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Summary of Benefitsfor AmerivantageClassic (HMO)Available in: Bernalillo, Sandoval, Torrance, Valencia, and Santa Fe CountiesPlan year: January 1, 2017 – December 31, 2017In this section, you’ll learn about some of the services we cover, what you’ll payfor those services and other important details to help you choose the rightMedicare Advantage plan for you. While the benefit information provided doesnot list every service that we cover or list every limitation or exclusion, you canget a complete list of those services. Just give us a call and ask for the Evidence ofCoverage.Have questions? Here’s how to reach us and our hours of operation:If you are not a member of this plan, please call toll free 1-877-470-4131 (TTY:711), and follow the instructions to be connected to a representative.If you are a member of this plan, call our toll-free Customer Service numberat 1-866-805-4589 (TTY: 711).8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas)from October 1 through February 14, and Monday to Friday (except holidays)from February 15 through September 30.You can learn more about us on our website atwww.myamerigroup.com/medicare.Y0114 17 27849 U 046 CMS Accepted 10/01/2016Amerivantage Classic (HMO)60800MUSENMUB 046H5746 016-000 NM-HMO1
What you should knowabout our planAmerivantage Classic (HMO) is a Medicare Advantage and prescription drug plan,which includes hospital, medical and prescription drug benefits in one plan. Tojoin this plan, you must be entitled to Medicare Part A, enrolled in Medicare PartB and live in our service area.Our service area includes: NM: Bernalillo, Sandoval, Santa Fe, Torrance, ValenciaWith this plan, you must use a provider in the plan’s network. If you use providersthat are not in our network, the plan may not pay for these services.You can find a doctor in the network online — visitwww.myamerigroup.com/medicare and choose Find a Doctor. (Be sure to checkthat the doctor displays as “In-Network” for these plans.) Or you can call CustomerService and request a copy of the provider directory.2Amerivantage Classic (HMO)
What do we cover?Like all Medicare health plans, we cover everything that Original Medicarecovers — Part A (hospital services) and Part B (medical services), plus more.For some of these benefits, you may pay more in our plan than you would inOriginal Medicare. For others, you may pay less (see benefits section for moredetails).Medicare Part D drugs and Part B drugs (such as chemotherapy and somedrugs administered by your provider).To see if your drugs are covered, you can view the plan’s Formulary (list ofcovered Part D prescription drugs) and any restrictions on our website atwww.myamerigroup.com/medicare. Or you can call us for a copy of theFormulary.What are my drugcosts?Our plan groups eachmedication into one of six“tiers.” The amount you paydepends on the drug’s tier andwhat stage of the benefit youhave reached (refer to The fourstages of coverage).Amerivantage Classic (HMO)How to find out what yourcovered drugs will cost:Step 1: Find your drug on the Formulary.Step 2: Next, identify the drug tier.Step 3: Then, go to the Prescription DrugBenefits section further in thisbooklet to match the tier.3
Can I use any pharmacyto fill my covered prescriptions?To receive the lowest out-of-pocket costs on your covered Part D drugs, you mustgenerally use a pharmacy in our network. If you use a pharmacy that is not in ournetwork, you may pay more for your covered drugs.You may be able to save even more money atpharmacies with preferred cost sharingWe've worked with certain network pharmacies to further reduce prices, so youcan save more on your covered drugs. Having available preferred pharmacies doesnot mean you can’t use other pharmacies in our network (pharmacies with standardcost sharing), but you may pay more at a pharmacy with standard cost-sharing.Pharmacies with preferred cost-sharing have lower copays and coinsuranceamounts for non-specialty drugs than pharmacies with standard cost-sharing.For a complete listing of network pharmacies, refer to our plan’s PharmacyDirectory on our website www.myamerigroup.com/medicare (under Useful Tools,select Find a Pharmacy). Next to the pharmacy name, you will see a preferredcost-sharing indicator (a symbol). Or you can give us a call, and we will send youa copy.4Amerivantage Classic (HMO)
