san francisco health plan | low income health insurance2013 medicare part d stand-alone prescription...

San Francisco HICAP- Part D Intake 407 Sansome Street, 4th Floor

San Francisco, CA 94111 415-677-7520 (Phone) 415-296-0313 (Fax)

Name _______________________________________________________________________________

Address _____________________________________________________________________________

Phone Number ___________________ Language __________________ Male Female

Marital status

Single Married Divorced Separated Widowed

Medicare Claim # __________________________ Date of Birth __________________

Part A Effective Date ___________________ OR Part B Effective Date ___________________

HICAP Disclosure statement Please check box after reading

HICAP counseling services are provided by Counselors registered by the California Department of Aging who are acting in good faith to provide information about health insurance policies and benefits to you, the client. Any information shall not be construed to be legal advice, and the volunteer HICAP Counselor is generally not liable for acts and omissions in providing counseling to recipients of this service. (W&I Code, Section 9541(f).) If you choose a plan and have difficulty in completing the necessary forms or process for enrollment, the HICAP Counselor will assist you. However, you will be responsible for the actual plan contract. The HICAP Counselor will NOT choose your plan for you.

I do not have Part A.

Current Medicare Coverage (Check all that apply)

Medi-Cal Medi-Cal with Share of Cost Veterans Benefits

Original Medicare Medigap

Part D Medicare Advantage Plan (HMO/ PPO) You may qualify for Extra Help for Part D. Please ask HICAP if your monthly income is

Less than $1,369/month and have assets less than $13,070 (single) Less than $1,891/month and have assets less than $26,120 (married)

Enter your Prescription Drugs.

You may attach a drug list print-out from your pharmacy.

Generic alternatives may save money.

Drug Name Dosage (e.g. ml, mg)

Frequency (e.g. twice daily)

Monthly supply (e.g. 30, 60, 90)

Is there a pharmacy you prefer to use? No

Yes (if yes, please provide the name and address of your preferred pharmacy)

2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222

or 1-800-Medicare

Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov

Monthly Low Drug Plan

Organization Name Plan Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality

Enrollment Telephone Number Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating

Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan

Aetna Medicare Rx Plans CVS Pharmacy Plan $28.60 $325 $2 $5 $45 47% 25% No Yes Yes 3.5

800-832-2640 aetnamedicare.com Premier Plan $118.40 $0 $5 $33 $45 49% 33%Many Generics

Some BrandsYes 3.5

Anthem Blue Cross Standard $41.30 $325 $2 $6 $39 $85 25% No Yes 3.0

800-261-8667 Plus $76.80 $0 $2 $7 $45 $90 $95 / 33% Few Generics Yes 3.0

anthem.com/ca/medicare Gold $113.00 $0 $2 $7 $45 $90 $95 / 33%Many Generic

Some BrandsYes 3.0

Blue Shield Basic $53.40 $325 $4 $37 $76 25% 25% No Yes 4.0

800-488-8000 blueshieldca.com Enhanced $72.50 $0 $5 $45 $90 25% 33% No Yes 4.0

Cigna

800-735-1459 cignamedicarerx.com

Envision Silver Plan $29.10 $325 25% 25% 23% 28% 25% No No Yes 3.0

800-250-2005 envisionrxplus.com Gold Plan $54.00 $150 $2 or 1% $5 or 1% $25 or 1% 30% 29% Some Generics Yes 3.0

Express Scripts Value $61.00 $325 $4 $6 25% 27%-50% 25% No Yes 4.0

866-477-5704 express-scriptsmedicare.com Choice $91.60 $200 $8 $45 $95 28% 28% Many Generics Yes 4.0

