Bronze (HMO-POS)
Plan Overview
Choose this plan if you want:
- a plan with no monthly premium
- no prescription deductible
- no referrals for network providers
- a choice in using network or out-of-network providers. If you use out-of-network providers, deductible and co-insurance apply.
- low prescription co-pays
Medical Coverage Overview
- Monthly Premium: $0 (You must continue to pay Medicare Part B premium)
- Preventive Care: $0
- Visits to chiropractors: $15 (Medicare-covered)
- Visits to primary care physician: $10
- Visits to specialists: $35
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
|
$6 Co-pay
|
$18 Co-pay
|
|
Preferred Formulary Brands
|
$45 Co-pay
|
$135 Co-pay
|
|
Non-Preferred Generic and Non-Preferred Brand
|
$85 Co-pay
|
$255 Co-pay
|
|
Formulary Specialty Pharmaceuticals
|
33%
|
33%
|
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.
You must use plan providers except in emergent or urgent care situations. If you
obtain routine care from out-of-network providers, neither Medicare nor Carilion
Clinic Medicare Health Plan will be responsible for the costs.
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: 877-233-7055, 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 (Bronze HMO-POS) benefits and plan design. Use the links below to view
Carilion Clinic Medicare Health Plan (Bronze 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 (Bronze HMO-POS).
Drugs That Require Prior Authorization
- you will need authorization by your Carilion Clinic Medicare Health Plan (Bronze
HMO-POS Plan) 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
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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