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2015 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart

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Company Brand New Day Brand New Day Brand New Day Brand New Day

Plan Name Bridges Drug Savings Bridges Extra Care Harmony Healthy Heart Drug Savings

Telephone Numbers Website

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

Plan Type

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with dementia.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with dementia.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic and disabling mental health conditions.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic heart failure.

Total Monthly Premium $0 Monthly Premium $28.80 Monthly Premium $28.80 Monthly Premium $0 Monthly Premium Size of Physician and Provider

Network 5001-5500 physicians and providers 5001-5500 physicians and providers 1001-1500 physicians and providers 5001-5500 physicians and providers

Doctor Visit $0 each visit $0 each visit $0 each visit $0 each visit

Specialist Visit $0 each visit $0 each visit $0 each visit $0 each visit

Out of Pocket Limit $3,400 In-Network $6,700 In-Network $6,700 In-Network $3,400 In-Network

In-patient Hospitalization period. 60 lifetime reserve days.$0 copay. 90 days each benefit 90 days each benefit period. 60 lifetime reserve days. Contact plan for more details.

90 days each benefit period. 60 lifetime reserve days. Contact plan for more details.

$0 copay. 90 days each benefit period. 60 lifetime reserve

days.

Skilled Nursing Facility 100: $148/day. 100 days each Days 1-20: $0/day. Days 21-benefit period.

100 days each benefit period.

Contact plan for more details. 100 days each benefit period. Contact plan for more details. $0 copay. 100 days each benefit period.

In-patient Mental Health $0 copay. 190-day psychiatric hospital lifetime limit. lifetime limit. Contact plan for 190-day psychiatric hospital more details.

190-day psychiatric hospital lifetime limit. Contact plan for

more details.

$ 0 copay. 190-day psychiatric hospital lifetime limit.

Outpatient Mental Health $0 each session $0 each session $0 each session $0 each session

Outpatient Hospital Services $65 - $100 each visit 0-20% of the cost each visit 0-20% of the cost each visit $0 each visit Ambulance 20% of the cost each service 20% of the cost each service 20% of the cost each service $65 each service

Emergency Room Visit $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. Outpatient Rehabilitation

Services $0 each visit occup. & cardiac 20% each visit all others 20% of the cost for each visit. 20% of the cost for each visit. $0 each visit occup. & cardiac 20% each visit all others Durable Medical Equipment 20% of cost foritems.Medicare-covered 20% of cost forcovered items.Medicare- 20% for each item.Medicare-covered 20% for each item.Medicare-covered

Diagnostic Tests procedures/tests. $0 for $0 for diagnostic diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

X-Rays $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray

Lab Services $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology.

Renal Dialysis 20% of the cost 20% of the cost 20% of the cost 20% of the cost

Part B Chemotherapy Drugs 20% of the cost 20% of the cost 20% of the cost 20% of the cost

Dental Services 0-20% of the cost for covered benefits. Contact plan Medicare-for additional benefits.

$0 for Medicare-covered benefits. Contact plan for

additional benefits.

$0 for Medicare-covered benefits. Contact plan for

additional benefits.

0-20% of the cost for Medicare-covered benefits. Contact plan

for additional benefits.

Hearing Services $0 for diagnostic exams. Routine exams and hearing aids not covered.

20% for diagnostic exams. Routine exams and hearing

aids not covered.

20% for diagnostic exams. Routine exams and hearing

aids not covered.

20% for diagnostic exams. Routine exams and hearing aids

not covered.

Vision Services

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

Transportation Transportation not covered. $0 copay $0 copay Transportation not covered.

2015 Orange County HICAP

Medicare Advantage Special Needs Plans

Comparison Chart

(2)

Company Plan Name

Telephone Numbers Website

Plan Type

Total Monthly Premium Size of Physician and Provider

Network Doctor Visit Specialist Visit Out of Pocket Limit

In-patient Hospitalization

Skilled Nursing Facility

In-patient Mental Health

Outpatient Mental Health Outpatient Hospital Services

Ambulance

Emergency Room Visit Outpatient Rehabilitation

Services

Durable Medical Equipment

Diagnostic Tests

X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs

Dental Services

Hearing Services

Vision Services

Transportation Prescription Drugs

Brand New Day Brand New Day Brand New Day Brand New Day

Healthy Heart Extra Care Hope Drug Savings In Control Drug Savings In Control Extra Care

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

New enrollment: 866-255-4795 Current members: 866-255-4795 bndhmo.com

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic heart failure.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic and disabling mental health conditions.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus. $28.80 Monthly Premium $0 Monthly Premium $0 Monthly Premium $28.80 Monthly Premium 5001-5500 physicians and

providers 1001-1500 physicians and providers 5001-5500 physicians and providers 5001-5500 physicians and providers $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $0 each visit $6,700 In-Network $3,400 In-Network $3,400 In-Network $6,700 In-Network 90 days each benefit period.