First Health Value Plus $24.20 $0 $0 $35 $70 33% 33% No Yes 3.0

877-815-8163 Premier $47.90 $325 $1 $25 43% N/A N/A No Yes 3.0

myfirsthealthpland.com Premier Plus $102.40 $0 $0 $20 25% 43% 33%Some Generics

Some BrandsYes 3.5

HealthMarkets Medicare888-625-5531 hmic-medicare.com

Health Spring877-357-1685 myhealthspring.com

Humana Wal Mart Plan $18.50 $325 $1 $3 20% 35% 25% No Yes Yes 3.5

800-706-0872 Enhancd $47.50 $0 $2 $5 $44 $90 33% No Yes 3.5

humana-medicare.com Complete $118.60 $0 $5 $37 $69 $33 33%Some Generics

Some BrandsYes 3.5

Yes 3.0No

Yes 2.5

No Yes new

No

$70 25%

$37 27% N/A

$28

25%Health Spring Drug Plan 46.90 $325 25% 25%

$325 $1 $2.50

Plan One 55.80 $325 $0 $8

25% 25%

Reader's Digest Value Plan $32.30

Rev.10/15/2012 Information subject to change.Contact plans to verify information. Tier 1 = Preferred GenericsTier 2 = Non Preferred GenericsTier 3 = Preferred BrandsTiers 4 = Non Preferred Brands Tier 5 = Specialty Drugs

2013 Medicare Part D Stand-Alone Prescription Drug Plans HICAP (800) 434-0222

or 1-800-Medicare

Beneficiary must have Medicare Part A and/or B to enroll in a Prescription Drug Plan. medicare.gov

Monthly Low Drug Plan

Organization Name Plan Annual Co-Payments after deductible has been met Gap Mail Income Quality

Enrollment Telephone Number Plan Name Premium Deductible and prior to reaching $2,970 in full drug cost Coverage Order Subsidy Rating

Website Information and Enrollment Tier 1 Tier 2 Tier 3 Tier 4 Tier 5/6 Plan

Silver Script Basic $30.60 $325 $2 21% 43% 25% N/A No Yes Yes 3.0

866-552-6106 Choice $29.10 $0 $0 $34 35% 33% N/A No Yes 3.0

silverscript.com Plus $113.10 $0 $0 $34 35% 33% N/AMany Generics

Some BrandsYes 3.0

Smart Rx Saver $31.40 $325 $0 $20 $32 $85 25% No Yes Yes new

855-976-2781 smartdrx.com Plus $73.00 $0 $0 $20 $32 $85 25% Some Generics Yes new

United American Select $36.50 $325 $1 $4 $37 $95 25% No Yes 3.5

866-524-4169 uamedicarepartd.com Enhanced $60.80 $80 $1 $7 $40 $95 29% No Yes 3.5

United Health Care - AARP MedicareRx Saver Plus $15.00 $325 $1 $2 $25 $45 25% No Yes Yes 3.0

888-867-5575 MedicareRx Preferred $47.90 $0 $3 $5 $40 $85 33% No Yes 3.0

aarpmedicarerx.com MedicareRx Enhanced $98.00 $0 $2 $5 $40 $76 33%Some Generics

Some BrandsYes 3.0

Well Care Classic $33.00 $0 $6 $45 $95 33% 33% No Yes 3.0

888-293-5151 wellcarepdp.com Extra $49.00 0 $0 25% 25% 50% 33% Many Generics Yes 3.0

Logo Here :-)

Used by permission from Council of Aging Orange County

San Francisco 2013 Medicare Advantage PlansPage 1 of 2

Care1st Chinese Com. Health Plan Health Net of California Humana Humana Kaiser Permanente

Plan Name Care1st AdvantageOptimum Plan (H5928-026) HMO Senior Program (H0571-001) HMO Health Net Healthy Heart (H0562-009) HMO Humana Gold Plus (H0108-028) HMO Humana Gold Plus (H0108-027) HMO Senior Advantage (H0524-032) HMO

Monthly Premium $28, MOOP $3400 $40, MOOP $3400 $89, MOOP $6700 $32, MOOP $5000 $62, MOOP $3400 $76, MOOP $3400

Phone Number 1-800-847-1222 Prospective Members 1-888-775-7888 ext. 3282 Prospective Members 1-800-977-6738 Prospective Members 1-800-833-2364 Prospective Members 1-800-833-2364 Prospective Members 1-800-777-1238 Prospective Members

1-800-544-0088 Current Members 1-888-775-7888 Current Members 1-800-275-4737 Current Members 1-800-457-4708 Current Members 1-800-457-4708 Current Members 1-800-443-0815 Current Members

