2018 Summary of Benefits Eon Select (HMO) and Eon Choice (PPO) GEORGIA / SOUTH CAROLINA

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1 208 Summary of Eon Select (HMO) and Eon Choice (PPO) GEORGIA / SOUTH CAROLINA For more information, call Y022_074 Accepted MAPD

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3 208 Summary of Eon Select (HMO) and Eon Choice (PPO) This is a summary of drug and health services covered by Eon Health January, December 3, 208. Eon Health has a contract with Medicare to offer HMO and PPO plans. Eon Health also has a contract with the Georgia Medicaid program and a contract with the South Carolina Medicaid program. Enrollment in Eon Health depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. You can obtain a copy of our Evidence of Coverage by calling us at: Current Members: , Prospective Members: , TTY: 7 or visiting our website at For coverage and cost of Original Medicare look in your current Medicare and You Handbook. View it online at or get a copy by calling -800-Medicare ( ). TTY users should call Eon Select: Eon Health has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. Eon Choice: Eon Health has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, your costs may be higher, deductibles and coinsurances may apply. You can see our Provider and Pharmacy Directory on our website at You can see our Formulary (List of Part D prescription drugs) on our website at

4 Introduction Eon Select is a Medicare Advantage HMO offered in Georgia and South Carolina. Eon Choice is a Medicare Advantage PPO offered in Georgia and South Carolina. To join Eon Select and Eon Choice, you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area. Eon Select and Eon Choice Service Areas: STATE GEORGIA SOUTH CAROLINA SERVICE AREA Baker, Baldwin, Banks, Barrow, Bibb, Bleckley, Bryan, Butts, Chatham, Cherokee, Clayton, Clinch, Crawford, Dawson, DeKalb, Dodge, Dooly, Fayette, Forsyth, Franklin, Greene, Hancock, Hart, Heard, Henry, Houston, Jasper, Jones, Lamar, Lumpkin, Macon, Madison, McIntosh, Meriwether, Monroe, Morgan, Newton, Oconee, Oglethorpe, Peach, Pickens, Pike, Pulaski, Putnam, Rabun, Rockdale, Schley, Screven, Stephens, Talbot, Taliaferro, Taylor, Twiggs, Walton, White, Wilcox, Wilkinson counties Beaufort, Chester, Colleton, Fairfield, Greenville, Hampton, Jasper, Lee, Saluda, Spartanburg, Union counties

5 Eon Select (HMO) Health Maintenance Organization (HMO) plans in most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan s network. In an urgent or emergency situation you can access innetwork and out of network providers.

6 Eon Select HMO / Plan Highlights Monthly Premium: $0 Doctor Visits: $0 PCP / $50 Specialist Prescription Drugs: Low copayment for generic drugs Dental Care: Preventative Comprehensive Dentures Vision Care: $75 towards glasses or contact lenses Hearing Care: Exams and up to $750 for hearing aids Over-The-Counter (OTC) items: $20 allowance per month Chiropractic Care: Routine visit $20 copay (4 visits per year) Meals: Up to 20 meals after inpatient hospital stay Fitness Program: SilverSneakers

7 Eon Select (HMO) Monthly Plan Premium Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Eon Select / Health $0 per month Part C (Medical) $0 Part D (Pharmacy) $250 only applies to Tiers 3, 4 and 5 $6,700 annually $300/day for days -5 Inpatient Hospital Coverage $0/day for days 6-90 $200 copay Ambulatory Surgical Center Outpatient Hospital Coverage $225 copay Outpatient Hospital Doctor Visits (Primary and Specialist) Preventive Care Emergency Care Urgently Needed Care Diagnostic Services / Labs / Imaging Primary Care Physician visit: $0 copay Specialist visit: $50 copay $0 copay $80 copay $50 copay Diagnostic radiology services (such as MRIs, CT scans): 20% coinsurance Diagnostic tests and procedures: 20% coinsurance Lab services: $5 copay Outpatient x-rays: $25 copay Therapeutic radiology services (such as radiation treatment for cancer): 20% coinsurance

