1. Healthcare

PHOENIX ADVANTAGE (HMO)
PHOENIX ADVANTAGE SELECT (HMO)
2015
PLAN GUIDE
H5985_024-2015 Accepted
Phoenix Advantage and Phoenix Advantage
Select are Medicare Advantage HMO plans.
We proudly serve Arizona residents in
Coconino, Gila, Maricopa, Mohave, Pima,
Pinal, Santa Cruz, and Yavapai counties,
offering doctor, hospital and prescription
drug coverage.
Phoenix Advantage (HMO)
Phoenix Advantage Select (HMO)
Call and learn more:
(602) 824-3900 or toll free (888) 864-1114
TTY users call 1-800-842-4681
8 a.m. to 8 p.m., 7 days a week
Join Us Online
Online enrollment is safe and secure.
www.PhoenixHealthPlans.com
ABOUT
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
Our Medicare-approved plans are based right
here in Arizona. For a $0 monthly premium,
we offer doctor, hospital and prescription drug
coverage. Or pay a $39 monthly premium and
get all this plus extras.
OUR $39 PLAN OFFERS
MORE THAN
ORIGINAL MEDICARE
•Open access to in-network specialists
•Personalized medical management
•Coverage for annual screenings
•Diabetic monitoring supplies,
therapeutic shoes and inserts
•Nationwide emergency and
urgent care coverage
•Maximum Out of Pocket
(MOOP) $4,500
•Vision benefit with low exam co-pay
•Dental benefit up to $750 per year
•OTC drug allowance up to $35 per
quarter, restrictions may apply
OUR MEMBER SERVICE
REPRESENTATIVES ARE
HERE TO HELP
Friendly and helpful member services
representatives are available seven days
a week.
Our first priority is supporting our members
and helping them manage their
healthcare effectively.
MEDICARE BASICS
Medicare is health insurance for the following:
• People 65 or older.
• People under 65 with certain
disabilities, restrictions may apply.
• People of any age with End-Stage
Renal Disease (ESRD) (permanent
kidney failure requiring dialysis or a
kidney transplant.)
THE DIFFERENT PARTS
OF MEDICARE
The different parts of Medicare help cover
specific services:
MEDICARE PART A
(Hospital Insurance)
• Helps cover inpatient care in
hospitals, skilled nursing facilities,
hospice, and home health care.
• Most people don’t have to pay
a premium for Medicare Part A
because they or a spouse paid
Medicare taxes while working in
the United States. If you don’t
automatically get premium-free Part
A, you may still be able to enroll,
and pay a premium.
MEDICARE PART B
(Medical Insurance)
• Helps cover doctors’ and other
health care providers’ services,
outpatient care, durable medical
equipment, and home health care.
• Helps cover some preventive services.
• Most people pay up to the standard
monthly Medicare Part B premium.
MEDICARE PART C
(also known as Medicare Advantage)
• Offers health plan options run
by Medicare-approved private
insurance companies. Medicare
Advantage Plans are a way to
get the benefits and services
covered under Part A and Part
B. Most Medicare Advantage
Plans cover Medicare prescription
drug coverage (Part D).
• Some Medicare Advantage
Plans may include extra
benefits for an extra cost.
MEDICARE PART D
(Medicare Prescription Drug Coverage)
• Helps cover the cost of
prescription drugs.
• May help lower your prescription
drug costs and help protect
against higher costs.
• Run by Medicare-approved
private insurance companies.
• Costs and benefits vary by plan.
Information provided by Centers for Medicare
& Medicaid Services, www.medicare.gov
LOW INCOME SUBSIDY (LIS)
YOU MAY QUALIFY
FOR EXTRA HELP
If you meet certain income and resource
requirements, you may qualify for Extra Help
to help pay the costs of Medicare prescription
drug coverage.
You automatically qualify for Extra Help
if you have Medicare and meet one of
these conditions:
• You have full Medicaid coverage, or
• You get help from your state Medicaid
program to pay your Part B premiums
(in a Medicare Savings Program), or
• You get Supplemental Security Income
(SSI) benefits.
APPLY FOR EXTRA HELP
Apply online at www.socialsecurity.gov
or by calling Social Security toll free at
1‑800‑772‑1213, 7 a.m. to 7 p.m.
Monday through Friday. TTY users should
call 1‑800‑325‑0778. Also you can call
1-800-MEDICARE (800) 633-4227).
TTY users should call (877) 486-2048,
24 hours a day/7 days a week and visit
www.medicare.gov to review “Programs for
People with Limited Income and Resources”
in the publication Medicare & You.
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
Covers all Original Medicare services and
includes prescription drug coverage for a
monthly premium of $0. Pay a $39 monthly
premium and receive these services plus
extras. (You must continue to pay your
Medicare Part B premium.)
