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Introduction to the Summary of Benefits Report
for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
January 1, 2009 - December 31, 2009
NEW YORK STATE
Thank you for your interest in Independent Health’s Medicare Anywhere Basic. Our
plan is offered by INDEPENDENT HEALTH BENEFITS CORPORATION/Independent
Health, a Medicare Advantage Private Fee-for-Service organization. This Summary of
Benefits tells you some features of our plan. It doesn’t list every service that we cover
or list every limitation or exclusion. To get a complete list of our benefits, please call
Independent Health’s Medicare Anywhere Basic and ask for the “Evidence of
Coverage.”
YOU HAVE CHOICES IN YOUR HEALTH CARE
As a Medicare beneficiary, you can choose from different Medicare options. One option
is the Original (fee-for-service) Medicare plan. Another option is a Medicare Advantage
Private Fee-for-Service plan, like Independent Health’s Medicare Anywhere Basic. You
may have other options too. You make the choice. No matter what you decide, you are
still in the Medicare program.
You may join or leave a plan only at certain times. Please call Independent Health’s
Medicare Anywhere Basic at the number listed at the end of this introduction or
1-800-MEDICARE (1-800-633-4227) for more information. TTY users should call
1-877-486-2048. You can call this number 24 hours a day, 7 days a week.
HOW CAN I COMPARE MY OPTIONS?
You can compare Independent Health’s Medicare Anywhere Basic and the Original
Medicare Plan using this Summary of Benefits. The charts in this booklet list some
important health benefits. For each benefit, you can see what our plan covers and what
the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also
offer more benefits, which may change from year to year.
WHERE IS INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
AVAILABLE?
The service area for this plan includes: Albany, Allegany, Bronx, Broome, Cattaraugus,
Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware,
Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson,
Kings, Lewis, Livingston, Madison, Monroe, Montgomery, Nassau, New York, Niagara,
Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Queens,
Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, St.
Lawrence, Steuben, Suffolk, Sullivan, Tioga, Tompkins, Ulster, Warren, Washington,
Wayne, Westchester, Wyoming, Yates Counties, NY. You must live in one of these areas
to join the plan.
H9519_C1269rev 10/2008
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 1
Introduction to the Summary of Benefits Report
for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
January 1, 2009 - December 31, 2009
NEW YORK STATE
WHO IS ELIGIBLE TO JOIN INDEPENDENT HEALTH’S MEDICARE ANYWHERE
BASIC?
You can join Independent Health’s Medicare Anywhere Basic if you are entitled to
Medicare Part A and enrolled in Medicare Part B and live in the service area. However,
individuals with End Stage Renal Disease are generally not eligible to enroll in
Independent Health’s Medicare Anywhere Basic unless they are members of our
organization and have been since their dialysis began.
CAN I CHOOSE MY DOCTORS?
A Medicare Advantage Private Fee-for-Service plan works differently than a Medicare
supplement plan. Your doctor or hospital is not required to agree to accept the plan’s
terms and conditions, and thus may choose not to treat you, with the exception of
emergencies. If your doctor or hospital does not agree to accept our payment terms and
conditions, they may choose not to provide healthcare services to you, except in
emergencies.
DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS?
Independent Health’s Medicare Anywhere Basic does cover both Medicare Part B
prescription drugs and Medicare Part D prescription drugs.
WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN?
Independent Health’s Medicare Anywhere Basic has formed a network of pharmacies.
You must use a network pharmacy to receive plan benefits. We may not pay for your
prescriptions if you use an out-of-network pharmacy, except in certain cases. The
pharmacies in our network can change at any time. You can ask for a current pharmacy
directory or visit us at www.independenthealth.com. Our customer service number is
listed at the end of this introduction.
WHAT IS A PRESCRIPTION DRUG FORMULARY?
