January 1 – December 31, 2019
Evidence of Coverage:
Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Simplify HealthCare PPO plan
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2019. You are a member of Simplify Healthcare (HMO) plan. It explain how to get coverage for the health care services and prescription drugs you need. This is an important legal document. Please keep it in a safe place.
Please contact our Customer Services number at 1-800-1X-12XXX for additional information. (TTY users should call 711. Hours are Monday through Sunday, 8 am to 8 pm, October 1 through March 31. April 1 through September 30, Monday through Sunday, 8 am to 8 pm. After these hours, you may leave a message on our secure voice messaging system.
Customer Service has free language interpreter services available for non-English speakers (See Page 2 of this booklet).
Benefits, premium, deductible, and/or copayments/coinsurance may change on January 1, 2020. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
H39XX_EOC19_C
Cost
2019 (this year)
2020 (next year)
Monthly plan Premium Plus
* Your Premium Plus may be higher or lower than this amount. See Section 1.1 for details.
$176.00
$199.00
Maximum out-of-pocket amount
This is the most you will pay out-of-pocket for your covered Part A and Part B services.
$4,200.00
$4,200.00
Doctor office visits
Primary care visits: $10 Copay per visit
Specialist visits: $20 Copay per visit
Primary care visits: $10 Copay per visit
Specialist visits: $20 Copay per visit
Inpatient hospital stays
Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services.
$100 Copay per day for Days 1-5 per admission, and $0 Copay after Day .
There is a out-of-pocket limit every year.
$150 Copay per day for Days 1-5 per admission and $0 Copay after Day .
There is a $2,250 out-of-pocket limit every year.
Part D prescription drug coverage
(See Section 1.6 for details.)
Deductible: $250
Applicable for Tiers 3,4,5
Copayment/Coinsurance during the Initial Coverage Stage:
• Drug Tier 1: $4
• Drug Tier 2: $10
• Drug Tier 3: $45
• Drug Tier 4: $95
• Drug Tier 5: 28%
Deductible: $250
Applicable for Tiers 3,4,5
Copayment/Coinsurance during the Initial Coverage Stage:
• Drug Tier 1: $4
• Drug Tier 2: $10
• Drug Tier 3: $45
• Drug Tier 4: $95
• Drug Tier 5: 28%