PHOENIX ADVANTAGE (HMO)
BENEFITS AT A GLANCE
MedicareCovered Benefit
Phoenix
Advantage (HMO)
Primary Care
Provider (PCP)
Office Visit
$5 co-pay
Specialist
Office Visit
$45 co-pay
Inpatient
Hospital Stay
Plan Covers
90 days
Each benefit
period
Days 1 - 6
$225 co-pay per day
Days 7 - 90
$0 co-pay per day
60 lifetime reserve
days, at $0 co-pay
per day
Urgently
Needed Care
$35 co-pay
Emergency
Care
$0 to $65* co-pay
Skilled Nursing
Facility Care
Up to 100 days
per benefit
period
Days 1 - 20
$0 co-pay per day
Days 21 - 100
$150 co-pay per day
$0 co-pay X-rays
X-Rays,
$15 co-pay
Diagnostic
Procedures, Tests lab services, diagnostic
procedures and tests
*$0 co-pay If admitted within 24-hours for the
same condition.
PHOENIX ADVANTAGE SELECT (HMO)
BENEFITS AT A GLANCE
MedicareCovered Benefit
Phoenix Advantage
Select (HMO)
Primary Care
Provider (PCP)
Office Visit
$0 co-pay
Specialist
Office Visit
$40 co-pay
Inpatient
Hospital Stay
Plan Covers
90 days
Each benefit
period
Days 1 - 6
$175 co-pay per day
Days 7 - 90
$0 co-pay per day
60 lifetime reserve
days, at $0 co-pay
per day
Urgently
Needed Care
$35 co-pay
Emergency Care
$0 to $65* co-pay
Skilled Nursing
Facility Care
Up to 100 days
per benefit
period
Days 1 - 20
$0 co-pay per day
Days 21 - 100
$100 co-pay per day
$0 co-pay
X-Rays,
X-rays, lab services,
Diagnostic
diagnostic procedures
Procedures, Tests
and tests
*$0 co-pay If admitted within 24-hours for the
same condition.
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
PRESCRIPTION DRUG
BENEFITS AT A GLANCE
Retail Pharmacy
Tier Levels
30 Days 60 Days
90 Days
Preferred
Generics
$3
co-pay
$6
co-pay
$9
co-pay
Non-Preferred
Generics
$10
co-pay
$20
co-pay
$30
co-pay
Preferred
Brand
$25
co-pay
$50
co-pay
$75
co-pay
Non-Preferred
Brand
$75
co-pay
$150
co-pay
$225
co-pay
Specialty
Drugs
33% cost sharing for 30 days
Not offered for 60 or 90 days
Medicare Part B Drugs –
20%
including
co-insurance
Chemotherapy Drugs
Mail order – 3-month prescription for the price
of 2.5 month retail prescription
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
PRESCRIPTION DRUG
BENEFITS AT A GLANCE
(CONTINUED)
Coverage Gap – During the coverage gap, you
pay 45% of the cost for brand name drugs. The
plan also covers Tier 1 preferred generic drugs
during the coverage gap, both via retail and
mail order. Cost for these drugs is the lower of
the following:
30-day supply - $3 or 65% of the costs
60-day supply - $6 or 65% of the costs
90-day supply - $9 or 65% of the costs
For all other generic drugs, you pay 65% of the
costs and the plan pays the rest.
You continue paying the discounted price
for brand name drugs and no more than the
amounts listed above for generic drugs until
your yearly out-of-pocket payments reach a
maximum of $4,700.
Catastrophic Coverage – After your total
yearly out-of-pocket drug costs reach $4,700,
you pay the greater of 5% co-insurance, or
$2.65 for generic drugs (including brand drugs
treated as generic) and a $6.60 co-pay for all
other drugs.
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
OUT-OF-NETWORK PHARMACY
OUT-OF-NETWORK
COVERAGE GAP COSTS
GENERIC DRUGS
You will be reimbursed up to 35% of the plan’s
allowable cost for generic drugs purchased out
of network until your total yearly out-of-pocket
drug costs reach $4,700.
BRAND DRUGS
You will be reimbursed up to 55% of the
plans allowable cost for brand name drugs
purchased out-of-network until your total
yearly out-of-pocket drug costs reach $4,700.
OUT-OF-NETWORK
CATASTROPHIC COVERAGE COSTS
After your total yearly out-of-pocket drug costs
reach $4,700, you will be reimbursed for drugs
purchased out-of-network up to the plan’s cost
of the drug minus your cost share, which is the
greater of 5% coinsurance, or $2.65 co-pay for
generic drugs, including brand drugs treated
as generic. For all other drugs, your co-pay is
$6.60
Traveling the U.S.? Phoenix Advantage (HMO)
and Phoenix Advantage Select (HMO)
offer nationwide in-network prescription
drug coverage.