Web Site Address www.care1st.com/ca/ www.cchphmo.com www.healthnet.com www.humana-medicare.com www.humana-medicare.com www.kp.org/medicare

Network Provider Brown and Toland Chinese Community Health Plan Physicians Brown and Toland; Hill Physicians Kaiser Network

Network Hospital CPMC CPMC, Chinese Hospital, St. Francis, St. Mary's CPMC, UCSF, St. Francis, St. Mary's CPMC CMPC Kaiser Permanente

Physician Visit $0 primary care. $10 specialist. $15 primary care, specialist, urgent care. $10 primary care, specialist or in-network urgent care. $0 primary care. $10 specialist. $0 primary care. $5 specialist. $25 primary care. $25 specialist.

Inpatient Hospital $100/day for days 1-5; $0 for days 6-90 and beyond.

Unlimited days each benefit period. Except in an

emergency, your doctor must notify plan of admission.

$195-295/day for days 1-7;$0 for days 7-90 and

beyond. Unlimited days each benefit period. Except in

an emergency, your doctor must notify plan of

admission.

$320/day for days 1-5; $0 for days 6-90 and

beyond. Unlimited days each benefit period. Except in

an emergency, your doctor must notify plan of

admission.

$125/day for days 1-8; $0 for days 9-90 and beyond.






$255/day for days 1-7; $0/day for days 8-90; $0 copay

for additional days. Except in emergency. Doctor must

tell the plan you are being admitted into a hospital.

Outpatient Surgery $20-$75 for each visit to outpatient surgical center.

$20-50 for each visit to outpatient hospital facility.

$195-295 for each visit to the surgical center or

outpatient hospital facility. Authorization rules may

apply.

$125 for each visit to outpatient surgical center.

$250 for each visit to outpatient hospital facility.


$10-$200 (or 20% of cost) for each visit to outpatient

hospital facility.


$5-$125 (or 20% of cost) for each visit to outpatient

hospital facility.

$250 for each outpatient surgical center visit.

$0-$250 for each visit to hospital facility.

Mental Health Inpatient : Days 1-8 $100/day; Days 9-90 $0/day,

except in an emergency, doctors must inform the plan.

Outpatient : Individual therapy w/ psychiatrist and

without & group therapy w/ psychiatrist and without

$10; Partial hospitalized program $0.

Inpatient : Days 1-7 $250/day; Days 8-90 $0/day.

Additional days are $0 except, in emergency, doctor

must inform plan.



$25; Partial hospitalized program services $0.

Inpatient : Part of 190 lifetime days inpatient hospital

care; $900/day. In an emergency, doctor must inform

plan.




Inpatient : Days 1-8 $125/day; Days 9-90 $0/day,





Inpatient : Days 1-8 $100/day; Days 9-90 $0/day,



without & group therapy w/ psychiatrist and without $5;

Partial hospitalized program $25.


Additional days are $0, except in an emergency,

doctors must inform the plan.


without $25. Group therapy w/ psychiatrist and without

$12; Partial hospitalized program services $0.

Ambulance Service $100; if admitted into the hospital you pay $0. $175 for Medicare-covered ambulance services.

Authorization rules may apply.

$275 for Medicare-covered ambulance services.






$200 for Medicare-covered ambulance visit.

Emergency Care $50; $25,000 plan coverage limit for supplemental

emergency services outside the U.S. every year; if

immediately admitted into the hospital you pay $0.

$65; waived if admitted within 24 hours for the same

condition. Worldwide coverage.

$65; waived if admitted immediately. Worldwide

coverage. Annual $50,000 limit for emergency

services outside the U.S.

$65; if immediately admitted into the hospital you pay

$0. Worldwide coverage.





Diagnostic Test, X-

Ray & Lab Service

$0 for Medicare-covered x-rays, clinical/ diagnostic lab

tests and diagnostic radiology services. 10% for

Medicare-covered therapeutic radiology services.

$0 for x-rays, clinical/ diagnostic lab tests and

therapeutic radiology service. $0-100 for diagnostic

radiology services.