Independent Health’s Medicare Anywhere Basic uses a formulary. A formulary is a list
of drugs covered by your plan to meet patient needs. We may periodically add, remove,
or make changes to coverage limitations on certain drugs or change how much you pay
for a drug. If we make any formulary change that limits our members’ ability to fill their
prescriptions, we will notify the affected enrollees before the change is made. We will
send a formulary to you and you can see our complete formulary on our Web site at
www.independenthealth.com.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 2
Introduction to the Summary of Benefits Report
for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
January 1, 2009 - December 31, 2009
NEW YORK STATE
If you are currently taking a drug that is not on our formulary or subject to additional
requirements or limits, you may be able to get a temporary supply of the drug. You can
contact us to request an exception or switch to an alternative drug listed on our
formulary with your physician’s help. Call us to see if you can get a temporary supply
of the drug or for more details about our drug transition policy.
HOW CAN I GET EXTRA HELP WITH PRESCRIPTION DRUG PLAN COSTS?
If you qualify for extra help with your Medicare prescription drug plan costs, your
premium and costs at the pharmacy will be lower. When you join Independent Health’s
Medicare Anywhere Basic, Medicare will tell us how much extra help you are getting.
Then we will let you know the amount you will pay. If you are not getting this extra
help you can see if you qualify by calling 1-800-MEDICARE (1-800-633-4227), TTY users
should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week.
WHAT ARE MY PROTECTIONS IN THIS PLAN?
All Medicare Advantage Plans agree to stay in the program for a full year at a time.
Each year, the plans decide whether to continue for another year. Even if a Medicare
Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan
decides not to continue, it must send you a letter at least 90 days before your coverage
will end. The letter will explain your options for Medicare coverage in your area.
As a member of Independent Health’s Medicare Anywhere Basic, you have the right to
request a coverage determination, which includes the right to request an exception, the
right to file an appeal if we deny coverage for a prescription drug, and the right to file a
grievance. You have the right to request a coverage determination if you want us to
cover a Part D drug that you believe should be covered. An exception is a type of
coverage determination. You may ask us for an exception if you believe you need a
drug that is not on our list of covered drugs or believe you should get a non-preferred
drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization
rules, such as a limit on the quantity of a drug. If you think you need an exception, you
should contact us before you try to fill your prescription at a pharmacy. Your doctor
must provide a statement to support your exception request. If we deny coverage for
your prescription drug(s), you have the right to appeal and ask us to review our
decision. Finally, you have the right to file a grievance if you have any type of problem
with us or one of our network pharmacies that does not involve coverage for a
prescription drug.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 3
Introduction to the Summary of Benefits Report
for INDEPENDENT HEALTH’S MEDICARE ANYWHERE BASIC
January 1, 2009 - December 31, 2009
NEW YORK STATE
WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM?
A Medication Therapy Management (MTM) Program is a free service we may offer.
You may be invited to participate in a program designed for your specific health and
pharmacy needs. You may decide not to participate but it is recommended that you
take full advantage of this covered service if you are selected. Contact Independent
Health’s Medicare Anywhere Basic for more details.
WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may
include, but are not limited to, the following types of drugs. Contact Independent
Health Medicare Anywhere for more details.
Some Antigens: If they are prepared by a doctor and administered by a properly
instructed person (who could be the patient) under doctor supervision.
Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with
Medicare.
Erythropoietin (Epoetin alpha or Epogen®): By injection if you have end-stage
renal disease (permanent kidney failure requiring either dialysis or
transplantation) and need this drug to treat anemia.
Hemophilia Clotting Factors: Self-administered clotting factors if you have
hemophilia.
Injectable Drugs: Most injectable drugs administered incident to a physician’s
service.
Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant
patients if the transplant was paid for by Medicare, or paid by a private insurance
that paid as a primary payer to your Medicare Part A coverage, in a Medicare-
certified facility.
Some Oral Cancer Drugs: If the same drug is available in injectable form.
Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic
regimen. Inhalation and infusion drugs provided through DME.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 4
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Please call Independent Health for more information about
Independent Health Medicare Anywhere.
Visit us at www.independenthealth.com or, call us:
Customer Service Hours:
Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,
8:00 a.m. - 8:00 p.m. Eastern
Current members should call toll-free (800)-665-1502 for questions related to the
Medicare Advantage Program and Medicare Part D Prescription Drug program
Prospective members should call toll-free (800)-958-4405 for questions related to the
Medicare Advantage Program and Medicare Part D Prescription Drug program.
