Senior Educators: Plan Overview for SecureHorizons by UnitedHealthcare AARP MedicareComplete Medicare Plan

1-800-505-8575

Plan Overview for:

AARP MedicareComplete

SecureHorizons by UnitedHealthcare

Please review the following important information about benefits and coverage for the plan you selected.

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Premium
$85.00
per month

Overview

Doctors	Primary Care	Specialists	See plan doctors only
	$10	$10	per visit in network

Hospitals	Use plan hospitals only
	In-Network $200 copay for each Medicare-covered hospital stay $0 copay for each additional hospital day. No limit to the number of days covered by the plan each benefit period.

Drugs		Preferred Generic	Non-Preferred Generic	Preferred Brand	Non-Preferred Brand
	Pharmacy (30 Days)	$6	$79	$42	33%
	Mail Order (90 Days)	$12	$227	$116	33%
	Important notes: These prices are for the first $2,700 in annual drug spend after a $0 deductible. After $2,700, you pay 100% of the cost of drugs until you reach the catastrophic coverage period. Catastrophic coverage begins once you have spent a total of $4,350 in out of pocket drug costs during the year. Once you reach the catastrophic period, your maximum co-pay is about 5% of the actual cost of the drugs.

Other Important Information

Important notes: The important information in this overview section is intended to provide a quick summary of the information most of our clients request. More complete summary information about the plan is shown below and is accurate as of October 7, 2009 according to Medicare. You can download a copy of the plan's Summary of Benefits here.