$0 for x-rays, lab services & diagnostic procedures &

tests. $60 for diagnostic & therapeutic radiology

services, not including x-ray.

$0-$10 for lab services & diagnostic procedures &

tests. $0-$125 (or 20% cost) for diagnostic, not

including x-ray services. $0-$10 (or 10% cost) for x-

rays. $10 (or 20% cost) copay for therapeutic

radiology services.

$0-$5 for lab services. $0-$10 for x-rays, diagnostic

procedures & tests. $0-$125 for diagnostic services,

not including x-rays. $5 (or 20% cost) copay for

therapeutic radiology services.

$0-$30 for lab services, diagnostic procedures and

tests. $30 for x-rays. $145 copay diagnostic radiology

services, not including x-ray.

Prescription Drugs

Copay

Tier 1: Preferred generic $0/ 30 day supply

Tier 2: Non-preferred generic $5/ 30 day supply

Tier 3: Preferred generic $30 /30 day supply

Tier 4: Non-preferred generic $50 /30 day supply

Tier 5: Specialty 30% coinsurance /30 day supply

Tier 1: Generic $10 /30 day supply

Tier 2: Brand name $40 /30 day supply



Tier 2: Non-preferred generic $12 /30 day supply

Tier 3: Preferred Brand $45 /30 day supply

Tier 4: Non-preferred brand $95 /30 day supply

Tier 5: 33% coinsurance /30 day supply


Tier 2: Non-Preferred generic $10 /30 day supply

Tier 3: Preferred brand $45 /30 day supply

Tier 4: Non-Preferred brand $45 /30 day supply

Tier 5: Specialty Tier 33% coinsurance /30 day supply

Tier 1: Preferred Generic $0/ 30 day supply

Tier 2: Non-Preferred generic $10 /30 day supply


Tier 4: Non-preferred brand $95 /30 day supply



Tier 2: Generic $10 /30 day-supply

Tier 3: Preferred brand name $45 /30 day supply

Tier 4: Non-Preferred brand name $65 /30 day supply

Tier 5: 25% coinsurance /30 day supply

Tier 6: Injectable Part D vaccines /no charge

Dental $0 copay for 1 cleaning every six months and 1 dental

x-ray every 2 years. $0-$570 copay for Medicare-

covered dental benefits. $5 copay for 1 fluoride

treatment a year.

Optional Supplemental Package: $14.60 monthly

premium includes preventive and comprehensive

dental.

3 Optional Supplemental Packages: $10-$28 monthly

premium includes eye exam, eye wear, preventative

dental, comprehensive dental.




Vision $0 copay for 1 pair of Medicare-covered eyeglasses or

contact lenses after cataract surgery. $0 copay for

Medicare-covered eye exams to look at eye condition.

$5 copay for up to 1 supplemental routine eye exams

every year.

No additional rider. 3 Optional Supplemental Packages: $10-$28 monthly






Two Optional Supplemental Packages:

$19 or $29 monthly premium includes preventive and

comprehensive dental, chiropractic, acupuncture, eye

wear, and education and wellness programs.

Optional Supplemental Package:

Advantage Plus - $20 monthly premium

includes preventive and comprehensive

dental, eye wear, and hearing aids.

For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012

http://www.care1st.com/ca/

http://www.cchphmo.com/

http://www.healthnet.com/

http://www.humana-medicare.com/

http://www.humana-medicare.com/

http://www.kp.org/medicare

San Francisco 2013 Medicare Advantage PlansPage 2 of 2

SCAN Health Plan SCAN Health Plan United Healthcare Health Net of California Anthem Blue Cross

Plan Name Plus (H5425-041) HMO Classic (H5425-019) HMO AARP Medicare Complete (H0543-085) HMO Health Net Seniority Plus Green (H0562-045) HMO Anthem Medicare Preferred Standard (H8522-008-0) PPO

Monthly Premium $27.50, MOOP $3000 $49, MOOP $3400 $0, MOOP $6700 **NO Part D. $99, MOOP $3400 $85, MOOP $3800

Phone Number 1-800-915-7226 Prospective Members 1-800-915-7226 Prospective Members 1-800-547-5514 Prospective Members 1-800-977-6738 Prospective Members 1-800-797-96439 Prospective Members

1-800-559-3500 Current Members 1-800-559-3500 Current Members 1-800-950-9355 Current Members 1-800-275-4737 Current Members 1-877-811-3107 Current Members

Web Site Address www.scanhealthplan.com www.scanhealthplan.com www.aarpmedicareplans.com www.healthnet.com www.anthem.com/ca/medicare

Network Provider Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Brown and Toland; Hill Physicians Lower copayments for in-network providers than for out-of-network providers. You may go to any doctor,

specialist or hospital out-of-network.

