1. Healthcare

Benefit highlights
AARP® MedicareComplete® Plan 2 (HMO)
This is a short description of 2015 plan benefits. For complete information, please refer to your Summary of
Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply.
Plan Costs
Monthly plan premium
Annual out-of-pocket maximum
$55
$4,200
Medical Benefits
In-Network
Benefits covered by Original Medicare and AARP® MedicareComplete® Plan 2 (HMO)
Doctor’s office visit
Preventive services
Inpatient hospital care
Skilled nursing facility (SNF)
Outpatient surgery
Diabetes monitoring supplies
Home health care
Diagnostic radiology services
(such as MRIs, CT scans)
Diagnostic tests and procedures
(non-radiological)
Lab services
Outpatient x-rays
Ambulance
Emergency care
Urgent care
Primary Care Physician: $5 copay
Specialist: $35 copay (referral needed)
$0 copay
$320 copay per day: days 1-5
$0 copay per day after that
$0 copay per day: days 1-20
$155 copay per day: days 21-48
$0 copay per day: days 49-100
20% of the cost
$0 copay for covered brands
$0 copay
20% of the cost
20% of the cost
$13 copay
$16 copay
$250 copay
$65 copay (worldwide)
$30 - $40 copay
Additional benefits and programs not covered under Original Medicare
Routine physical
Vision - routine eye exams
Vision - eyewear
Dental - preventive
Foot care - routine
Hearing - routine exam
Hearing aids
$0 copay; 1 per year
$35 copay; 1 per year
$0 copay every 2 years; up to $70 for frames (standard lenses
included) or $105 for contacts (up to 4 boxes)
$0 copay for covered services (exam, cleaning, x-rays)
$35 copay; 6 visits per year
$5 copay; 1 per year
$330 - $380 copay for each hi HealthInnovations™ hearing aid, up to
2 per year (Additional fees with Power Max model)
Medical Benefits
In-Network
Fitness program through
SilverSneakers® Fitness program
NurseLineSM
Basic membership in a fitness program at a network location
Prescription Drugs
Your Cost
Annual prescription deductible
Initial coverage stage
$0 Tier 1, Tier 2, and Tier 5; $180 for Tier 3 and Tier 4
Standard Retail
Preferred Mail Order
(30-day)
(90-day)
$2 copay
$4 copay
$8 copay
$16 copay
Tier 1: Preferred Generic Drugs
Tier 2: Non-Preferred Generic
Drugs
Tier 3: Preferred Brand Drugs
Tier 4: Non-Preferred Brand
Drugs
Tier 5: Specialty Tier Drugs
Coverage gap stage
Catastrophic coverage stage
Speak with a registered nurse (RN) 24 hours a day, 7 days a week
$45 copay
$95 copay
$125 copay
$275 copay
33% of the cost
33% of the cost
After your total drug costs reach $2,960, you will pay no more than
65% of the total cost for generic drugs or 45% of the total cost for
brand name drugs, for any drug tier during the coverage gap
After your total out-of-pocket costs reach $4,700, you will pay the
greater of $2.65 copay for generic (including brand drugs treated as
generic), $6.60 copay for all other drugs, or 5% of the cost
Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a
Medicare Advantage organization with a Medicare contract. Enrollment in the plan depends on the plan’s
contract renewal with Medicare.
Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may
change on January 1 of each year.
The benefit information provided is a brief summary, not a complete description of benefits. For more
information, contact the plan. You must continue to pay your Medicare Part B premium, if not otherwise paid
for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply.
Y0066_MABH_FINAL_H1286009 ACCEPTED
AAWA15HM3574840_000