Click To Enroll or Call 1-800-505-8575


Resources
	Benefits Summary	Click to Download
	Application Form	Click to Download
Fixed Cost Details
	Premium	$85.00
	Drug Deductible	$0 deductible
Important Information
	General Plan Information	Medicare Health Plan For Profit HMO Provides health and drug coverage Approved by Medicare Stanislaus County
1	Premium and Other Important Information	General $85.00 monthly plan premium in addition to your monthly Medicare Part B premium.
2	Doctor and Hospital Choice	In-Network You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits).
Inpatient Care
3	Inpatient Hospital Care	In-Network $200 copay for each Medicare-covered hospital stay $0 copay for each additional hospital day. No limit to the number of days covered by the plan each benefit period.
4	Inpatient Mental Health Care	In-Network $200 copay for each Medicare-covered hospital stay. You get up to 190 days in a Psychiatric Hospital in a lifetime.
5	Skilled Nursing Facility	In-Network For Medicare-covered SNF stays: Days 1 - 100: $0 copay per day Plan covers up to 100 days each benefit period No prior hospital stay is required.
6	Home Health Care	In-Network $0 copay for each Medicare-covered home health visit.
7	Hospice	General You must get care from a Medicare-certified hospice.
Outpatient Care
8	Doctor Office Visits	General See "Physical Exams," for more information. In-Network $10 copay for each primary care doctor visit for Medicare-covered benefits. $20 copay for each in-area, network urgent care Medicare-covered visit. $10 copay for each specialist visit for Medicare-covered benefits.
9	Chiropractic Services	In-Network $10 copay for each Medicare-covered visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.
10	Podiatry Services	In-Network $10 copay for each Medicare-covered visit. Medicare-covered podiatry benefits are for medically-necessary foot care.
11	Outpatient Mental Health Care	In-Network $10 copay for each Medicare-covered individual or group therapy visit.
12	Outpatient Substance Abuse Care	In-Network $10 copay for Medicare-covered individual or group visits.
13	Outpatient Services/Surgery	In-Network $0 copay for each Medicare-covered ambulatory surgical center visit. $0 copay for each Medicare-covered outpatient hospital facility visit.
14	Ambulance Services	In-Network $150 copay for Medicare-covered ambulance benefits.
15	Emergency Care	General $40 copay for Medicare-covered emergency room visits. Worldwide coverage.
16	Urgently Needed Care	General $40 copay for Medicare-covered urgently needed care visits.
17	Outpatient Rehabilitation Services	In-Network $0 copay for Medicare-covered Occupational Therapy visits. $0 copay for Medicare-covered Physical and/or Speech/Language Therapy visits.
Outpatient Medical Services and Supplies
18	Durable Medical Equipment	In-Network 20 % of the cost for Medicare-covered items.
19	Prosthetic Devices	In-Network 20 % of the cost for Medicare-covered items.
20	Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies	In-Network $0 copay for Diabetes self-monitoring training. $0 copay for Nutrition Therapy for Diabetes . $0 copay for Diabetes supplies.
21	Diagnostic Tests, X-Rays, and Lab Services	In-Network $10 copay for Medicare-covered lab services. $0 to $10 copay for Medicare-covered diagnostic procedures and tests. $0 copay for Medicare-covered X-rays. 20 % of the cost for Medicare-covered diagnostic radiology services. 20 % of the cost for Medicare-covered therapeutic radiology services.
Preventive Services
22	Bone Mass Measurement	In-Network $0 copay for Medicare-covered bone mass measurement.
23	Colorectal Screening Exams	In-Network $0 copay for Medicare-covered colorectal screenings.
24	Immunizations	In-Network $0 copay for Flu and Pneumonia vaccines. No referral needed for Flu and pneumonia vaccines. $0 copay for Hepatitis B vaccine.
25	Mammograms (Annual Screening)	In-Network $0 copay for Medicare-covered screening mammograms.
26	Pap Smears and Pelvic Exams	In-Network $0 copay for Medicare-covered pap smears and pelvic exams $0 copay up to 1 additional pap smear(s) and pelvic exam(s) every year
27	Prostate Cancer Screening Exams	In-Network $0 copay for Medicare-covered prostate cancer screening.
28	End-Stage Renal Disease (ESRD)	In-Network $0 copay for renal dialysis $0 copay for Nutrition Therapy for End-Stage Renal Disease.
Additional Benefits
29	Prescription Drugs	Drugs Covered under Medicare Part B General 20 % of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. Drugs Covered under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.SecureHorizons.com/ourplans/searchformulary.html on the web. Different out-of-pocket costs may apply for people who have limited incomes, live in long term care facilities, or have access to Indian/Tribal/Urban (Indian Health Service). The plan offers national in-network prescription coverage (i.e., this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and the plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from AARP MedicareComplete (HMO) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements for these drugs that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website, formulary, and printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. If you request a formulary exception for a drug and AARP MedicareComplete (HMO) approves the exception, you will pay Tier 3 Non-Preferred Generic Non-Preferred Brand cost-sharing for that drug. In-Network $0 deductible. Initial Coverage You pay the following until total yearly drug costs reach $2,830: Retail Pharmacy Tier 1 Preferred Generic Brand Tier 2 Generic Preferred Brand Tier 3 Non-Preferred Generic Non-Preferred Brand Tier 4 Specialty $6 copay for a one-month (31-day) supply of drugs in this tier $42 copay for a one-month (31-day) supply of drugs in this tier $79 copay for a one-month (31-day) supply of drugs in this tier 33 % coinsurance for a one-month (31-day) supply of drugs in this tier $18 copay for a three-month (90-day) supply of drugs in this tier $126 copay for a three-month (90-day) supply of drugs in this tier $237 copay for a three-month (90-day) supply of drugs in this tier 33 % coinsurance for a three-month (90-day) supply of drugs in this tier Long Term Care Pharmacy Tier 1 Preferred Generic Brand Tier 2 Generic Preferred Brand Tier 3 Non-Preferred Generic Non-Preferred Brand Tier 4 Specialty $6 copay for a one-month (31-day) supply of drugs in this tier $42 copay for a one-month (31-day) supply of drugs in this tier $79 copay for a one-month (31-day) supply of drugs in this tier 33 % coinsurance for a one-month (31-day) supply of drugs in this tier Mail Order Tier 1 Preferred Generic Brand Tier 2 Generic Preferred Brand Tier 3 Non-Preferred Generic Non-Preferred Brand Tier 4 Specialty $12 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $116 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $227 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. 33 % coinsurance for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy. $18 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $126 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. $237 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. 33 % coinsurance for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy. Coverage Gap After your total yearly drug costs reach $2,830, you pay 100 % until your yearly out-of-pocket drug costs reach $4,550. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $ 4,550, you pay the greater of: A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or 5 % coinsurance. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from AARP MedicareComplete (HMO). Out-of-Network Initial Coverage You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2,830: Out-of-Network Pharmacy Tier 1 Preferred Generic Brand Tier 2 Generic Preferred Brand Tier 3 Non-Preferred Generic Non-Preferred Brand Tier 4 Specialty $6 copay for a one-month (31-day) supply of drugs in this tier $42 copay for a one-month (31-day) supply of drugs in this tier $79 copay for a one-month (31-day) supply of drugs in this tier 33 % coinsurance for a one-month (31-day) supply of drugs in this tier Out-of-Network Coverage Gap After your total yearly drug costs reach $2,830, you pay 100 % of the pharmacy's full charge for drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4,550. You will not be reimbursed by AARP MedicareComplete (HMO) for out-of-network purchases when you are in the coverage gap. However, you should still submit documentation to AARP MedicareComplete (HMO) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $ 4,550, you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus the following: A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs, or 5 % coinsurance.
30	Dental Services	In-Network In general, preventive dental benefits (such as cleaning) not covered. $10 copay for Medicare-covered dental benefits.
31	Hearing Services	In-Network $10 copay for Medicare-covered diagnostic hearing exams $0 copay for up to 1 routine hearing test(s) every year $0 copay per hearing aid $300 limit for hearing aids every two years.
32	Vision Services	In-Network $0 copay for one pair of eyeglasses or contact lenses after cataract surgery. $10 copay for exams to diagnose and treat diseases and conditions of the eye. $30 copay for up to 1 routine eye exam(s) every two years $30 copay for contacts $0 copay for up to 1 pair(s) of lenses every two years $30 copay for up to 1 frame(s) every two years $105 limit for contact lenses every two years. $70 limit for eye glass frames every two years.
33	Physical Exams	In-Network $0 copay for routine exams. Limited to 1 exam(s) every year. $0 copay for Medicare-covered benefits.
34	Health/Wellness Education	In-Network The plan covers the following health/wellness education benefits: Written health education materials, including Newsletters Nursing Hotline $0 copay for each Medicare-covered smoking cessation counseling session.
35	Transportation	In-Network This plan does not cover routine transportation.
36	Acupuncture	In-Network This plan does not cover Acupuncture.
37	Point of Service	Information Not Available
38	Estimated Annual Cost	$4,200
39	Provider Network	1001-1500 physicians and providers. Click to View Provider and Physician Network Website
Important Notes
	Important Notes	The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
	Footnotes	¹Monthly Premiums and Estimated Annual Costs don't include any Medicare Part D (prescription drug) late enrollment penalty amounts that may apply to you. ²This is the Medicare Part B premium that most people will pay in 2010.

	Effective Dates	Effective Starting 01/01/2010 Effective Through 12/31/2010
Resources
	Benefits Summary	Click to Download
	Application Form	Click to Download

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