Network Hospital CPMC, St. Francis, St. Mary's CPMC, St. Francis, St. Mary's CPMC, St. Mary's, UCSF, UCSF Cancer Center CPMC, UCSF, St. Francis, St. Mary's

Physician Visit 20% of the cost for each Medicare-covered primary

care visit, specialist visit, urgent care.

$5 primary care. $10 specialist. $5 primary care. $10 specialist. $10 primary care or specialist. In-Network : $15 primary care. $45 for specialist.

Out-of-Network : $35 primary care. $55 for specialist.

Inpatient Hospital 1-90 days covered each benefit period. Will not be

charged additional sharing for professional services. In

an emergency, doctor must tell plan you will be

admitted into the hospital.

$125 for days 1-8; $0 for days 9-90 . $0 copay for

additional days, except in emergency. Doctor must tell

the plan you are being admitted into a hospital.

$395/day for days 1-4. $0 for days 5-90. Unlimited

days each benefit period. Except in an emergency,

your doctor must notify plan of admission.




In-Network : $695 copay for each Medicare-covered stay.

Out-of-Network : 15% of the cost of each stay. Unlimited days each benefit period. Except in an

emergency, your doctor must authorize.

Outpatient Surgery 20% for each visit to outpatient surgical center or

outpatient hospital facility.



20% for each visit to outpatient surgical center or

outpatient hospital facility.



In-Network : 15% of cost for each Medicare-covered ambulatory surgical center visit; $0- $45 copay (or

15% of the cost) for each Medicare-covered outpatient hospital facility visit. Authorization rules may apply.

Out-of Network : 25% of cost for each ambulatory surgical center or outpatient hospital facility visit.

Mental Health Inpatient : Inpatient psychiatric services count toward

190-day lifetime inpatient psychiatric hospital care in a

lifetime.



35% of cost. Partial hospitalized program services

20% of cost.


Additional days are $0 except in an emergency,

doctors must inform plan.



$25. Partial hospitalized program services $25.

Inpatient : Days 1-7 $255/day; Days 8-90 $0/day;

Additional days are $0; except in emergency, doctor

must inform plan.

Outpatient : Individual therapy w/ psychiatrist & without

$25. Group Therapy w/ psychiatrist and without $12;

Partial hospitalized Medicare program services $60.

Inpatient : Part of 190 lifetime days inpatient hospital

care; $900/day; in an emergency, doctor must inform

plan.




Inpatient: In-Network: Up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count

toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services

furnished in a general hospital. $695 copay for each hospital stay. Except in an emergency, your doctor must tell the plan that you are

going to be admitted to the hospital.

Out-of-Network : 15% of the cost for each hospital stay.

Outpatient: In-Network : Individual therapy w/ psychiatrist and without & group therapy w/ psychiatrist and without $40.

Out-of-Network : 30% of the cost for Mental Health visits w/ psychiatrist and without. 30% of the cost for partial hospitalization program

services.

Ambulance Service 20% of Medicare-approved cost. $150 for Medicare-covered ambulance benefits. $200 for Medicare-covered ambulance service. $125 for Medicare-covered ambulance services.


In- or Out-of-Network : $200 for Medicare-covered ambulance service. Authorization rules may apply.

Emergency Care 20% of the cost (up to $65). $65; if immediately admitted into the hospital you pay

$0.

$65; waive if admitted within 24 hours for same

condition. Worldwide coverage.

$50; waived if admitted immediately. Worldwide

coverage. Yearly $50,000 limit for emergency services

outside the U.S.

