Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Copayment/Coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Generally, your costs for services will be the lowest when using Tier 1 providers.
Drug Tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier 1 (Preferred Generic) • Tier 2 (Generic) • Tier 3 (Preferred Brand) • Tier 4 (Non-Preferred Drug) • Tier 5 (Specialty Tier) Generally, the higher the tier, the more you pay for the drug. You can find our formulary in the back pocket of this book. Some prescriptions require step therapy (for you to try a lower tier first), preauthorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary. Emergency Care: The amount you pay for emergency care, like a trip to the emergency room. Inpatient Hospital Care: The amount you pay for a stay in an in-network hospital.*
Medicare Advantage
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care
Generally gives you the flexibility to see any doctor who accepts Original Medicare
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Replaces Original Medicare
Supplements Original Medicare
Primary Care Provider (PCP) Visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
May cover benefits that Original Medicare doesn't
Only covers expenses covered by Original Medicare
No medical underwriting
Medical underwriting (except for guaranteed issue plans)
Lower premiums than Medicare Supplement plans
Higher premiums than Medicare Advantage plans
Who pays in what order: Health plan, you
Who pays in what order: Original Medicare, health plan, you
Not age- or tobacco-rated
Age- and tobacco-rated
Outpatient Surgery: What you pay for an outpatient procedure. Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. For more information turn to the Perks tab.
Skilled Nursing Facility (SNF): What you pay for an approved stay at a SNF. Specialist Visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent Care: The amount you pay for urgent or convenient care.
Lab: What you pay for lab services, like blood tests. Medical Deductible: What you pay out-of-pocket before your coverage starts.
You get more out of Medicare with Medicare Advantage.
Yearly Limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
Medical Tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network. • Tier 1 – Most OSF HealthCare providers, hospitals and facilities. • Tier 2 – Other chosen providers, hospitals and facilities in the counties OSF MedAdvantage plans are offered. *Review the provider directory at OSFMedAdvantage.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You are not covered out of network unless it’s for emergency or urgent care. With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You will save money by staying in network, though.
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF Med Advantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Health Alliance Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-965-4022 (TTY: 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 1-800-965-4022 (TTY: 711). Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage 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.
MDMKOS21-foldguide-0420 H1463_21_86002_M
2021 MEDICARE ADVANTAGE Key Benefits Guide
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. (877) 633-2531 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1-September 30 OSFMedAdvantage.org
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Copayment/Coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Generally, your costs for services will be the lowest when using Tier 1 providers.
Drug Tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier 1 (Preferred Generic) • Tier 2 (Generic) • Tier 3 (Preferred Brand) • Tier 4 (Non-Preferred Drug) • Tier 5 (Specialty Tier) Generally, the higher the tier, the more you pay for the drug. You can find our formulary in the back pocket of this book. Some prescriptions require step therapy (for you to try a lower tier first), preauthorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary. Emergency Care: The amount you pay for emergency care, like a trip to the emergency room. Inpatient Hospital Care: The amount you pay for a stay in an in-network hospital.*
Medicare Advantage
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care
Generally gives you the flexibility to see any doctor who accepts Original Medicare
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Replaces Original Medicare
Supplements Original Medicare
Primary Care Provider (PCP) Visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
May cover benefits that Original Medicare doesn't
Only covers expenses covered by Original Medicare
No medical underwriting
Medical underwriting (except for guaranteed issue plans)
Lower premiums than Medicare Supplement plans
Higher premiums than Medicare Advantage plans
Who pays in what order: Health plan, you
Who pays in what order: Original Medicare, health plan, you
Not age- or tobacco-rated
Age- and tobacco-rated
Outpatient Surgery: What you pay for an outpatient procedure. Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. For more information turn to the Perks tab.
Skilled Nursing Facility (SNF): What you pay for an approved stay at a SNF. Specialist Visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent Care: The amount you pay for urgent or convenient care.
Lab: What you pay for lab services, like blood tests. Medical Deductible: What you pay out-of-pocket before your coverage starts.
You get more out of Medicare with Medicare Advantage.
Yearly Limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
Medical Tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network. • Tier 1 – Most OSF HealthCare providers, hospitals and facilities. • Tier 2 – Other chosen providers, hospitals and facilities in the counties OSF MedAdvantage plans are offered. *Review the provider directory at OSFMedAdvantage.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You are not covered out of network unless it’s for emergency or urgent care. With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You will save money by staying in network, though.