60 lifetime reserve days. Call plan for more details.

$0 copay. 90 days each benefit period. 60 lifetime reserve days.

$0 copay. 90 days each benefit period. 60 lifetime reserve

days.

90 days each benefit period. 60 lifetime reserve days. Contact plan for more details. 100 days each benefit period.

Call plan for more details. $0 copay. 100 days each benefit period. $0 copay. 100 days each benefit period. 100 days each benefit period. Contact plan for more details. 190-day psychiatric hospital

lifetime limit. Contact plan for more details.

$0 copay. 190-day psychiatric

hospital lifetime limit. $0 copay. 190-day psychiatric hospital lifetime limit.

190-day psychiatric hospital lifetime limit. Contact plan for

more details. $0 each session $0 each session $0 each session $0 each session 0-20% of the cost each visit $0 each visit $0 each visit 20% of the cost each visit 20% of the cost each service $65 each service $65 each service 20% of the cost each service

$65 each visit, waived if

admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. $65 each visit, waived if admitted within 3-days. 20% of the cost for each visit. $0 each visit occup. & cardiac 20% each visit all others $0 each visit occup. & cardiac 20% each visit all others 20% of the cost for each visit

20% for each

Medicare-covered item. 20% for each

Medicare-covered

item. 20% for each

Medicare-covered

item. 20% for each

Medicare-covered item. $0 for diagnostic

procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services. $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 copay each X-ray $0 each lab service. 20% of the

cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. $0 each lab service. 20% of the cost for therapeutic radiology. 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost 20% of the cost $0 for Medicare-covered

benefits. Contact plan for additional benefits.

0-20% of the cost for Medicare-covered benefits. Contact plan

for additional benefits.

0-20% of the cost for Medicare-covered benefits. Contact plan

for additional benefits.

$0 for Medicare-covered

benefits. Contact plan for additional benefits. 20% for diagnostic exams.

Routine exams and hearing aids not covered.

20% for diagnostic exams. Routine exams and hearing aids

not covered.

20% for diagnostic exams. Routine exams and hearing aids

not covered.

20% for diagnostic exams. Routine exams and hearing

aids not covered. $0 copay for diagnosis and

treatment of eye conditions. Contact plan for additional

benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits. $0 copay Transportation not covered. Transportation not covered. $0 copay See separate Chart See separate Chart See separate Chart See separate Chart

2015 Orange County HICAP

Medicare Advantage Special Needs Plans

Comparison Chart

(3)

Company Plan Name

Telephone Numbers Website

Plan Type

Total Monthly Premium Size of Physician and Provider

Network Doctor Visit Specialist Visit Out of Pocket Limit

In-patient Hospitalization

Skilled Nursing Facility

In-patient Mental Health

Outpatient Mental Health Outpatient Hospital Services

Ambulance

Emergency Room Visit Outpatient Rehabilitation

Services

Durable Medical Equipment

Diagnostic Tests

X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs

Dental Services

Hearing Services

Vision Services

Transportation

CareMore Health Plan CareMore Health Plan CareMore Health Plan CareMore Health Plan

Breathe ESRD Heart Reliance

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com SPECIAL NEEDS HMO

(Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic lung disorders.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with end-stage renal disease requiring any mode of dialysis.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders and/or chronic heart failure.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic diabetes mellitus. $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium 1001-1500 physicians and

providers 1001-1500 physicians and providers 1001-1500 physicians and providers 1001-1500 physicians and providers

$0 each visit $0 each visit $0 each visit $0 each visit

$0 each visit $0 each visit $0 each visit $0 each visit

$3,000 In-Network $3,000 In-Network $3,000 In-Network $3,000 In-Network $0 copay. 250 days each

benefit period. 60 lifetime reserve days

Days 1-5: $75/day, Days 6-90: $0/Day, $0/day after 90 days. 260 days each benefit period.

60 lifetime reserve days.

$0 copay. 250 days each benefit period. 60 lifetime

reserve days.

$0 copay. 270 days each benefit period. 60 lifetime

reserve days. Days 1-31: $0/day, Days

32-100: $25/day. 100 days each benefit period.

Days 1-31: $0/day, Days 32-100: $25/day. 100 days each

benefit period.