Current members should call locally (716)-250-4401 for questions related to the
Medicare Advantage Program and Medicare Part D Prescription Drug Program
(TTY/TDD (716)-631-3108)
Prospective members should call locally (716)-635-4900 for questions related to the
Medicare Advantage Program and Medicare Part D Prescription Drug Program.
(TTY/TDD (716)-635-4840)
For more information about Medicare, please call Medicare at
1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.
You can call 24 hours a day, 7 days a week.
Or, visit www.medicare.gov on the web.
If you have special needs, this document may be available in other formats.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 5
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
IMPORTANT INFORMATION
1 - Premium and Other In 2008 the monthly Part General
Important Information B Premium was $96.40 $35 monthly plan premium in
and will change for 2009 addition to your monthly
and the yearly Part B Medicare Part B premium.
deductible amount was The Part B premium will
$135 and will change for change for 2009.
2009.
If a doctor or supplier
does not accept
assignment, their costs
are often higher, which
means you pay more.
2. Doctor and Hospital You may go to any You may have to pay a
Choice doctor, specialist or separate copay for certain
(For more information, see hospital that accepts doctor office visits.
Emergency - #15 and Medicare. You may go to any doctor,
Urgently Needed Care - specialist, or hospital that
#16.) accepts the plan’s payment.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 6
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
SUMMARY OF BENEFITS
INPATIENT CARE
3. Inpatient Hospital Care In 2008 the amounts for General
(Includes Substance Abuse each benefit period were: You may go to any doctor,
and Rehabilitation Services) Days 1 - 60: $1,024 specialist, or hospital that
deductible. accepts the plan’s Terms &
Days 61 - 90: $256 per Conditions of payment
day. except in emergencies.
Days 91 - 150: $512 per
lifetime reserve day.
$500 copay for each
These amounts will Medicare-covered hospital
change for 2009. stay.
Call 1-800-MEDICARE
(1-800-633-4227) for
information about $0 copay for additional
lifetime reserve days. hospital days.
Lifetime reserve days
can only be used once.
$500 out of pocket limit every
A “benefit period” starts year.
the day you go into a
hospital or skilled
nursing facility. It ends No limit to the number of
when you go for 60 days days covered by the plan
in a row without hospital each benefit period.
or skilled nursing care. If
you go into the hospital
after one benefit period
has ended, a new benefit
period begins. You must
pay the inpatient
hospital deductible for
each benefit period.
There is no limit to the
number of benefit
periods you can have.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 7
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
4. Inpatient Mental Health Same deductible and $500 copay for each Medicare
Care copay as inpatient - covered hospital stay.
hospital care (see The maximum out-of-pocket
“Inpatient Hospital limit is covered under,
Care” above). “Inpatient Hospital Care.”
190 day lifetime limit. You get up to 190 days in a
lifetime.
5 - Skilled Nursing Facility In 2008 the amounts for $500 copay for each SNF stay.
(in a Medicare-certified each benefit period after
at least a 3-day covered $500 out-of-pocket limit
skilled nursing facility) every year.
hospital stay:
Days 1 - 20: $0 per day
Days 21 - 100: $128 per Plan covers up to 100 days
day each benefit period.
These amounts will
change for 2009.
No prior hospital stay is
100 days for each benefit required.
period.
A “benefit period” starts
the day you go into a
hospital or skilled
nursing facility. It ends
when you go for 60 days
in a row without hospital
or skilled nursing care. If
you go into the hospital
after one benefit period
has ended, a new benefit
period begins. You must
pay the inpatient
hospital deductible for
each benefit period.
There is no limit to the
number of benefit
periods you can have.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 8
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
6 - Home Health Care $0 Copay $5 copay for each Medicare-
(includes medically covered home health visit.
necessary intermittent
skilled nursing care, home
health aide services, and
rehabilitation services, etc.)
7 - Hospice You pay part of the cost General
for outpatient drugs and You must get care from a
inpatient respite care. Medicare-certified hospice.
You must get care from a
Medicare-certified
hospice.
OUTPATIENT CARE
8 – Doctor Office Visits 20% coinsurance1 2 General
You may go to any doctor,
specialist, or hospital that
accepts the plan’s payment.
See “Physical Exams,” for
more information.
$20 to $35 copay for each
primary care doctor visit for
Medicare-covered benefits.