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
OFFER DIABETIC
PROGRAMS AND SUPPLIES
AT NO EXTRA COST TO YOU:
DIABETES PROGRAMS
AND SUPPLIES
Original
Medicare
Phoenix Advantage (HMO)
and Phoenix Advantage
Select (HMO)
20%
coinsurance
$0 co-pay
for diabetes
self-management
training
20%
coinsurance
$0 co-pay
for diabetes
monitoring supplies
20%
coinsurance
$0 co-pay
for therapeutic
shoes and inserts
MORE
PHOENIX ADVANTAGE (HMO) AND
PHOENIX ADVANTAGE SELECT (HMO)
EXTRAS AT NO EXTRA COST!
HOME HEALTH VISITS*
$0 co-pay for Medicare-covered visits
including medically-necessary intermittent
skilled nursing care, home health aide services
and rehabilitation services.
OUTPATIENT MENTAL HEALTH*
$40 co-pay each Medicare-covered
visit, including:
•Individual Therapy
•Psychiatrist (Individual)
•Group Therapy
•Psychiatrist (Group Therapy)
•0% or 20% co-pay for Medicarecovered partial hospitalization
program services
*Authorization rules may apply
GOOD HEALTH BEGINS
WITH PREVENTIVE CARE
Phoenix Advantage (HMO) and
Phoenix Advantage Select (HMO) members
receive all these preventive services at no
extra cost to them:
Abdominal Aortic
Screening
Mammogram
Bone Mass
Measurement
Medical Nutritional
Therapy Services
Cardiovascular
Screening
Annual
Wellness Visits
Cervical and
Vaginal Screening
Pneumococcal
Vaccine
PAP Test and
Pelvic Exam
Prostate Cancer
Screening
Colorectal Cancer
Screening
Smoking Cessation
Diabetes Screening
“Welcome to
Medicare”
Physical Exam
HIV Screening
Educational/
Health Newsletters
Influenza &
Hepatitis B Vaccine
24-hour
Nurse Advice Line
WHEN CAN YOU ENROLL?
INITIAL ENROLLMENT PERIOD (IEP)
Your IEP begins three months before the
month you get Medicare, during the month
you get Medicare and ends three months after
the month you get Medicare.
ANNUAL ELECTION PERIOD (AEP)
You may join or switch from your current plan
during the Annual Election Period that begins
October 15 and ends December 7 annually.
SPECIAL ENROLLMENT PERIOD (SEP)
A Special Enrollment Period allows you
to change your Medicare Advantage and
Medicare prescription drug coverage
when certain events happen in your life,
For example: you move out of your plan’s
service area or leave coverage from your
employer or union.
There are many situations that qualify you for
a Special Enrollment Period. For more SEP
information, call Medicare at (1‑800‑633‑4227)
24 hours a day, 7 days a week. TTY users
should call 1‑877‑486‑2048. Or visit Medicare
online at www.Medicare.gov
JOIN US
$0/39 PREMIUM WITH
EXTRAS YOU CAN’T GET FROM
ORIGINAL MEDICARE!
Contact
Phoenix Advantage (HMO) and
Phoenix Advantage Select (HMO)
Today!
By Phone
(602) 824-3900
or Toll Free (888) 864-1114
TTY users call 1-800-842-4681
8 a.m. to 8 p.m., 7 days a week
Online
Visit us at
www.PhoenixHealthPlans.com
to learn more or enroll online
NOTES
ENROLL ONLINE!
Visit our website at
www.PhoenixHealthPlans.com
to complete and submit your
2015 enrollment application online.
CALL TO ENROLL
Phoenix Advantage (HMO)
Phoenix Advantage Select (HMO)
(602) 824-3900
or Toll Free (888) 864-1114
TTY users call 1-800-842-4681
8 a.m. to 8 p.m., 7 days a week
Phoenix Health Plans is an HMO and HMO SNP
plan with a Medicare contract and a contract
with the Arizona Medicaid program. Enrollment
in Phoenix Health Plans depends on contract
renewal. You must continue to pay your Medicare
Part B Premium. The benefit information
provided is a brief summary, not a complete
description of benefits. For more information
contact the plan. Limitations, co-payments,
and restrictions may apply. Benefits, formulary,
pharmacy network, premium and/ or copayments/coinsurance may change on January
1 of each year. For more information, contact
the plan. Please contact our Member Services
number at (602) 824-3900 or (888) 864-1114 for
additional information. (TTY users should call
(800) 842-4681). Hours are seven days a week,
8 a.m. to 8 p.m.This information is available for
free in other languages. Esta información está
disponible gratuitamente en otros lenguajes.
Por favor llame a servicio al miembro al (888)
864-1114 para información adicional. (Usuarios
de TTY llamar al (800) 842-4681). Horario es
siete días a la semana de 8 a.m. a 8 p.m.