plan details.
Low Income Subsidy (LIS) Premium Summary Table
Medicare Part D Tiering or Formulary
Exception Request
Notice of
Privacy Practices - describes how your medical information may be used and
disclosed and how you can get access to this information.
Provider Directory
Provider Directory
(Supplemental Hearing and Vision)
Summary of Benefits
- provides a general summary of benefits and services for each of our health
plans.
Request for Appointment of Representative
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