Days 1-31: $0/day, Days 32-100: $25/day. 100 days each

benefit period.

Days 1-31: $0/day, Days 32-100: $25/day. 100 days each

benefit period. $0 copay. 150 days each

benefit period.

Days 1-5: $75/day, Days 6-150: $0/Day. 150 days each

benefit period.

$0 copay. 150 days each

benefit period. $0 copay. 150 days each benefit period. $0 each session $0 each session $0 each session $0 each session

$0 each visit $0 each visit $0 each visit $0 each visit

$100 each service. $0-$100 each service, waived if admitted. $100 each service. $100 each service. $65 each visit, waived if

admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted within 24-hrs.

$0 each visit $0 each visit $0 each visit $0 each visit

0-20% for each

Medicare-covered item. 0-20% for each

Medicare-covered item. 0-20% for each

Medicare-covered item. 0-20% for each

Medicare-covered item. $0 for diagnostic

procedures/tests. $0 - $75 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 - $75 for

diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 - $75 for

diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 - $75 for

diagnostic radiology services.

$0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray

$0 each lab service. $60 for

therapeutic radiology services. therapeutic radiology services.$0 each lab service. $60 for therapeutic radiology services.$0 each lab service. $60 for therapeutic radiology services.$0 each lab service. $60 for

$0 copay $0 copay $0 copay $0 copay

20% of the cost 20% of the cost 20% of the cost 20% of the cost $0 for Medicare-covered

benefits. Contact plan for additional benefits.

$0 for Medicare-covered

benefits. Contact plan for additional benefits.

$0 for Medicare-covered

benefits. Contact plan for additional benefits.

$0 for Medicare-covered

benefits. Contact plan for additional benefits. $0 for diagnostic exams.

Contact plan for additional benefits.

$0 for diagnostic exams. Contact plan for additional

benefits.

$0 for diagnostic exams. Contact plan for additional

benefits.

$0 for diagnostic exams. Contact plan for additional

benefits. $0 copay for diagnosis and

treatment of eye conditions. Contact plan for additional

benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay $0 copay $0 copay $0 copay

2015 Orange County HICAP

Medicare Advantage Special Needs Plans

Comparison Chart

(4)

Company Plan Name

Telephone Numbers Website

Plan Type

Total Monthly Premium Size of Physician and Provider

Network Doctor Visit Specialist Visit Out of Pocket Limit

In-patient Hospitalization

Skilled Nursing Facility

In-patient Mental Health

Outpatient Mental Health Outpatient Hospital Services

Ambulance

Emergency Room Visit Outpatient Rehabilitation

Services

Durable Medical Equipment

Diagnostic Tests

X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs

Dental Services

Hearing Services

Vision Services

Transportation Prescription Drugs

CareMore Health Plan Central Health Health Net SCAN

Touch Focus Jade Heart First

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com

New enrollment: 866-314-2427 Current members: 800-589-3147 centralhealthplan.com

New enrollment: 800-877-4814 Current members: 800-275-9737 healthnet.com/medicare

New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com SPECIAL NEEDS HMO

(Institutional) Medicare Health Plan with Prescription Drug Benefit for individuals residing in a long-term care setting.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with chronic diabetes mellitus.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders, chronic heart failure and/or diabetes.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with cardiovascular disorders and/or chronic heart failure.

$0 Monthly Premium $0 Monthly Premium $0 Monthly Premium $0 Monthly Premium

1001-1500 physicians and

providers 4501-5000 physicians and providers 3001-3500 physicians and providers 9001-10000 physicians and providers

$0 each visit $0 each visit $0 each visit $0 each visit

$0 each visit $0 each visit $0 each visit $0 each visit

$3,000 In-Network $3,400 In-Network $3,400 In-Network $3,400 In-Network

$0 copay. 245 days each benefit period. 60 lifetime

reserve days.

$0 copay. Unlimited days each

benefit period. $0 copay. Unlimited days each benefit period. $0 copay. Unlimited days each benefit period.

$0 copay. 100 days each benefit period.

Days 1-20: $0/day, Days 21-65: $75/day. Days 66-100: $0.

100 days each benefit period.

Days 1-31: $0/day, Days 32-100: $25/day. 100 days each

benefit period.

Days 1-20: $0/day, Days 21-100: $25/day. 100 days each

benefit period. $0 copay. 150 days each

benefit period. $0 copay. 190-day psychiatric hospital lifetime limit.

$900 copay. 190-days psychiatric hospital lifetime

limit.

$0 copay. 190-days psychiatric hospital lifetime limit.