8 Eon Select (HMO) Hearing Services Dental Services Vision Services Eon Select / Health Exam to diagnose and treat hearing and balance issues: $25 copay Routine hearing exam (for up to every year): $25 copay Hearing aid fitting/evaluation (for up to every 3 years): $0 copay Our plan pays up to $750 every three years for hearing aids. Benefit amount applies to both ears combined. Preventive dental services: Cleaning (for up to every six months): $0 copay Dental x-ray(s) (for up to every six months): $0 copay Oral exam (for up to every six months): $0 copay dental bitewing x-ray per side every six months: $0 copay panoramic x-ray every five years: $0 copay Comprehensive dental services: Coverage limit is $800 every year. $0 copay for non-medicare covered services $50 copay for Medicare covered services Coverage is limited to fillings, simple extractions, dentures, and denture repair. Additional dental services, such as root canals, crowns, surgical extractions, denture relines and periodontal (gum) treatments, are not covered. partial or complete denture per arch every five years. $0 copay Exam to diagnose and treat diseases and conditions of the eye: $25 copay Annual Glaucoma screening: $0 copay Routine eye exam (for up to every year): $0 copay Contact lenses: (for up to every year): $0 copay Eyeglasses (frames and lenses): (for up to every year): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay $75 every year for contact lenses and or eyeglasses (frames and lenses)

9 Eon Select (HMO) Mental Health Services Eon Select / Health Inpatient: $300/Day for Days -5 $0/Day for Days 6-90 Outpatient group therapy visit: $40 copay Outpatient individual therapy visit: $40 copay $0 / Day for Days -20 Skilled Nursing Facility (SNF) $67 / Day for Days 2-00 Physical Therapy (Outpatient) Physical therapy visit: $40 copay Ambulance $225 copay Transportation Not covered Medicare Part B drugs 20% coinsurance

10 Eon Select (HMO) Eon Select / Prescription Drug Deductible Part D (Pharmacy) $250 Only applies to Tiers 3, 4, and 5 Tier : Preferred Generic month supply: $4 2 month supply: $8 3 month supply: $2 Initial Coverage Retail (after Tier 2: Non-Preferred Generic month supply: $5 2 month supply: $30 3 month supply: $45 you pay your deductible, if Tier 3: Preferred Brand month supply: $47 2 month supply: $94 3 month supply: $4 applicable) Tier 4: Non-Preferred Brand month supply: $00 2 month supply: $200 3 month supply: $300 Tier 5 Specialty month supply: 28% 2 month supply: 28% 3 month supply: 28% Tier : Preferred Generic 3 month: $8 Tier 2: Non-Preferred Generic 3 month: $30 Initial coverage Mail Order Tier 3: Preferred Brand 3 month: $94 Tier 4: Non-Preferred Brand 3 month: $200 Tier 5 Specialty 3 month: 28% After you enter the coverage gap, you pay 35% of the plan s cost for covered brand name drugs and Coverage Gap 44% of the plan s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For generic (including brand drugs treated as generic): 5% of the cost, or $3.35 copay whichever Catastrophic Coverage is greater For all other drugs: 5% of the cost, or $8.35 copay, whichever is greater

11 Eon Select (HMO) Chiropractic Care Foot Care (Podiatry Services) Diabetic Supplies and Services Meals Rehabilitation Services (Outpatient) Medical Equipment and Supplies Over-the-Counter (OTC) Items Fitness Program Eon Select / Additional Health Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position): $20 copay Medicare Covered Visit Routine Visit $20 copay (4 visits per yr.) Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: $45 copay. Routine foot care: Not covered. Diabetes monitoring supplies: 20% coinsurance Therapeutic shoes or inserts: 20% coinsurance Up to 20 meals. Plan covers up to 28 days after inpatient hospital stay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions for a period of up to 36 weeks): 20% Coinsurance Occupational therapy visit: $40 copay Speech and language therapy visit: $40 copay 20% Coinsurance Prosthetic devices: 20% coinsurance Related medical supplies: 20% coinsurance Members receive a $20 allowance every month Fitness program: SilverSneakers Basic membership to one Plan approved fitness facility per month Orientation to the fitness center and instructions about how to use equipment and services workout Pak per year

12 Eon Choice (PPO) Preferred Provider Organization (PPO) plan: In a PPO, you pay less if you use doctors, hospital, and other health care providers that participate in the plan s network. With a PPO you also have access to doctors, hospital, and other health care providers that do not participate in the plan s network. You will usually pay more if you access provider(s) outside the plans network.