How can I learn more aboutMedicare or compare mychoices with other plans?Refer to your current Medicare & You handbook. You can view it online atwww.medicare.gov or call Medicare for a copy at 1-800-MEDICARE(1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call1-877-486-2048.If you want to compare our plan with other Medicare health plans, ask theother plans for their Summary of Benefits booklets. Or you can go online towww.medicare.gov and use the Medicare Plan Finder.Now that you are familiar withhow Medicare works and someof the benefits included in ourplans, it’s time to consider thetype of plan you may need. Onthe following pages, you canreview our available plans withvarying coverage levels to helpyou choose the right plan foryou.Be in the knowBefore you continue, here are a few important things to know asyou review our available plan options:Services with a 1 may require prior authorization.Services with a 2 may require a referral from your doctor.Amerivantage Classic (HMO)5
Amerivantage Classic (HMO)How much is my premium? 0.00 per monthYou must continue to pay your Medicare Part B premium.How much is my deductible?This plan does not have a medical deductible.Is there a limit on how much I will pay for my covered medical services?(does not include Part D drugs) 6,700 per year from in-network providersLike all Medicare health plans, our plan protects you by having yearly limits onyour out-of-pocket costs for medical and hospital care.Your limit for services received from in-network providers will count toward theyearly limit. If you reach the limit on out-of-pocket costs, you will not have topay any out-of-pocket costs for the rest of the year for covered in-network Part Aand Part B services.You will still need to pay your monthly premiums (if you have one) and costsharing for your Part D prescription drugs.Inpatient Hospital1In-network:Days 1 - 6: 295 per day, per admission / Days 7 - 90: 0 per day, peradmissionThis plan covers unlimited inpatient days.In-network per day cost-sharing applies to each inpatient admission. (note:transfers to an inpatient rehabilitation hospital is considered a new admissionand cost-sharing per day applies).6Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Doctor’s Office Visits1,2Primary care physician visit:In-network: 5.00 copaySpecialist visit:In-network: 40.00 copayPreventive Care Screenings and Annual Physical ExamsPreventive care screenings:In-network: 0.00 copayAnnual physical exam:In-network: 0.00 copayAmerivantage Classic (HMO)7
Amerivantage Classic (HMO)Preventive Care Screenings and Annual Physical Exams - continuedCovered Preventive care screenings:Abdominal aortic aneurysm screeningAlcohol misuse counselingAnnual “Wellness” visitBone mass measurementBreast cancer screening(mammogram)Cardiovascular disease (behavioraltherapy)Cardiovascular screeningCervical and vaginal cancer screeningColorectal cancer screenings(colonoscopy, fecal occult blood test,flexible sigmoidoscopy)Depression screeningDiabetes screenings and monitoringHIV screeningLung cancer screeningsMedical nutrition therapy servicesObesity screenings and counselingProstate cancer screenings (PSA)Sexually transmitted infectionsscreenings and counselingTobacco use cessation counseling(counseling for people with no signof tobacco-related disease)Vaccines, including flu shots, hepatitisB shots, pneumococcal shots“Welcome to Medicare” preventivevisit (one-time)Any additional preventive services approved by Medicare during the contractyear will be covered. This plan covers preventive care screenings and annualphysical exams at 100% when you use in-network providers.Emergency Care 75.00 copayThis plan offers limited coverage for urgent and emergency care outside of theUnited States. This plan may provide coverage up to a 25,000 limit. If the costof the service exceeds 25,000, you are responsible for the difference.Urgently Needed Services 30.00 copay8Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Diagnostic Radiology Services (such as MRIs, CT scans)1,2In-Network: 115.00 - 230.00 copayCosts for these services may vary based on place of service.Diagnostic Tests and Procedures1,2In-Network: 0.00 - 200.00 copayCosts for these services may vary based on place of service.Lab Services1,2In-Network: 0.00 - 10.00 copayOutpatient X-rays1,2In-Network: 30.00 - 200.00 copayCosts for these services may vary based on place of service.Therapeutic Radiology Services (such as radiation treatment for cancer)1,2In-Network: 20% coinsuranceHearing Services1,2Medicare covered hearing services(Exam to diagnose and treat hearing and balance issues):In-network: 40.00 copayAmerivantage Classic (HMO)9