$0 each session $5 each session $25 each session $20 each session

$0 each visit $0 each visit $0 - $60 each visit $0-$100 each visit

$100 each service. $50 each service. $40 each service, waived if admitted. $200 each service $65 each visit, waived if

admitted within 24-hrs. $50 each visit, waived if admitted within 24-hrs. $65 each visit, waived if admitted immediately. $65 each visit, waived if immediately admitted. $0 each visit $0 each visit $0 each visit $10 each visit all others$0 each visit cardiac 0-20% for each

Medicare-covered item. 0-20% for each

Medicare-covered item. 10% for each

Medicare-covered item. 0-20% for each Medicare-covered item. $0 for diagnostic

procedures/tests. $0 - $75 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $0 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $60 for diagnostic radiology services.

$0 for diagnostic procedures/tests. $100 for diagnostic radiology services.

$0 each X-ray $0 each X-ray $0 each X-ray $0 each X-ray

$0 each lab service. $60 for therapeutic radiology services.

$0 each lab service. 20% of the cost for therapeutic radiology

services.

$0 each lab service. $60 for

therapeutic radiology services. therapeutic radiology services.$0 each lab service. $50 for

$0 copay 20% of the cost 20% of the cost $0 copay

20% of the cost 20% of the cost 20% of the cost 20% of the cost

$0 for Medicare-covered benefits. Preventive benefits

not covered.

$0 for Medicare-covered benefits. Contact plan for

additional benefits.

$0 for Medicare-covered benefits. Contact plan for

additional benefits.

$0 for Medicare-covered benefits. Preventive benefits

not covered. $0 for diagnostic exams.

Contact plan for additional benefits.

$0 for diagnostic exams. Contact plan for additional

benefits.

$0 for diagnostic exams. Contact plan for additional

benefits.

$0 for diagnostic exams. Contact plan for additional

benefits. $0 copay for diagnosis and

treatment of eye conditions. Contact plan for additional

benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

$0 copay $0 copay $0 copay $0 copay

See separate Chart See separate Chart See separate Chart See separate Chart

2015 Orange County HICAP

Medicare Advantage Special Needs Plans

Comparison Chart

(5)

Company Plan Name

Telephone Numbers Website

Plan Type

Total Monthly Premium Size of Physician and Provider

Network Doctor Visit Specialist Visit Out of Pocket Limit

In-patient Hospitalization

Skilled Nursing Facility

In-patient Mental Health

Outpatient Mental Health Outpatient Hospital Services

Ambulance

Emergency Room Visit Outpatient Rehabilitation

Services

Durable Medical Equipment

Diagnostic Tests

X-Rays Lab Services Renal Dialysis Part B Chemotherapy Drugs

Dental Services

Hearing Services

Vision Services

Transportation

SCAN SCAN VillageHealth

Balance Healthy at Home VillageHealth

New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com

New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com

New enrollment: 877-916-1234 Current members: 800-399-7226 villagehealthca.com SPECIAL NEEDS HMO

(Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with diabetes mellitus.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those qualify for nursing home care but are deemed eligible to live in their own home.

SPECIAL NEEDS HMO (Chronic or Disabling Condition) Medicare Health Plan with Prescription Drug Benefit for those with end-stage renal disease requiring any mode of dialysis . $0 Monthly Premium $0 Monthly Premium Contact Plan for health plan $28.80 Monthly Premium

deductible 9001-10000 physicians and

providers 15001-16000 physicians and providers 3001-3500 physicians and providers

$0 each visit $10 each visit $0 each visit

$0 each visit $20 each visit 20% of the cost each visit $3,400 In-Network $6,700 In-Network $6,700 In-Network $0 copay. Unlimited days each

benefit period.

Days 1-10: $150/day. Days 11-90: $0, $0/day after 90 days.

Unlimited days each benefit period.

90 days each benefit period. 60 lifetime reserve days. Contact plan for more details. Days 1-20: $0/day, Days

21-100: $25/day. 100 days each benefit period.

Days 1-20: $0/day, Days 21-100: $100/day. 100 days each

benefit period.

100 days each benefit period. Contact plan for more details.

$0 copay. 190-days psychiatric hospital lifetime limit.

Days 1-10: $150/day. Days 11-90: $0. Contact plan for days

beyond 90. 190-days psychiatric hospital lifetime

limit.