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF Med Advantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Health Alliance Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-965-4022 (TTY: 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 1-800-965-4022 (TTY: 711). Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage 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.
MDMKOS21-foldguide-0420 H1463_21_86002_M
2021 MEDICARE ADVANTAGE Key Benefits Guide
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. (877) 633-2531 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1-September 30 OSFMedAdvantage.org
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Copayment/Coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Generally, your costs for services will be the lowest when using Tier 1 providers.
Drug Tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier 1 (Preferred Generic) • Tier 2 (Generic) • Tier 3 (Preferred Brand) • Tier 4 (Non-Preferred Drug) • Tier 5 (Specialty Tier) Generally, the higher the tier, the more you pay for the drug. You can find our formulary in the back pocket of this book. Some prescriptions require step therapy (for you to try a lower tier first), preauthorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary. Emergency Care: The amount you pay for emergency care, like a trip to the emergency room. Inpatient Hospital Care: The amount you pay for a stay in an in-network hospital.*
Medicare Advantage
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care
Generally gives you the flexibility to see any doctor who accepts Original Medicare
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Replaces Original Medicare
Supplements Original Medicare
Primary Care Provider (PCP) Visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
May cover benefits that Original Medicare doesn't
Only covers expenses covered by Original Medicare
No medical underwriting
Medical underwriting (except for guaranteed issue plans)
Lower premiums than Medicare Supplement plans
Higher premiums than Medicare Advantage plans
Who pays in what order: Health plan, you
Who pays in what order: Original Medicare, health plan, you
Not age- or tobacco-rated
Age- and tobacco-rated
Outpatient Surgery: What you pay for an outpatient procedure. Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. For more information turn to the Perks tab.
Skilled Nursing Facility (SNF): What you pay for an approved stay at a SNF. Specialist Visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent Care: The amount you pay for urgent or convenient care.
Lab: What you pay for lab services, like blood tests. Medical Deductible: What you pay out-of-pocket before your coverage starts.
You get more out of Medicare with Medicare Advantage.
Yearly Limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
Medical Tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network. • Tier 1 – Most OSF HealthCare providers, hospitals and facilities. • Tier 2 – Other chosen providers, hospitals and facilities in the counties OSF MedAdvantage plans are offered. *Review the provider directory at OSFMedAdvantage.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You are not covered out of network unless it’s for emergency or urgent care. With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You will save money by staying in network, though.
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF Med Advantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Health Alliance Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-965-4022 (TTY: 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 1-800-965-4022 (TTY: 711). Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage 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.
MDMKOS21-foldguide-0420 H1463_21_86002_M
2021 MEDICARE ADVANTAGE Key Benefits Guide
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. (877) 633-2531 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1-September 30 OSFMedAdvantage.org
Plan Costs Plan†
Premium
Office Visits
Medical Deductible
Yearly Limit (doesn’t include pharmacy)
PCP Visit
Specialist Visit
Virtual Visit
Diagnostic Services
Physical Therapy
Chiropractic
Lab
X-Ray
CT/MRI
Emergency Services Ambulance»
Initial Rx Coverage (for 30-day supply)