Amerivantage Classic (HMO)Hearing Services1,2 - continuedRoutine hearing services:This plan covers 1 routine hearing exam(s) and hearing aid fitting /evaluation(s) every year. 250.00 maximum plan benefit for hearing aids everyyear.In-network: 0.00 copay for routine hearing exam(s). 0.00 copay for hearingaids.Dental ServicesMedicare covered dental services (this does not include services in connectionwith care, treatment, filling, removal or replacement of teeth):In-network: 40.00 copayPreventive dental services:This plan covers: 1 oral exam(s) every year, 1 cleaning(s) every year.In-network: 0.00 copayComprehensive dental services:Not CoveredVision ServicesMedicare covered vision services:Exam to diagnose and treat diseases and conditions of the eyeIn-network: 0.00 - 40.00 copay10Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Vision Services - continuedEyeglasses or contact lenses after cataract surgeryIn-network: 0.00 copayRoutine vision services:Routine eye examThis plan covers 1 routine eye exam(s) every year.In-network: 0.00 copayRoutine eye wearNot CoveredMental Health CareInpatient visit:1In-network: Days 1-6: 260 per day, per admission / Days 7-90: 0 per day,per admissionOur plan covers up to 190 days in a lifetime for inpatient mental health care ina psychiatric hospital. The inpatient hospital care limit does not apply to inpatientmental services provided in a general hospital.This plan covers unlimited inpatient days.In-network per day cost-sharing applies to each inpatient admission. (note:transfers to an inpatient rehabilitation hospital is considered a new admissionand cost-sharing per day applies).Outpatient individual and group therapy visit:1,2In-network: 40.00 copayAmerivantage Classic (HMO)11
Amerivantage Classic (HMO)Skilled Nursing Facility (SNF)1In-network: Days 1 - 20: 0 per day / Days 21 - 100: 160 per dayThis plan covers up to 100 days in a Skilled Nursing Facility (SNF).The copays for SNF benefits are based on benefit periods. A benefit period beginsthe day you’re admitted to the hospital or skilled nursing facility and ends whenyou haven't received any inpatient hospital care or skilled nursing care for 60days in a row. If you are admitted to an SNF after one benefit period has ended,a new benefit period begins. There’s no limit to the number of benefit periods.Outpatient Rehabilitation1,2Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per dayfor up to 36 sessions up to 36 weeks):In-network: 40.00 copayPulmonary (lung) rehab services (for a maximum of 2 one-hour sessions perday for up to 36 sessions):In-network: 30.00 copayOccupational therapy visit:In-network: 40.00 copayPhysical therapy and speech/language therapy visit:In-network: 40.00 copay12Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Ambulance1Ground/Water Ambulance:In-network: 375.00 copay per tripAir Ambulance:In-network: 20% coinsurance per tripTransportation1Not CoveredFoot Care (podiatry services)1,2Medicare covered podiatry:In-network: 40.00 copayFoot exams and treatment are covered if you have diabetes-related nerve damageand/or meet certain conditions.Routine foot care:In-network: 0.00 copayThis plan covers 24 routine foot care visit(s) every year.Medical Equipment/Supplies1Durable Medical Equipment (wheelchairs, oxygen, etc.)In-network: 20% coinsuranceMedical supplies and prosthetic devices (braces, artificial limbs, etc.)In-network: 20% coinsuranceAmerivantage Classic (HMO)13
