Plan Details
Costs and Other Important Information
Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$3,400 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00
Benefits
Service
Cost
Inpatient hospital coverage
$0 copay
Outpatient hospital coverage
$0 copay
Doctor visits
Primary:
$0 copay
Specialist:
$0 copay
$0 copay
Specialist:
$0 copay
Preventive care
$0 copay
Emergency care/Urgent care
Emergency:
$100 per visit (always covered)
Urgent care:
$0-25 per visit (always covered)
$100 per visit (always covered)
Urgent care:
$0-25 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
$0 copay
Lab services:
$0 copay
Diagnostic radiology services (e.g., MRI):
$0 copay
Outpatient x-rays:
$0 copay
Mental health services
$300 per stay
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$15
Outpatient individual therapy visit:
$15
Outpatient group therapy visit with a psychiatrist:
$0 copay
Outpatient individual therapy visit with a psychiatrist:
$0 copay
Outpatient group therapy visit:
$15
Outpatient individual therapy visit:
$15
Skilled Nursing Facility
$0 for days 1 through 20
$50 for days 21 through 100
$50 for days 21 through 100
Rehabilitation services
Occupational therapy visit:
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
$0 copay
Physical therapy and speech and language therapy visit:
$0 copay
Ambulance
$200
Transportation
$0 copay
Foot care (podiatry services)
Foot exams and treatment:
$0 copay
Routine foot care:
Not covered
$0 copay
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
0-20% per item
Prosthetics (e.g., braces, artificial limbs):
0-20% per item
Diabetes supplies:
$0 copay
0-20% per item
Prosthetics (e.g., braces, artificial limbs):
0-20% per item
Diabetes supplies:
$0 copay
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
20%
Other Part B drugs:
20%
20%
Other Part B drugs:
20%
Coverage Area for Golden State Medicare Gold (HMO)
| State | California |
|---|---|
| County | Los Angeles |
Cost Sharing Information
All cost-sharing assumes in-network healthcare providers.
Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit
| 30 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offereds | $5 copay | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | $10 copay | Not offered |
| Tier 3: Preferred Brand Name | Not offered | $45 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | Not offered | $95 copay | Not offered |
| Tier 5: Specialty Tier | Not offered | 33% coinsurance | Not offered |
| 90 Day Supply | Preferred Retail Pharmacies | Non-Preferred Retail Pharmacies | Mail-Order Pharmacies |
|---|---|---|---|
| Tier 1: Preferred Generic | Not offered | $15 copay | Not offered |
| Tier 2: Non-Preferred Generic | Not offered | $30 copay | Not offered |
| Tier 3: Preferred Brand Name | Not offered | $135 copay | Not offered |
| Tier 4: Non-Preferred Brand Name | Not offered | $285 copay | Not offered |
| Tier 5: Specialty Tier | Not offered | 33% coinsurance | Not offered |
CMS Ratings
Staying healthy - screenings, tests and vaccines
Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment
Managing Chronic Conditions
Special needs plan care management
Not Rated
Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Not Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions
Member Experience with Health Plan
Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan
Care Coordination
Member Complaints, and Changes in Health Plan's Performance
Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement
Health Plan Customer Service
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical
Drug Plan Customer Service
Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld
Member Complaints, and Changes in Drug Plan's Performance
Complaints about the drug plan
Members choosing to leave the drug plan
Beneficiary access and performance problems
Drug plan quality improvement
Member Experience with Drug Plan
Rating of drug plan
Getting needed prescription drugs
Drug Pricing and Patient Safety
MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate
Physician Finder
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