$35 copay for each specialist
visit for Medicare-covered
benefits.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 9
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
9 - Chiropractic Services Routine care not $35 copay for Medicare-
covered. covered visits.
20% coinsurance for Medicare-covered
manual manipulation chiropractic visits are for
of the spine to correct manual manipulation
subluxation (a of the spine to correct a
displacement or displacement or
misalignment of a joint misalignment of a joint or
or body part) if you get it body part.
from a chiropractor
or other qualified
provider.1 2
10 – Podiatry Services Routine care not $35 copay for each Medicare-
covered. covered visit.
20% coinsurance for Medicare-covered podiatry
medically necessary foot benefits are for medically-
care, including care for necessary foot care.
medical conditions
affecting the lower
limbs.1 2
11 – Outpatient Mental 50% coinsurance for 50% of the cost for each
Health Care most outpatient mental Medicare-covered individual
health services.1 2 or group therapy visit.
12 - Outpatient Substance 20% coinsurance1 2 50% of the cost for Medicare-
Abuse Care covered individual or group
visits.
13 - Outpatient 20% coinsurance for the 20% of the cost for each
Services/Surgery doctor1 2 Medicare-covered
ambulatory surgical center
20% of outpatient
visit.
facility1 2
20% of the cost for each
Medicare-covered outpatient
hospital facility visit.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 10
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
14 - Ambulance Services 20% coinsurance1 2 $100 copay for Medicare-
(medically necessary covered ambulance benefits
ambulance services)
15 - Emergency Care 20% coinsurance for the $50 copay for Medicare-
(You may go to any doctor1 2 covered emergency room
emergency room if you visits.
20% of facility charge, or
reasonably believe you need a set copay per Worldwide coverage.
emergency care.) emergency room visit. 1 2 If you are admitted to the
You don’t have to pay hospital within 24-hour(s) for
the emergency room the same condition, you pay
copay if you are $0 for the emergency room
admitted to the hospital visit.
for the same condition
within 3 days of the
emergency room visit. 1 2
NOT covered outside the
U.S. except under limited
circumstances.
16 - Urgently Needed Care 20% coinsurance, or a set General
(This is NOT emergency copay1 2 Cost sharing is the same as
care, and in most cases, is NOT covered outside the Doctor Office Visit cost
out of the service area.) U.S. except under limited sharing.
circumstances.
17 - Outpatient 20% coinsurance1 2 $35 copay for Medicare-
Rehabilitation Services covered Occupational
(Occupational Therapy, Therapy visits.
Physical Therapy, Speech $35 copay for Medicare-
and Language Therapy) covered Physical and/or
Speech/Language Therapy
visits.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 11
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
OUTPATIENT MEDICAL SERVICES AND SUPPLIES
18 - Durable Medical 20% coinsurance1 2 20% of the cost for Medicare-
Equipment covered items.
(includes wheelchairs,
oxygen, etc.)
19 - Prosthetic Devices 20% coinsurance1 2 20% of the cost for Medicare-
(includes braces, artificial covered items.
limbs and eyes, etc.)
20 - Diabetes Self- 20% coinsurance1 2 $35 copay for Diabetes self-
Monitoring Training, monitoring training.
Nutrition Therapy, and Nutrition therapy is for
Supplies people have diabetes or $35 copay for Nutrition
kidney disease (but Therapy for Diabetes.
(includes coverage for aren’t on dialysis or
glucose monitors, test strips, haven’t had a kidney 20% of the cost for Diabetes
lancets, screening tests, and transplant) when supplies.
self-management training) referred by a doctor.
These services can be
given by a registered
dietitian or include a
nutritional assessment
and counseling to help
you manage your
diabetes or kidney
disease.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 12
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
21 - Diagnostic Tests, 20% coinsurance for $0 copay for Medicare-
X-Rays, and Lab Services diagnostic tests and covered lab services.
x-rays1 2 $20 to $35 copay for
$0 copay for Medicare- Medicare-covered diagnostic
covered lab services1 2 procedures and tests.