Amerivantage Classic (HMO)Medical Equipment/Supplies - continuedDiabetic supplies and servicesIn-network: 0.00 copayWellness ProgramsHealthways SilverSneakers * Fitness program: You pay nothingWhen you become our member, you can sign up for SilverSneakers. Additionaldetails can be found at www.silversneakers.com. Or you can call SilverSneakersCustomer Service at 1-855-741- 4985 (TTY: 711), Monday through Friday, 8 a.m.to 8 p.m. ET.* The SilverSneakers Fitness Program is provided by Healthways, Inc., anindependent company. Healthways and SilverSneakers are registered marks ofHealthways, Inc. and/or its subsidiaries. 2016 Healthways, Inc. All rights reserved.Medicare Part B Drugs1In-network: 20% coinsurance14Amerivantage Classic (HMO)
The four stages of drug coverageWhat you pay for your covered drugs depends, in part, on which coverage stageyou are in.Stage 1Stage 2Stage 3Stage 4DeductibleInitial CoverageCoverage GapCatastrophicCoverageIf you have adeductible, youwill pay 100% ofyour drug costuntil yourdeductible ismet. (If you haveno deductible, orif a specific drugtier does notapply to thedeductible, youwill skip toStage 2.)You will pay acopay orcoinsurance, andyour plan paysthe rest for yourcovered drugsIn this stage, you paya greater share of thecosts. It begins afteryou and your planhave paid a certainamount, which canvary by plan, oncovered drugs duringStages 1 and 2. SeeStage 2: InitialCoverage below forthe exact amount.After you enter thecoverage gap, you pay40% of the plan’s costfor covered brandname drugs and 51%of the plan’s cost forcovered generic drugsuntil your costs total 4,950. Some planshave additionalcoverage. See theCoverage Gap sectionon later pages fordetails.In this stage, afteryour yearlyout-of-pocket drugcosts (includingdrugs purchasedthrough your retailpharmacy andthrough mail order)reach 4,950, youpay the greater of:5% of the cost, or 3.30 copay forgeneric (includingbrand drugstreated asgeneric) and a 8.25 copaymentfor all otherdrugs.Which coverage stageam I in?You will get an Explanation ofBenefits (EOB) each monthyou fill a prescription. It willshow which coverage stageyou're in and how close youare to entering the next one.Amerivantage Classic (HMO)15
Outpatient Prescription Drug BenefitsHow much do I pay for Part D drugs?Amerivantage Classic (HMO)Stage 1: DeductibleThis plan does not have a deductibleStage 2: Initial CoverageAfter you pay your yearly deductible (if your plan has one), you pay the followinguntil your total yearly drug costs reach 3,590. Total yearly drug costs are thetotal drug costs paid by both you and our Part D plan.You may get your drugs at network retail pharmacies and mail-order pharmacies.You may get drugs from an out-of-network pharmacy, but may pay more thanyou pay at an in-network pharmacy.If you reside in a long-term care facility, you pay the same as at a standard retailpharmacy.Stage 2: Initial Coverage - Preferred Retail Cost SharingTier 1: Preferred GenericOne-month supply: 4.00 copayThree-month supply: 12.00 copayTier 2: GenericOne-month supply: 14.00 copayThree-month supply: 42.00 copay16Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Stage 2: Initial Coverage - Preferred Retail Cost Sharing - continuedTier 3: Preferred BrandOne-month supply: 42.00 copayThree-month supply: 126.00 copayTier 4: Nonpreferred DrugsOne-month supply: 95.00 copayThree-month supply: 285.00 copayTier 5: Specialty TierOne-month supply:33% of the costThree-month supply:N/ATier 6: Select Care DrugsOne-month supply: 0.00 copayThree-month supply: 0.00 copayAmerivantage Classic (HMO)17
Amerivantage Classic (HMO)Stage 2: Initial Coverage - Standard Retail Cost SharingTier 1: Preferred GenericOne-month supply: 9.00 copayThree-month supply: 27.00 copayTier 2: GenericOne-month supply: 19.00 copayThree-month supply: 57.00 copayTier 3: Preferred BrandOne-month supply: 47.00 copayThree-month supply: 141.00 copayTier 4: Nonpreferred DrugsOne-month supply: 100.00 copayThree-month supply: 300.00 copayTier 5: Specialty TierOne-month supply:33% of the costThree-month supply:N/A18Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Stage 2: Initial Coverage - Standard Retail Cost Sharing - continuedTier 6: Select Care DrugsOne-month supply: 0.00 copayThree-month supply: 0.00 copayStage 2: Initial Coverage - Standard Mail Order Cost SharingTier 1: Preferred GenericOne-month supply: 4.00 copayThree-month supply: 12.00Tier 2: GenericOne-month supply: 14.00 copayThree-month supply: 42.00 copayTier 3: Preferred BrandOne-month supply: 42.00 copayThree-month supply: 126.00 copayAmerivantage Classic (HMO)19
