January 1 – Dec 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 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-12XX for additional information. (TTY users should call . hours are Monday through Sunday, 8 am to 8 pm, October 1 through March 31. April 1st through September 30th, 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 Jan 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)
2019 (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
Maximum out-of-pocket amount
This is the most you will pay out-of-pocket for your covered Part A and Part B services.
$4200.00
$4,200
Doctor office visit
Primary care visits: $10 per visit
Specialist visits: $20 Copay per visit
Primary care visits: $10 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 5.
There is a $1,500 out-of-pocket limit every year.
$150 Copay per day for Days 1-5 per admission and $0 Copay after Day 5.
There is a $2,250 out-of-pocket limit every year.
Part D prescription drug coverage
Applicable for Tiers 3,4,5
Copayment, Coinsurance during the Initial Coverage Stage:
• Drug Tier 1: $4
• Drug Tier 2: $10
• Drug Tier 2: $45
• Drug Tier 4: $95
• Drug Tier 5: 28%
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%