Covenant Retirees Advantage Plan 2021 Summary
This document provides a summary of the Covenant Retirees Advantage Plan 2021, a PHP Medicare Plan, outlining the benefits, coverage, and costs for members. It includes details on in-network and out-of-network coverage, deductible amounts, copays, coinsurance percentages, and specific services covered, such as primary care visits, specialist visits, emergency care, preventive services, and more. To join the plan, individuals must be entitled to Medicare Part A, enrolled in Part B, and reside in specific service areas in Michigan. Contact information for inquiries and customer service is also provided.
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Covenant Retirees Advantage Plan 2021 Summary of Benefits Medicare Advantage PHP Medicare (HMO-POS) H7646_21-325_M
Covenant Retirees Advantage Medicare Summary of Benefits This document gives you a summary of the benefits you can expect when you choose the Covenant Retirees Advantage Plan, a PHP Medicare Plan, including what the Plan covers and what you pay. It doesn t list every limitation, exclusion or covered service. To get a list of services we cover, call us and ask for the Evidence of Coverage. Note that Covenant Hospital is a Tier 1 facility, as well as Sparrow Health System and Michigan Medicine (University of Michigan). To join Covenant Retirees Advantage, you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in the PHP Medicare service area, which includes the following counties: Bay, Calhoun, Clinton, Eaton, Gratiot, Ingham, Ionia, Kalamazoo, Montcalm, Saginaw, Shiawassee and Tuscola. Contact Us If you have questions, call one of our Physicians Health Plan Medicare experts at 866.830-2012 (TTY: 711). From October 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. E.T. For additional information, you may visit CovenantRetireesAdvantage.com Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.
Overview of Medical Benefits In-Network Coverage (Tier 1) Member Pays/Plan Pays % Out-of-Network Coverage (Tier 2) Member Pays/Plan Pays % Health Care Services Deductible $0 $0 Out-of-Pocket Maximum $3,800 $6,700 Annual Physical Exam $0 copay N/A Primary Care Physician Visits $5 copay 80% coinsurance Specialist visits $30 copay 80% coinsurance Telemedicine visits (PCP only) $0 copay N/A Emergency Care visits $90 copay (waived if admitted within 24 hours) $90 copay (waived if admitted within 24 hours) Ground or Air Ambulance Services $200 copay $200 copay Urgent Care visits $60 copay $60 copay Worldwide Emergency and Urgent Care $90 copay $90 copay Preventive Services $0 copay (check with plan) 80% coinsurance Flu Shots $0 copay 80% coinsurance Inpatient Hospital Services Acute and Psychiatric $200 copay Days 1-7; $0 copay Day 8> (per stay) 80% coinsurance
Overview of Medical Benefits In-Network Coverage (Tier 1) Member Pays/Plan Pays % Out-of-Network Coverage (Tier 2) Member Pays/Plan Pays % Health Care Services Outpatient Hospital Services $150 copay 80% coinsurance Radiology Services (X-rays) $35 copay 80% coinsurance Diagnostic Radiological Services (CT, MRI, PET Scans) 80% coinsurance ($0 copay mammograms) 80% coinsurance Radiation Therapy $25 copay 80% coinsurance Diagnostic Procedures and Laboratory Services $10 copay ($0 copay colonoscopies) 80% coinsurance Diabetic Supplies (check with Plan for any restrictions or authorizations) Zero cost 80% coinsurance Physical/Speech/Occupational Therapy $30 copay 80% coinsurance Cardiac & Pulmonary Rehab $30 copay 80% coinsurance Mental Health Specialty & Psychiatric Services and Outpatient Substance Abuse Individual Sessions $30 copay 80% coinsurance Mental Health Specialty & Psychiatric Services and Outpatient Substance Abuse Group Sessions $25 copay 80% coinsurance