$65 for Medicare-covered ER visits; waived if admitted within 72 hours for same condition. Worldwide

coverage.

Diagnostic Test, X-

Ray & Lab Service

20% of cost for diagnostic tests, x-rays and lab

services.

$0 for lab services, diagnostic procedures and tests.

20% of costs for x-rays.

$13 for lab tests. $15 for x-rays. 20% for diagnostic

procedures & tests, including therapeutic radiology

services.

$0 for x-rays, lab services & diagnostic procedures &

tests. $60 for diagnostic, not including x-ray &

therapeutic radiology services.

In-network : $0 copay for Medicare-covered lab services. $65- $200 copay for Medicare-covered diagnostic

radiology services (not including x-rays). 20% of the cost for Medicare-covered therapeutic radiology services.

$0- $200 copay for Medicare-covere diagnostic procedures and tests. $65 copay for Medicare-covered x-rays.

Out-of-Network : 30% of the cost for Medicare-covered therapeutic radiology services, Medicare-covered

outpatient x-rays, Medicare-covered diagnostic radiology services, Medicare-covered diagnostic procedures,

tests, and lab services.

Prescription Drugs

Copay

Tier 1: Preferred Generic $0 /31 day supply

Tier 2: Non- Preferred Generic $0 /31 day supply

Tier 3: Preferred brand 25% of cost /31 day supply

Tier 4: Non- Preferred brand 25% of cost /31 day

supply


Tier 6: Select Care $10 /31 day supply

Tier 1: Preferred generic drugs $5 /31 day supply

Tier 2: Non-Preferred generic drugs $10 /31 day

supply

Tier 3: Preferred brand drugs $45 /31 day supply

Tier 4: Non-Preferred brand drugs $75 /31 day supply

Tier 5: Specialty drugs 33% of cost /31 day supply

Tier 6: Select care drugs $10 /31 day supply


Tier 2: Non-Preferred Generic $8 /31 day supply


Tier 4: Non-Preferred brand $95 /31 day supply


This plan does not offer prescription drug coverage.

Note: You cannot enroll in a Part D, in addition to this

plan.

20% of cost for Part B-covered drugs.

In-Network: $90 deductible on all drugs, except Tiers 1, 5, and 6.


Tier 2: Non-preferred Generic $8 /30 day supply

Tier 3: Preferred Brand: $40 /30 day supply

Tier 4: Non-preferred Brand: $90 /30 day supply

Tier 5: Injectable Drugs: 33% coinsurance /30 day supply

Tier 6: Specialty: 33% coinsurance /30 day supply

20% of cost for Part B-covered drugs for in-network and out-of-network.

Dental Optional Supplemental Package: $15 monthly

premium in addition to the monthly plan premium.

Includes preventative dental.

Optional Supplemental Benefits:

#1: Basic Options- $8 monthly premium includes

preventive dental.

#2: High Option- $15 monthly premium includes

preventative dental.

2 Optional Supplemental Packages: $19 or $29

monthly premium includes preventive and



Vision No additional rider. 2 Optional Supplemental Packages: $19 or $29

monthly premium includes preventive and



Two Optional Supplemental Packages:

#1: Deluxe Rider- $37 monthly premium includes

preventive and comprehensive, dental, vision &

hearing aids.

#2: Dental 467 Rider- $15 monthly premium includes

preventive dental.

3 Optional Supplemental Packages:

#1: Preventive Dental - $12 monthly premium includes preventive dental.

#2: Comprehensive Dental & Vision - $31 monthly premium includes preventive and comprehensive dental,

eye exams, eye wear.

#3: Combination Package - $36 monthly premium includes preventive and comprehensive dental, eye

exams, eye wear, chiropractic, and acupuncture.

For more information, call San Francisco HICAP 415-677-7520, or Medicare 1-800-633-4227 or www.medicare.gov, or contact plan directly. DRAFT Updated 10/17/2012

http://www.scanhealthplan.com/

http://www.scanhealthplan.com/

http://www.aarpmedicareplans.com/

http://www.healthnet.com/

http://www.anthem.com/ca/medicare

san francisco health plan | low income health insurance2013 medicare part d stand-alone prescription...

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