Amerivantage Classic (HMO)Stage 2: Initial Coverage - Standard Mail Order Cost Sharing - continuedTier 4: Nonpreferred DrugsOne-month supply: 95.00 copayThree-month supply: 285.00 copayTier 5: Specialty TierOne-month supply:33% of the costThree-month supply:N/ATier 6: Select Care DrugsOne-month supply: 0.00 copayThree-month supply: 0.00 copayStage 3: Coverage GapAfter you enter the coverage gap, you pay 40% of the plan’s cost for coveredbrand name drugs and 51% of the plan’s cost for covered generic drugs until yourcosts total 4,950, which is the end of the coverage gap. Not everyone will enterthe coverage gap.You may pay even less for the generic drugs on the formulary. Your cost variesby tier. You will need to use your formulary to locate your drug’s tier. Foradditional gap coverage, see the chart that follows to find out how much yourdrugs will cost you.20Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Stage 3: Coverage Gap - Preferred Retail Cost SharingTier 6: Select Care DrugsDrugs Covered:AllOne-month supply: 0.00 copayThree-month supply: 0.00 copayStage 3: Coverage Gap - Standard Retail Cost SharingTier 6: Select Care DrugsDrugs Covered:AllOne-month supply: 0.00 copayThree-month supply: 0.00 copayStage 3: Coverage Gap - Standard Mail Order Cost-SharingTier 6: Select Care DrugsDrugs Covered:AllOne-month supply: 0.00 copayThree-month supply: 0.00 copayAmerivantage Classic (HMO)21
Amerivantage Classic (HMO)Stage 4: Catastrophic CoverageAfter your yearly out-of-pocket drug costs (including drugs purchased throughyour retail pharmacy and through mail order) reach 4,950, you pay the greaterof:5% of the cost, or 3.30 copay for generic (including brand drugs treated as generic) and a 8.25 copayment for all other drugs.22Amerivantage Classic (HMO)
Additional BenefitsAmerivantage Classic (HMO)Chiropractic Care1,2In-Network: 20.00 copayMedicare coverage includes manipulation of the spine to correct a subluxation(when one or more of the bones of your spine move out of position).Home Health Care1,2In-Network: 0.00 copayOutpatient Substance Abuse1,2Individual & Group therapy visit:In-Network: 40.00 copayOutpatient Surgery1,2Ambulatory surgical center:In-Network: 225.00 copayOutpatient hospital:In-Network: 295.00 copayRenal DialysisIn-Network: 20% coinsuranceAmerivantage Classic (HMO)23
More ways we support yourhealthAmerigroup: We’re here to help.Amerigroup is more than a company that provides medical coverage. We’re agroup of people committed to your health. Now, when times are tougher for manyof us, Amerigroup is committed to helping everyone get the tools and solutionsthey need to lead healthier lives.Looking for Medicare coverage that goes beyondoriginal Medicare?Amerigroup works with the federal government to bring you even more benefitsthan you get with Original Medicare. Lower copays, extra benefits, pharmacy andmedical coverage, advice from nurses and many other important health benefitsare yours from one company — all with 0 monthly plan premiums.Our plan gives you extra benefits not included in Original Medicare, such as:Amerivantage Classic (HMO)Personal Emergency Response System (PERS): Coverage of a PersonalEmergency Response System (PERS) which includes the monitoring device andmonitoring service. Members should contact customer service to initiate thisservice and installation. Please refer to the Evidence of Coverage for additionalinformation.LiveHealth Online: LiveHealth Online provides members with access to a doctorvia live, two-way video on a computer, smartphone or tablet.Telemonitoring: Coverage of in-home equipment and telecommunicationtechnology to monitor specific health conditions.24/7 Nurse HelpLine: 24-hour access to a nurse helpline,7 days a week, 365 days a year.Healthways SilverSneakers * Fitness program: You pay nothing24Amerivantage Classic (HMO)
Amerivantage Classic (HMO)When you become our member, you can sign up for SilverSneakers. Additionaldetails can be found at www.silversneakers.com. Or you can call SilverSneakersCustomer Service at 1-855-741-4985 (TTY: 711), Monday through Friday, 8 a.m.to 8 p.m. ET.* The SilverSneakers Fitness Program is provided by Healthways, Inc., anindependent company. Healthways and SilverSneakers are registered marks ofHealthways, Inc. and/or its subsidiaries. 2016 Healthways, Inc. All rights reserved.Amerivantage Classic (HMO)25