Overview of Medical Benefits In-Network Coverage (Tier 1) Member Pays/Plan Pays % Out-of-Network Coverage (Tier 2) Member Pays/Plan Pays % Health Care Services Chiropractic Care $20 copay 80% coinsurance Durable Medical Equipment 80% coinsurance 80% coinsurance Prosthetics & Orthotics 80% coinsurance 80% coinsurance Skilled Nursing Facility (SNF) $0/Day 1-20; $150/Day 21-100 (per stay) 80% coinsurance Home Health Services Zero cost 80% coinsurance Podiatry Services $30 copay 80% coinsurance Opioid Program Treatment Services $30 copay 80% coinsurance Dialysis Services 80% coinsurance 80% coinsurance Blood Services Zero cost 80% coinsurance Medicare-covered eye exams $30 copay 80% coinsurance Hearing Exam Routine Exam $25 copay 80% coinsurance
Overview of Medical Benefits In-Network Coverage (Tier 1) Member Pays/Plan Pays % Out-of-Network Coverage (Tier 2) Member Pays/Plan Pays % Health Care Services Supplemental Benefits Fitness Memberships at a participating Silver Sneakers facility Zero cost N/A Twenty (20) one-way non-emergent transportation visits Zero cost N/A Preventive Dental (Exam, Cleanings 2 per year, Fluoride, Dental X-rays 1 per year Zero cost N/A Hearing Aids Fitting/Evaluation and hardware ($1,000 allowance every 2 calendar years) Zero cost Zero cost
Overview of Pharmacy Benefits Preferred Retail Pharmacy Member Pays Preferred Generics Tier 1 Preferred Brand Tier 3 Non-Preferred Brand Tier 4 Day Supply Generics Tier 2 Specialty Tier 5 30 $0.00 $0.00 $40.00 $90.00 $90.00 60 $0.00 $0.00 $80.00 $180.00 N/A 90 $0.00 $0.00 $120.00 $270.00 N/A Standard or Non-Preferred Retail Pharmacy Member Pays Preferred Generics Tier 1 Preferred Brand Tier 3 Non-Preferred Brand Tier 4 Day Supply Generics Tier 2 Specialty Tier 5 30 $5.00 $10.00 $45.00 $95.00 $95.00 60 $10.00 $20.00 $90.00 $190.00 N/A 90 $15.00 $30.00 $135.00 $285.00 N/A Note: Covenant Outpatient Pharmacy is a Preferred Pharmacy (check with Plan for a complete list of Preferred Pharmacies.
Overview of Pharmacy Benefits 3Mail Order Pharmacy Member Pays * Preferred Generics Tier 1 Preferred Brand Tier 3 Non-Preferred Brand Tier 4 Day Supply Generics Tier 2 Specialty Tier 5 30 $0.00 $0.00 $45.00 $95.00 $95.00 60 $0.00 $0.00 $90.00 $190.00 N/A 90 $0.00 $0.00 $112.50 $237.50 N/A * Mail Order Pharmacy is filled through Express Scripts
CovenantRetireesAdvantage.com Toll-free: 866.830.2012 TTY users call: 711. From October 1 to March 31, you can call us seven days a week from 8 a.m. to 8 p.m. E.T. From April 1 to September 30, you can call us Monday-Friday, 8 a.m. to 8 p.m. ET. Physicians Health Plan 1400 E. Michigan Ave. Lansing, MI 48912 PHP Medicare offers employer/union-sponsored HMO-POS plans with a Medicare contract. Enrollment in PHP Medicare depends on contract renewal. To enroll, you must have both Medicare Parts A and B. You must continue to pay your Medicare Part B premium. Enrollment in a PHP Medicare plan may be limited to specific times of the year. This information is not a complete description of benefits. Call 866.830.2012 (TTY: 711) for more information. Out-of-network/non-contracted providers are under no obligation to treat PHP Medicare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services. PHP complies with applicable federal civil rights laws and does not discriminate on the basis of race, national origin, age, disability or sex.