Lab Services: Medicare $35 copay for Medicare-
covers medically covered X-rays.
necessary diagnostic lab $35 copays for Medicare-
services that are ordered covered diagnostic radiology
by your treating doctor services.
when they are provided
by a Clinical Laboratory $35 copay for Medicare-
Improvement covered therapeutic
Amendments (CLIA) radiology services.
certified laboratory that
participates in Medicare.
Diagnostic lab services
are done to help your
doctor diagnose or rule
out a suspected illness or
condition. Medicare does
not cover most routine
screening tests, like
checking your
cholesterol.
PREVENTIVE SERVICES
22 - Bone Mass 20% coinsurance1 2 $0 copay for Medicare-
Measurement covered bone mass
Covered once every 24
(for people with Medicare measurement
months (more often if
who are at risk) medically necessary) if
you meet certain medical
conditions.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 13
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
23 - Colorectal Screening 20% coinsurance1 2 $0 copay for Medicare-
Exams covered colorectal screenings
Covered when you are
(for people with Medicare high risk or when you
age 50 and older) are age 50 and older.
24 – Immunizations $0 copay for Flu and $0 copay for Flu and
(Flu vaccine, Hepatitis B Pneumonia vaccines Pneumonia vaccines.
vaccine – for people with 20% coinsurance for $0 copay for Hepatitis B
Medicare who are at risk, Hepatitis B vaccine. 1 2 vaccine.
Pneumonia vaccine)
You may only need the
Pneumonia vaccine once
in your lifetime. Call
your doctor for more
information.
25 - Mammograms (Annual 20% coinsurance1 2 $0 copay for Medicare-
Screening) covered screening
No referral needed.
(for women with Medicare mammograms
age 40 and older) Covered once a year for
all women with
Medicare aged 40 and
older. One baseline
mammogram covered
for women with
Medicare between age 35
and 39.
26 - Pap Smears and Pelvic $0 copay for Pap smears2 $0 copay for Medicare-
Exams covered pap smears and
Covered once every 2
(for women with Medicare) pelvic exams
years. Covered once a
year for women with $0 copay for additional pap
Medicare at high risk. smears and pelvic exams
20% coinsurance for No limit on the number of
Pelvic Exams2 covered pap smears and
pelvic exams.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 14
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
27 - Prostate Cancer 20% coinsurance for the $0 copay for Medicare-
Screening Exams digital rectal exam. 1 2 covered prostate cancer
(for men with Medicare age screening.
$0 for the PSA test;
50 and older) 20% coinsurance for
other related services. 1 2
Covered once a year for
all men with Medicare
over age 50.
28 – End-Stage Renal 20% coinsurance for $0 copay for renal dialysis
Disease dialysis. 1 2 $35 copay for Nutrition
20% coinsurance for Therapy for End-Stage Renal
Nutrition Therapy for Disease.
End-Stage Renal Disease.
Nutrition therapy is for
people who have
diabetes or kidney
disease (but aren’t on
dialysis or haven’t had a
kidney transplant) when
referred by a doctor.
These services can be
given by a registered
dietitian or include a
nutritional assessment
and counseling to help
you manage your
diabetes or kidney
disease.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 15
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Independent Health’s
Benefit Category Original Medicare
Medicare Anywhere Basic
29 - Prescription Drug Most drugs not covered Drugs covered under
under original Medicare. Medicare Part B
You can add prescription General
drug coverage to $20 to $35 copay [or 20% of
Original Medicare by the cost] for Part B-covered
joining a Medicare drugs (not including Part B-
Prescription Drug Plan, covered chemotherapy
or you can get all your drugs).
Medicare coverage,
including prescription $0 copay for Part B-covered
drug coverage, by chemotherapy drugs.
joining a Medicare Drugs Covered under
Advantage Plan or a Medicare Part D
Medicare Cost Plan that General
offers prescription drug
This plan uses a formulary.
coverage.
The plan will send you the
formulary. You can also see
the formulary at
www.independenthealth.com
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
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 16
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug of the plan’s service area for
(Continued) 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
Independent Health’s
Medicare Anywhere Basic for
certain drugs.
The plan will pay for certain
over-the-counter drugs as
part of its utilization
management program. Some
over-the-counter drugs are
less expensive than
prescription drugs and work
just as well. Contact the plan
for details.