Optional Supplemental Benefits – Package 1Preventive Dental PackageAmerivantage Classic (HMO)How much is the monthly premium?Additional 7.00 per month. You must keep paying your Medicare Part Bpremium.How much is the deductible?This package does not have a deductible.Is there a limit on how much the plan will pay?In-network:The plan will pay up to 500 for the following preventive dental benefits eachyear (benefit maximum).Talk to your provider and confirm all coverage, costs and codes prior to servicesbeing rendered.26Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Benefits included:In-network:You pay no copay for:Two examsTwo cleaningsDental X-rays: include one full-mouth or panoramic X-ray and one set/series of bitewing X-rays each year and up to seven Periapical images percalendar yearTwo fluoride treatmentsAs a Supplemental Benefit, these services are not routinely covered under OriginalMedicare. They are offered for an additional premium through this OptionalSupplemental Package 1 – Preventive Dental Package. Please reference theEvidence of Coverage for additional details about this package.Amerivantage Classic (HMO)27
Optional Supplemental Benefits – Package 2Dental and Vision PackageAmerivantage Classic (HMO)How much is the monthly premium?Additional 19.00 per month. You must keep paying your Medicare Part Bpremium.How much is the deductible?This package does not have a deductible.Is there a limit on how much the plan will pay?In-network:DENTAL:The plan will pay up to 1,000 for dental benefits each year (benefit maximum).Talk to your provider and confirm all coverage, costs and codes prior to servicesbeing rendered.28Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Benefits included:DENTAL:In-network:You pay no copay for:Two examsTwo cleaningsDental X-rays: include one full-mouth or panoramic X-ray and one set/series of bitewing X-rays each year and up to seven Periapical images percalendar yearTwo fluoride treatments.You pay 20% as your portion of the covered charges for certain restorativedental services (fillings).You pay 50% as your portion of the covered charges for certain endodontic,periodontic, and oral surgery dental services which include, but are not limitedto, the following:Root canal treatmentPeriodontal scaling and root planingSimple and surgical extractionsExclusions & Limitations for this benefit package:Dentures and crowns are excluded.VISION:You can select the option of:Paying 10 copay for 1 pair of standard plastic (single, bifocal or trifocal)lenses and receiving a retail allowance of 100 for 1 eyeglass frame everycalendar year.ORAlternatively, if you want contact lenses instead of eyeglass lenses andframes, the plan will cover up to 150 for contact lenses every calendaryear.Exclusions & Limitations for this benefit package:Amerivantage Classic (HMO)29
Amerivantage Classic (HMO)Benefits included: - continuedSafety eyewear, non-prescription sunglasses, glass lenses, non-prescriptionlenses or contacts, or lens treatments are not covered.As a Supplemental Benefit, these services are not routinely covered under OriginalMedicare. They are offered for an additional premium through this OptionalSupplemental Package 2 – Dental and Vision Package. Please reference theEvidence of Coverage for additional details about this package.30Amerivantage Classic (HMO)
Optional Supplemental Benefits – Package 3Enhanced Dental and Vision PackageAmerivantage Classic (HMO)How much is the monthly premium?Additional 28.00 per month. You must keep paying your Medicare Part Bpremium.How much is the deductible?This package does not have a deductible.Is there a limit on how much the plan will pay?In-network:DENTAL:The plan will pay up to 1,500 for dental benefits each year (benefit maximum).Talk to your provider and confirm all coverage, costs and codes prior to servicesbeing rendered.Amerivantage Classic (HMO)31