13 Eon Choice PPO / Plan Highlights Monthly Premium: $5 Doctor Visits: $5 PCP / $50 Specialist Prescriptions: Low copayment for generic drugs Dental Care: Preventative Services Vision Care: $75 towards glasses or contact lenses Hearing Care: Exams and up to $750 for hearing aids Over-The-Counter (OTC) items: $20 allowance per month Chiropractic Care: Routine visit $20 copay (4 visits per year) Meals: Up to 20 meals after inpatient hospital stay Fitness Program: SilverSneakers

14 Eon Choice (PPO) Eon Choice / Health IN-NETWORK OUT-OF-NETWORK Monthly Plan Premium $5 per month Deductible Part C (Medical) $0 Part C (Medical): $500 Part D (Pharmacy): $250 only applies to Tiers 3, 4, and 5 (In-Network and Out-of-Network) Maximum Out-of- Pocket Responsibility $6,700 annually (does not include prescription drugs) Inpatient Hospital $300 / Day for Days -5 Coverage $0 / Day for Days 6-90 $0,000 - Services received from in-network providers WILL count toward this limit. 40% Coinsurance Outpatient Hospital $200 Copay Ambulatory Surgical Center 40% Coinsurance Ambulatory Surgical Center Coverage $225 Copay Outpatient Hospital 40% Coinsurance Outpatient Hospital Doctor Visits (Primary Primary care physician visit: $5 copay Primary care physician visit: 40% coinsurance and Specialist) Specialist visit: $50 copay Specialist visit: 40% coinsurance Preventive Care $0 copay 0% coinsurance Emergency Care $80 copay $80 copay Urgently Needed Care $50 copay $50 copay

15 Eon Choice (PPO) Diagnostic Services/ Labs/Imaging Hearing Services Eon Choice / Health IN-NETWORK Diagnostic radiology services (such as MRIs, CT scans): 20% coinsurance Diagnostic tests and procedures: 20% coinsurance Lab services: $5 copay Outpatient x-rays: $25 copay Therapeutic radiology services (such as radiation treatment for cancer): 20% coinsurance Exam to diagnose and treat hearing and balance issues: $25 copay Routine hearing exam (for up to every year): $25 copay Hearing aid fitting/evaluation (for up to every 3 years): $0 copay Our plan pays up to $750 every three years for hearing aids. Benefit amount applies to both ears combined. OUT-OF-NETWORK Diagnostic radiology services (such as MRIs, CT scans): 40% coinsurance Diagnostic tests and procedures: 40% coinsurance Lab services: 40% coinsurance Outpatient x-rays: 40% coinsurance Therapeutic radiology services (such as radiation treatment for cancer): 40% coinsurance Exam to diagnose and treat hearing and balance issues: 40% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

16 Eon Choice (PPO) Dental Services Vision Services Eon Choice / Health IN-NETWORK Preventive dental services: Cleaning (for up to every six months): $0 copay Dental x-ray(s) (for up to every six months): $0 copay Oral exam (for up to every six months): $0 copay Dental bitewing x-ray per side (for up to every six months): $0 copay Panoramic x-ray (for up to every five years): $0 copay Comprehensive dental services: $50 copay for Medicare-covered comprehensive benefits Exam to diagnose and treat diseases and conditions of the eye: $25 copay Glaucoma Screening: $25 copay Routine eye exam (for up to every year): $0 copay Contact lenses: (for up to every year): $0 copay Eyeglasses (frames and lenses): (for up to every year): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay $75 every year for contact lenses and or eyeglasses (frames and lenses). OUT-OF-NETWORK Preventive dental services: Cleaning (for up to every six months): 50% coinsurance Dental x-ray(s) (for up to every six months): 50% coinsurance Oral exam (for up to every six months): 50% coinsurance Dental bitewing x-ray per side (for up to every six months): 50% coinsurance Panoramic x-ray (for up to every five years): 50% coinsurance Comprehensive dental services: 40% coinsurance for Medicarecovered comprehensive benefits Exam to diagnose and treat diseases and conditions of the eye: 40% coinsurance Glaucoma Screening: 40% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance

17 Eon Choice (PPO) Eon Choice / Health IN-NETWORK Inpatient: $300 / Day for Days -5 $0 / Day for days 6 90 Mental Health Services Outpatient: Group therapy visit: $40 copay Individual therapy visit: $40 copay $0 / Day for Days -20 Skilled Nursing Facility (SNF) $67 / Day for Days 2-00 Physical therapy visit: Physical Therapy $40 copay OUT-OF-NETWORK Inpatient: 40% coinsurance Outpatient: Group therapy visit: 40% coinsurance Individual therapy visit: 40% coinsurance 40% coinsurance Physical therapy visit: 40% coinsurance Ambulance $225 copay $225 copay Transportation Not covered Not covered Medicare Part B Drugs 20% coinsurance 40% coinsurance

18 Eon Choice (PPO) Eon Choice / Prescription Drug Deductible Part D (Pharmacy) $250 Only applies to Tiers 3, 4, and 5 Tier : Preferred Generic month supply: $4 2 month supply: $8 3 month supply: $2 Initial Coverage Retail Tier 2: Non-Preferred Generic month supply: $5 2 month supply: $30 3 month supply: $45 (after you pay your deductible, Tier 3: Preferred Brand month supply: $47 2 month supply: $94 3 month supply: $4 if applicable) Tier 4: Non-Preferred Brand month supply: $00 2 month supply: $200 3 month supply: $300 Tier 5 Specialty month supply: 28% 2 month supply: 28% 3 month supply: 28% Tier : Preferred Generic 3 month: $8 Tier 2: Non-Preferred Generic 3 month: $30 Initial coverage Mail Order Tier 3: Preferred Brand 3 month: $94 Tier 4: Non-Preferred Brand 3 month: $200 Tier 5 Specialty 3 month: 28% After you enter the coverage gap, you pay 35% of the plan s cost for covered brand name drugs and Coverage Gap 44% of the plan s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For generic (including brand drugs treated as generic): 5% of the cost, or $3.35 copay whichever is Catastrophic Coverage greater For all other drugs: 5% of the cost, or $8.35 copay, whichever is greater

19 Eon Choice (PPO) Chiropractic Care Eon Choice / Additional Health IN-NETWORK Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position): $20 copay Medicare Covered Visit OUT-OF-NETWORK Manipulation of the spine to correct a subluxation (when or more of the bones of your spine move out of position): 40% coinsurance Medicare Covered Visit Outpatient Rehabilitation Services Routine Visit: $20 copay (4 visits per yr.) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks): 20% Coinsurance Occupational therapy visit: $40 copay Speech and language therapy visit: $40 copay Diabetes monitoring supplies: 20% coinsurance Routine Visit: 50% coinsurance (4 visits per yr.) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks): 40% coinsurance Occupational therapy visit: 40% coinsurance Speech and language therapy visit: 40% coinsurance Diabetes monitoring supplies: 40% coinsurance Diabetic Supplies and Services Therapeutic shoes or inserts: 20% coinsurance Therapeutic shoes or inserts: 40% coinsurance Meals Up to 20 meals. Plan covers up to 30 days after inpatient hospital stay Not covered Foot exams and treatment if you have diabetes Foot exams and treatment if you have diabetes Foot Care (Podiatry Services) related nerve damage and/or meet certain related nerve damage and/or meet certain conditions: $45 copay conditions: 40% coinsurance Routine foot care: Not covered Routine foot care: Not covered. Over-the-Counter (OTC) Items Members receive a $20 allowance every month Not covered

20 Eon Choice (PPO) Eon Choice / Additional Health IN-NETWORK OUT-OF-NETWORK Medical Equipment and Supplies Prosthetic devices: 20% coinsurance Prosthetic devices: 40% coinsurance 20% coinsurance 40% coinsurance Related medical supplies: 20% coinsurance Related medical supplies: 40% coinsurance Fitness program: SilverSneakers Wellness Programs (e.g. Fitness) Basic membership to one Plan approved fitness facility per month Orientation to the fitness center and instructions about how to use equipment and services workout Pak per year

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22 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply., premiums and/ or copayments/coinsurance may change on January of each year. You must continue to pay your Medicare Part B premium The State pays the Part B premium for full dual members. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Eon Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Current Members: TTY: 7 Prospective Members: TTY: 7 Hours of Operation: October February 4: Seven days a week, 8:00am 8:00pm EST February 5 September 30: Monday through Friday, 8:00am 8:00pm EST (You may leave a voic Saturday, Sunday and Federal Holidays)