190-day psychiatric hospital lifetime limit. Contact plan for

more details. $20 each session $35 each session 20% of the cost each session $0-$100 each visit $20-$100 or 20% of the cost each visit 20% of the cost each visit $200 each service $110 each service 20% of the cost each service $65 each visit, waived if

immediately admitted. $65 each visit, waived if immediately admitted. $65 each visit $0 each visit cardiac

$10 each visit all others $20 each visit 20% of the cost each visit 0-20% for each

Medicare-covered item.

20% for each Medicare-covered item.

20% for each Medicare-covered item. $0 for diagnostic

procedures/tests. $100 for diagnostic radiology services.

$0 for diagnostic procedures/tests. 20% of the costs for diagnostic radiology

services.

20% of the cost for diagnostic procedures/tests. 20% of the cost for diagnostic radiology

services. $0 each X-ray $0 each X-ray 20% of the cost each X-ray $0 each lab service. $50 for

therapeutic radiology services.

$0 each lab service. 20% of the costs for therapeutic radiology

services.

$0 each lab service. 20% of the cost for therapeutic radiology

services.

$0 copay $0 copay 20% of the cost

20% of the cost 20% of the cost 0% -20% of the cost $0 for Medicare-covered

benefits. Preventive benefits not covered.

$20 for Medicare-covered benefits. Preventive benefits

not covered.

20% of the cost for Medicare-covered benefits. Contact plan

for additional benefits. $0 for diagnostic exams.

Contact plan for additional benefits.

$20 for diagnostic exams. Routine exams and hearing

aids not covered.

20% of the cost for diagnostic exams. Routine exams and

hearing aids not covered. $0 copay for diagnosis and

treatment of eye conditions. Contact plan for additional

benefits.

$0 copay for diagnosis and treatment of eye conditions.

Contact plan for additional benefits.

0-20% of the cost for diagnosis and treatment of eye conditions. Contact plan for

additional benefits. $0 copay Transportation not covered. $0 copay

2015 Orange County HICAP

Medicare Advantage Special Needs Plans

Comparison Chart

(6)

Prescription Drug Plans associated with Health Maintenance Organiazations (HMO's )

Organization Name

Non-Member Telephone No.

Plan Internet Website

Plan Name

Monthly

Plan

Premium*

Annual

Deductible

for Part D

Copayments**

Coinsurance**

Overall

Quality

Rating

(Out of 5)

Drug Plan

Rating

(Out of 5)

Brand New Day

Bridges Drug Savings

$0

$0

$0 - $90

33%

3.5

3.0

866-255-4795

Bridges Extra Care

$28.80

$320

$0 - $10

25%

3.5

3.0

bndhmo.com

Harmony

$28.80

$320

see coinsurance

25%

3.5

3.0

Healty Heart Drug Savings

$0

$0

$0 - $90

33%

3.5

3.0

Healthy Heart Extra Care

$28.80

$320

$0 - $10

25%

3.5

3.0

Hope Drug Savings

$0

$0

$0 - $90

33%

3.5

3.0

In Control Drug Savings

$0

$0

$0 - $90

33%

3.5

3.0

In Control Extra Care

$28.80

$320

see coinsurance

25%

3.5

3.0

CareMore

Breathe

$0

$0

$0 - $85

33%

4.5

4.0

888-291-1358

ESRD

$0

$0

$0 - $85

33%

4.5

4.0

caremore.com

Heart

$0

$0

$0 - $85

33%

4.5

4.0

Reliance

$0

$0

$0 - $85

33%

4.5

4.0

Touch

$0

$0

$0 - $85

33%

4.5

N/A***

Central Health Medicare Plan

866-314-2427

Central Health Focus Plan

$0

$0

$0 - $50

33%

3.5

3.5

centralhealthplan.com

Health Net

800-877-4814

Health Net Jade

$0

$0

$0 - $95

33%

4.0

3.5

healthnet.com/medicare

SCAN Health Plan

Heart First

$0

$0

$0 - $95

33%

4.0

4.0

877-452-5898

Balance

$0

$0

$0 - $95

33%

4.0

4.0

scanhealthplan.com

Healthy at Home

$0

$0

$3 - $95

33%

3.5

3.5

VillageHealth

877-916-1234

VillageHealth

$28.80

$320

see coinsurance

25%

N/A***

2.0

villagehealthca.com

*Total premium cost is shown on the Medicare Advantage Special Needs Plans Comparison Chart.

***Information not available at time of publication.

**Amount you may be required to pay for each prescription, which may be either a dollar amount (copay) or a percentage (coinsurance).

2015 Medicare Part D Coverage Included in the Chroninc Illness and Institutional Special Needs Plans

Beneficiary must have both Medicare Parts A and B to enroll in a Medicare Advantage Plan with the drug benefits shown below.

References

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