Amerivantage Classic (HMO)Benefits included:DENTAL:In-network:You pay no copay for:Two examsTwo cleaningsDental X-rays: include one full-mouth or panoramic X-ray and one set/series of bitewing X-rays each year and up to seven Periapical images percalendar yearTwo fluoride treatments.You pay 20% as your portion of the covered charges for certain restorativedental services (fillings).You pay 50% as your portion of the covered charges for certain endodontic,periodontic, and oral surgery dental services which include, but are not limitedto, the following:Root canal treatmentPeriodontal scaling and root planingSimple and surgical extractionsCrowns (once per tooth every five years)Complete denture, immediate denture, or partial denture (one set ofdentures every five years)Denture adjustment, repair, replacement, rebasing and reliningLocal anesthesia (a drug to numb a part of the body) or regional blockanesthesiaVISION:You can select the option of:Paying 10 copay for 1 pair of standard plastic (single, bifocal or trifocal)lenses and receiving a retail allowance of 150 for 1 eyeglass frame everycalendar year.OR32Amerivantage Classic (HMO)
Amerivantage Classic (HMO)Benefits included: - continuedAlternatively, if you want contact lenses instead of eyeglass lenses andframes, the plan will cover up to 200 for contact lenses every calendaryear.Exclusions & Limitations for this benefit package:Safety eyewear, non-prescription sunglasses, glass lenses, non-prescriptionlenses or contacts, or lens treatments are not covered.As a Supplemental Benefit, these services are not routinely covered under OriginalMedicare. They are offered for an additional premium through this OptionalSupplemental Package 3 – Enhanced Dental and Vision Package. Please referencethe Evidence of Coverage for additional details about this package.Amerivantage Classic (HMO)33
This document is available in other formats such as Braille. This information isavailable for free in other languages. Please call our Customer Service number at1-866-805-4589 (TTY: 711), 8 a.m. to 8 p.m., seven days a week, October 1 toFebruary 14 (except holidays); 8 a.m. to 8 p.m., Monday – Friday, February 15 toSeptember 30 (except holidays).Este documento está disponible en otros formatos, como braille. Esta informaciónestá disponible en otros idiomas de manera gratuita. LLame al servicio de atenciónal cliente al 1-866-805-4589(TTY: 711), de 8 a. m. a 8 p. m., los 7 dias de la semana(excepto los dias feriados) desde el 1 de octubre hasta el 14 de febrero, y de 8 a.m. a 8 p. m., de lunes a viernes (except los dias feriados) del 15 de febrero hastael 30 de septiembre.This information is not a complete description of benefits. Contact the plan formore information.Limitations, copayments, and restrictions may apply.Benefits, premiums and/or co-payments/co-insurance may change on January 1of each year.The Formulary, pharmacy network, and/or provider network may change at anytime. You will receive notice when necessary.AMERIGROUP Community Care of New Mexico, Inc. is an HMO plan with a Medicarecontract. Enrollment in Amerivantage Classic depends on contract renewal.
Multi-language Interpreter ServicesEnglish: ATTENTION: If you speak English, language assistance services, free of charge, are availableto you. Call 1-866-805-4589 (TTY: 711).Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencialingüística. Llame al 1-866-805-4589 (TTY: 711).Arabic: ﺍﺗﺼﻞ ﺑﺮﻗﻢ . ﻓﺈﻥ ﺧﺪﻣﺎﺕ ﺍﻟﻤﺴﺎﻋﺪﺓ ﺍﻟﻠﻐﻮﻳﺔ ﺗﺘﻮﺍﻓﺮ ﻟﻚ ﺑﺎﻟﻤﺠﺎﻥ ، ﺇﺫﺍ ﻛﻨﺖ ﺗﺘﺤﺪﺙ ﺍﺫﻛﺮ ﺍﻟﻠﻐﺔ : ﻣﻠﺤﻮﻅﺔ .(711 : )ﺭﻗﻢ ﻫﺎﺗﻒ ﺍﻟﺼﻢ ﻭﺍﻟﺒﻜﻢ 1-866-805-4589Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող ենտրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-866-805-4589 (TTY(հեռատիպ)՝ 711):Chinese: �費獲得語言援助服務。請致電 1-866-805-4589（TTY：711）。Farsi: ﺗﺴﻬﻴﻼﺕ ﺯﺑﺎﻧﯽ ﺑﺼﻮﺭﺕ ﺭﺍﻳﮕﺎﻥ ﺑﺮﺍی ﺷﻤﺎ ، ﺍﮔﺮ ﺑﻪ ﺯﺑﺎﻥ ﻓﺎﺭﺳﯽ ﮔﻔﺘﮕﻮ ﻣﯽ ﮐﻨﻴﺪ : ﺗﻮﺟﻪ . ﺗﻤﺎﺱ ﺑﮕﻴﺮﻳﺪ 1-866-805-4589 (TTY: 711) ﺑﺎ . ﻓﺮﺍﻫﻢ ﻣﯽ ﺑﺎﺷﺪ French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposésgratuitement. Appelez le 1-866-805-4589 (ATS : 711).German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachlicheHilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-805-4589 (TTY: 711).Gujarati:ુચના:જો તમેુુજરાતીબોલતા હો, તો િન: લ્ેાાા સહાય સવાઓતમારા માટ ઉપલબ્ છ.ેફોન ્રો
www.medicare.gov or call Medicare for a copy at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users can call 1-877-486-2048. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or you can go online to www.medicare.gov and use the Medicare Plan Finder.