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 more pharmacies in
your network. These drugs
are listed on the plan’s
website, formulary, and
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 17
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug printed materials, as well as
(Continued) on the Medicare Prescription
Drug Plan Finder on
Medicare.gov.
If the actual cost of the drug
is less than the normal cost-
sharing amount for that drug,
you will pay the actual cost,
not the higher cost-paying
amount.
$0 deductible.
Initial Coverage
You pay the following until
total yearly drug costs reach
$2,700:
Retail Pharmacy
Tier 1
$5 copay for a one-
month (30-day) supply
of drugs in this tier
$15 copay for a three-
month (90-day) supply
of drugs in this tier
Tier 2
$35 copay for a one-
month (30-day) supply
of drugs in this tier
$105 copay for a three-
month (90-day) supply
of drugs in this tier
Tier 3
$70 copay for a one-
month (30-day) supply
of drugs in this tier
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 18
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug $210 copay for a three-
(Continued) month (90-day) supply
of drugs in this tier
Specialty Tier 4
33% coinsurance for a
one-month (30-day)
supply of drugs in this
tier
Long Term Care Pharmacy
Tier 1
$5 copay for a one-
month (34-day) supply
of drugs in this tier
Tier 2
$35 copay for a one-
month (34-day) supply
of drugs in this tier
Tier 3
$70 copay for a one-
month (34-day) supply
of drugs
Specialty Tier 4
33% coinsurance for a
one-month (34-day)
supply of drugs
Mail Order
Tier 1
$12.50 copay for a three-
month (90-day) supply
of drugs in this tier
Tier 2
$87.50 copay for a three-
month (90-day) supply
of drugs in this tier.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 19
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug Coverage Gap
(Continued) The plan covers Some
Generics, Some Brands
through the coverage gap.
You pay the following:
Retail Pharmacy
Tier 1
$5 copay for a one-
month (30-day) supply
of Some Generics, Some
Brands drugs covered in
this tier
$15 copay for a three-
month (90-day) supply
of Some Generics, Some
Brands drugs covered in
this tier
Long Term Care Pharmacy
Tier 1
$5 copay for a one-
month (34-day) supply
of Some Generics, Some
Brands drugs
Mail Order
Tier 1
$12.50 copay for a three-
month (90-day) supply
of Some Generics, Some
Brands drugs covered in
this tier
Please contact the Plan for a
complete list of drugs
covered through the gap.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 20
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug For all other covered drugs,
(Continued) after your total yearly drug
costs reach $2,700, you pay
100% until your yearly out-
of-pocket drug costs reach
$4,350.
Catastrophic Coverage
After your yearly out-of-
pocket drug costs reach
$4,350, you pay the greater
of:
A $ 2.40 copay for
generic (including brand
drugs treated as generic)
and a $6.00 copay for all
other drugs, or
5% coinsurance.
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
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
Independent Health
Medicare Anywhere.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 21
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug Out-of-Network Initial
(Continued) 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 $2,700:
Out-of-Network Pharmacy
Tier 1
$5 copay for a one-
month (30-day) supply
of drugs in this tier
Tier 2
$35 copay for a one-
month (30-day) supply
of drugs in this tier
Tier 3
$70 copay for a one-
month (30-day) supply
of drugs in this tier
Specialty Tier 4
33% coinsurance for a
one-month (30-day)
supply of drugs in this
tier
Out-of-Network Coverage
Gap
The plan covers Some
Generics, Some Brands
through the gap.
You pay the following:
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 22
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug Tier 1
(Continued)
$5 copay for a one-
month (30-day) supply
of Some Generics, Some
Brands drugs covered in
this tier.
Tier 2
After your total yearly
drug costs reach $2,700,
you pay 100% of the
pharmacy’s full charge
for drugs purchased
out-of-network until
your yearly out-of-
pocket drug costs reach
$4,350. You will not be
reimbursed by
Independent Health
Medicare Anywhere for
out-of-network
purchases when you are
in the coverage gap.
However, you should
still submit
documentation to
Independent Health
Medicare Anywhere so
we can add the amounts
you spent out-of-
network to your total
out-of-pocket costs for
the year.
