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Pennsylvania Service Area39 Total CountiesCONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.14
Pennsylvania MAPDSelect and Value PlansCONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.15
Pennsylvania hingtonWestmorelandYork*Three county service area for the MAPD Select and Value plans.CONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.16
2018 PlansConfidential. All benefits pending CMS approval.
Medicare Advantage PrescriptionDrug Plans (MAPD)Gateway HealthMedicare Assured PrimeSMGateway HealthMedicare Assured SelectSMGateway HealthMedicare Assured ValueSM
2018 MAPD Plans – PABenefitsMedicare Assured SelectMedicare Assured ValueMonthly Premium 0 29MOOP 6700 6700Inpatient Hospital CopayDays 1-6: 350 per dayDays 1-6: 250 per dayPCP/Specialist Visit Copay 0/ 50 0/ 40Part D Deductible* 400 250Rx: Tiers 1/2/3/4/5 0/ 15/ 47/ 100/25% 0/ 15/ 47/ 100/28%Dental(every six months) 0 copay exam, cleaning &x-rays 0 copay exam, cleaning &x-raysVisionNot available 25 annual eye examHearingNot available 25 diagnostic examSilver SneakersIncludedIncludedOver the Counter (OTC)Quarterly Benefit 15 per quarter w/rollover 15 per quarter w/rolloverCONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.21
Special Needs Plans (SNPs)Gateway HealthMedicare Assured DiamondSMGateway HealthMedicare Assured RubySM
2018 Dual Special Needs PlansBenefitsMedicare AssuredDiamondMedicare Assured RubyMonthly Premium 0TBD*Inpatient Hospital CopayDays 1-90: 0 per dayDays 1-5: 275 per dayPCP/Specialist Visit Copay 0/ 0 0/ 35Part D Deductiblen/a 0-xxx*Rx* 1.25 - 3.35 generic 3.70 – 8.35 name brand 1.25 - 3.35 generic 3.70 – 8.35 name brandTransportation36 one-way trips per year24 one-way trips per yearDental(every six months) 0 copay – exam, cleaning& x-rays 0 copay - exam, cleaning& x-raysCONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.21
2018 Dual Special Needs PlansBenefitsMedicare AssuredDiamondMedicare Assured RubyOver the Counter (OTC)Quarterly Benefit*PA - 200KY, NC & OH - 120PA - 40, OH - 50NC - 25, KY - 15VisionOne exam every threemonths 150 towardeyewearOne exam every threemonths 100 towardeyewearHearing 0 diagnostic exam/ 1500for hearing aids every twoyears 25 – diagnostic hearingexamSilver SneakersIncludedIncludedLifeline Personal ResponseSystemIncludedNot availablePost-discharge mealsIncludedNot availableCONFIDENTIAL – NOT FOR DISTRIBUTION.ALL CONTENT SUBJECT TO CHANGE PENDING CMS APPROVAL.21
Medicare Assured Diamond. SM. Gateway Health Medicare Assured Ruby. SM. Special. Needs Plans (SNPs) 2018 Dual Special Needs Plans. 21. Benefits. Medicare Assured Diamond. Medicare Assured Ruby. Monthly Premium. 0: TBD* Inpatient Hospital Copay: Days 1-90: 0 per day. Days 1-5: 275 per day: PCP/Specialist Visit Copay. 0/ 0: 0/ 35.
