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2018 Classic Plus Rx (HMO) | HeartlandPlains Health

Classic Plus Rx offers comprehensive medical coverage and includes Medicare prescription drug coverage. This plan includes worldwide emergency coverage. What follows is a partial list of 2018 benefits.

Medical Service Area: Douglas and Lancaster Counties in Nebraska

BENEFIT*

COST

Monthly Premium

$0 per month

In addition, you must keep paying your Medicare Part B premium.

Out of Pocket Maximum

$6,700 out-of-pocket limit every year for all member cost sharing excluding Part D pharmacy

Non-Medicare covered preventive dental, eyewear, eye exam, fitness and hearing aid cost sharing does not count towards the out of pocket maximum amount.

Doctor Office Visits

  • Primary Care Provider: $5 copay 
  • Annual Physical: $0 copay 
  • Specialist: $35 copay

Emergency Care 
(You may go to any emergency room if you reasonably believe you need emergency care)

$80 copay; waived if admitted within 24 hours for same condition

Ambulance Services 
(Medically necessary ambulance services)

$255 copay; not waived if admitted

Prior authorization is required for non-emergency ambulance transportation.*

Urgently Needed Services 
(This is NOT emergency care)

$40 copay; not waived if admitted

Inpatient Hospital Care 
(Includes Substance Abuse & Rehabilitation Services)

$450 copay per day, days 1-4;
$0 copay per day, days 5-90;
$0 copay for additional days 

Prior authorization is required for non-urgent and non-emergent admissions. Urgent and/or emergent facility stays requires the treating provider to notify the health plan within 24 hours of initiation of services in order for the health plan to coordinate the care that you receive.*

Outpatient Services/Surgery

  • Ambulatory Surgery Center: $350 copay
  • Outpatient Hospital Facility: 20% coinsurance
  • Outpatient Clinic: $35 copay

Prior authorization is required for certain services.*

Outpatient Rehabilitation Services

Occupational Therapy, Physical Therapy, Speech & Language Therapy: $35 copay for each visit

Prior authorization is required on some services.*

Skilled Nursing Facility 
(In a Medicare-certified skilled nursing facility)

$0 copay per day, days 1-20;
$167.50 copay per day, days 21-60;
$0 copay per day, days 61-100

100 days per benefit period; no prior hospital stay is required. Prior authorization is required.*

Outpatient Mental Health Care

  • Individual or Group Therapy Visit: $40 copay 
  • Partial Hospitalization Program Services: $55 copay per day

Prior authorization is required for certain services.*

Diagnostic Tests, X-Rays, Lab Services & Radiology Services

  • Lab Services: $10 copay per day, per visit
  • X-rays: $20 copay per day maximum
  • Diagnostic Radiology Services (not including X-rays): 20% coinsurance
  • Therapeutic Radiology Services: 20% coinsurance

Prior authorization is required for certain services.*

Limited Dental Services 
(Medicare covered dental benefits)

$35 copay

Preventive Dental

$20 copay per visit, through plan vendor 

  • One exam every 6 months 
  • One x-ray every 6 months 
  • One cleaning every 6 months

Hearing Services

  • Medicare-covered diagnostic hearing exams: $0-$35 copay; $0 copay through plan vendor; higher copay applies to exams performed by all other providers
  • $1,000 annual hearing aid discount (per ear)
  • One routine hearing exam every year: $0-$35 copay

Health Club Membership & Fitness Classes

American Specialty Health Silver&Fit® program including membership to local fitness centers, exercise classes, and online support to achieve fitness goals: $0 copay

Vision Services

  • One standard pair of eyeglasses or contact lenses after cataract surgery: $0 copay
  • Exams to diagnose and treat diseases and conditions of the eye: $0-$35 copay; $0 copay through plan vendor; $0 copay for Medicare-covered Glaucoma test; higher copay applies to all other Medicare-covered eye exams.
  • One routine eye exam every year through plan vendor: $20 copay
  • One pair of eyeglasses or contact lenses through plan vendor, every 24 months: $30 copay.
  • Plan coverage limit for eye wear: $120 every 24 months

Part D Deductible

$160 per year on drugs in Tier 3, Tier 4 and Tier 5

Prescription Drug 31-day

Supply (Retail)

Tier 1: $2 copay
Tier 2: $12 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance

Prescription Drug 62-day

Supply (Retail)

Tier 1: $4 copay
Tier 2: $24 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not covered

Prescription Drug 93-day

Supply (Retail)

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not covered

Prescription Drug 93-day

Supply (Mail Order)

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not covered



Benefit 
Plan Information

Download Plan Information For Classic Plus Rx (HMO):

2018 Evidence of Coverage (EOC) Download
2018 Summary of Benefits (SB) Download
HeartlandPlains Health Prescription Transition Policy Download
2018 Comprehensive Formulary Download
Appeals and Grievances Information View Page
Multi-Language Sheet Download
HeartlandPlains Health Star Rating Information Download

Note: Members of our plan generally must use network pharmacies to receive plan coverage. You may choose to have your prescription drugs shipped to your home through the network mail order delivery program. For refills, please contact your pharmacy before you run out of the prescription drugs you have on hand. Usually, a mail-order pharmacy order will get to you within 14 days. If your mail order prescription drug is delayed, we recommend you contact the mail-order pharmacy directly. If you have questions or concerns, the Customer Service phone number is listed on your ID card. Quantity limitations and restrictions may apply.

Out-of-network coverage rules:

With limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which our Plan authorizes use of out-of-network providers. See Chapter 3 of your Evidence of Coverage book (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

*For complete information about your benefits, and about limitations or restrictions to your medical or drug benefits, please see Chapters 4, 5, and 6 in your Evidence of Coverage (EOC) document.



Page Last Updated: October 01, 2017