Tier 3
After your total yearly
drug costs reach $2,700,
you pay 100% of the
pharmacy’s full charge
for drugs purchased
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 23
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug out-of-network until
(Continued) your yearly out-of-
pocket drug costs reach
$4,350. You will not be
reimbursed by
Independent Health
Medicare Anywhere for
out-of-network
purchases when you are
in the coverage gap.
However, you should
still submit
documentation to
Independent Health
Medicare Anywhere so
we can add the amounts
you spent out-of-
network to your total
out-of-pocket costs for
the year.
Specialty Tier 4
After your total yearly
drug costs reach $2,700,
you pay 100% of the
pharmacy’s full charge
for drugs purchased
out-of-network until
your yearly out-of-
pocket drug costs reach
$4,350. You will not be
reimbursed by
Independent Health
Medicare Anywhere for
out-of-network
purchases when you are
in the coverage gap.
However, you should
still submit
documentation to
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 24
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
29 - Prescription Drug Independent Health
(Continued) Medicare Anywhere 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
$4,350, you will be
reimbursed for drugs
purchased out-of-network
up to the full cost of the
drug minus the following:
A $2.40 copay for
generic (including brand
drugs treated as generic)
and a $6.00 copay for all
other drugs, or
5% coinsurance.
30 - Dental Service Preventive dental In general, preventive dental
services (such as benefits (such as cleaning)
cleaning) not covered. not covered.
$35 to $50 copay for
Medicare-covered dental
benefits.
Plan offers additional
comprehensive dental
benefits.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 25
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
31 - Hearing Services Routine hearing exams Hearing aids not covered.
and hearing aids not
$35 copay for Medicare-
covered.
covered diagnostic
20% coinsurance for hearing exams
diagnostic hearing
$35 copay for routine
exams. 1 2
hearing tests
$35 copay for each
fitting-evaluation for
hearing aid fitting
evaluations
32 - Vision Services 20% coinsurance for $0 copay for:
diagnosis and treatment
one pair of eyeglasses or
of diseases and
contact lenses after
conditions of the eye. 1 2
cataract surgery.
Routine eye exams and
Up to 1 pair(s) of
glasses not covered.
contacts
Medicare pays for one
Up to 1 pair(s) of lenses
pair of eyeglasses or
contact lenses after Up to 1 frame(s)
cataract surgery. 1 2 $35 copay for exams to
Annual glaucoma diagnose and treat
screenings covered for diseases and conditions
people at risk. 1 2 of the eye
$5 copay for up to 1
routine eye exam(s)
$60 limit for eye wear.
Plan offers additional vision
benefits.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 26
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
33. Physical Exams 20% coinsurance for one $0 copay for routine exams.
exam within the first Limited to 1 exam(s) every
12 months of your new year.
Medicare Part B
coverage. 1 2
When you get Medicare
Part B, you can get a one
time physical exam
within the first 12
months of your new Part
B coverage. The
coverage does not
include lab tests.
Health Wellness Education Smoking Cessation: This plan covers
Covered if ordered by health/wellness education
your doctor. Includes benefits.
two counseling attempts Written health education
within a 12-month materials, including
period if you are Newsletters
diagnosed with a
smoking-related illness Nutritional Training
or are taking medicine Nutritional benefit
that may be affected by
Additional Smoking
tobacco. Each counseling
Cessation
attempt includes up to
four face-to-face visits. Health Club
You pay coinsurance, Membership/Fitness
and Part B deductible Classes
applies.
Nursing Hotline
Copays may apply for these
benefits.
$0 copay for each Medicare-
covered smoking cessation
counseling session.
1Each year, you pay a total of one $135 Deductible. This deductible will change for 2009.
2
If a doctor or supplier does not accept assignment, their costs are often higher, which
means you pay more.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 27
SUMMARY OF BENEFITS REPORT
FOR CONTRACT H9519 PLAN 003
Benefit Category Original Medicare Independent Health’s
Medicare Anywhere Basic
Transportation Not covered. This plan does not cover
(Routine) routine transportation.
Acupuncture Not covered. This plan does not cover
Acupuncture.
H9519_003 Independent Health’s Medicare Anywhere Basic (PFFS Individual with Part D) 28
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