Hospital Services
Emergency Care***
Urgent Care+ Outpatient Hospital Care
Inpatient Hospital Care^ (including services received)
Skilled Nursing Facility (noncustodial care based on medical necessity)
Rx Deductible
Rx Cost by Tier 1
2
3
4
5
1
OSF MedAdvantage Core (HMO)
$0
$0
$4,000
Tier 1: $0 Tier 2: $35
Tier 1: $40 Tier 2: $50
$0
Tier 1: $10 Tier 2: $40
Tier 1: $20 Tier 2: $20
Tier 1: $15 Tier 2: 20%
Tier 1: $35 Tier 2: 20%
Tier 1: $35 Tier 2: 20%
$220
$90
$25
Tier 1: $250 Tier 2: $375
Tier 1: $300/Day (1-5), $0/Day (Days 6+) Tier 2: $350/Day (1-5), $0/Day (Days 6+)
Tier 1: $0/Day (1-20), $165 (Days 21-100) Tier 2: $0/Day (1-20), $178 (Days 21-100)
$0
$2
$15
$47
50%
33%
2
OSF MedAdvantage Open (HMO-POS)
$35
$0
IN: $4,500 OON: $11,300
Tier 1: $0 Tier 2: $35 OON: $50
Tier 1: $10 Tier 2: $50 OON: $60
$0
Tier 1: $10 Tier 2: $40 OON: $60
Tier 1: $20 Tier 2: $20 OON: $50
Tier 1: $10 Tier 2: $25 OON: 25%
Tier 1: $35 Tier 2: $60 OON: 25%
Tier 1: $35 Tier 2: $60 OON: 25%
$220
$90
$25
Tier 1: $200 Tier 2: 30% OON: 50%
Tier 1: $200/Day (1-7), $0/Day (Days 8+) Tier 2: $325/Day (1-6), $0/Day (Days 7+) OON: $600/Day (1-4), $0/Day (Days 5-90)
Tier 1: $0/Day (1-20), $160 (Days 21-100) Tier 2: $0/Day (1-20), $178 (Days 21-100) OON: $100/Day (1-20), $200 (Days 21-100)
$0
$2
$15
$47
50%
33%
3
OSF MedAdvantage Select (HMO)
$110
$1,650
$3,400
Tier 1: $0 Tier 2: $35
Tier 1: $0 Tier 2: $50
$0
Tier 1: $0 Tier 2: $40
Tier 1: $0 Tier 2: $20
Tier 1: $0 Tier 2: 25%
Tier 1: $0 Tier 2: 20%
Tier 1: $0 Tier 2: 20%
$0
*$0
*$0
Tier 1: $0 Tier 2: 25%
Tier 1: $0 Tier 2: $350/Day (1-5), $0/Day (Days 6+)
Tier 1: $0/Day (1-20), $160 (Days 21-100) Tier 2: $0/Day (1-20), $178 (Days 21-100)
$0
$2
$15
$47
50%
33%
4
OSF MedAdvantage Plus (HMO-POS)
$135
$1,650
IN: $3,400 OON: $5,800
Tier 1: $0 Tier 2: $35 OON: $50
Tier 1: $0 Tier 2: $50 OON: $60
$0
Tier 1: $0 Tier 2: $40 OON: $60
Tier 1: $0 Tier 2: $20 OON: $50
Tier 1: $0 Tier 2: 25% OON: 50%
Tier 1: $0 Tier 2: 20% OON: 30%
Tier 1: $0 Tier 2: 20% OON: 30%
$0
*$0
*$0
Tier 1: $0 Tier 2: 25% OON: 25%
Tier 1: $0 Tier 2: $350/Day (1-5), $0/Day (Days 6+) OON: $600/Day (1-4), $0/Day (Days 5-90)
Tier 1: $0/Day (1-20), $160 (Days 21-100) Tier 2: $0/Day (1-20), $178 (Days 21-100) OON: $100/Day (1-20), $200 (Days 21-100)
$0
$2
$15
$47
50%
33%
Key: This is a summary of commonly used benefits. IN means in network, and OON means out of network. The OON yearly limit includes your combined costs for both in-network and out-of-network care. *Deductible doesn’t apply.
† Members on POS plans may pay more for preventive care out of network. » Non-emergency cost-sharing may vary. Contact the plan for details. *** Emergency care available worldwide. + Also called convenient or walk-in care ^ You pay nothing for days 91 and beyond in network. o Members may have costs related to travel services.
Perks and Programs HEARING BENEFIT
Through TruHearing®, you can get one routine hearing exam for a $45 copay and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.
PREVENTIVE CARE
Yearly wellness visit, routine screenings, flu shot and more.
DENTAL COVERAGE
Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $200 a year. (Some plans may have higher coverage.)
ASSIST AMERICA
o
Get expert medical help when you’re 100 miles or more from home.
WELLNESS REWARDS
ANYTIME NURSE LINE
Earn a $50 gift card for taking specific healthy steps outlined at OSFMedAdvantage.org.
24/7 answers to your health questions.
BE FIT
Personalized help to end your tobacco use.
Get fit with a $360/year reimbursement at the fitness center of your choice.
QUIT FOR LIFE®
VIRTUAL VISITS
Talk to a board certified doctor or counselor by phone or secure video through the Hally app, 24/7.
VISION COVERAGE
Vision services beyond what Original Medicare covers.
Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.
• Out-of-network coverage – Providers not part of Tier 1 or Tier 2.
Copayment/Coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).
Generally, your costs for services will be the lowest when using Tier 1 providers.
Drug Tier: The cost group a drug belongs to. Drugs in our Medicare Part D formulary are in one of five groups: • Tier 1 (Preferred Generic) • Tier 2 (Generic) • Tier 3 (Preferred Brand) • Tier 4 (Non-Preferred Drug) • Tier 5 (Specialty Tier) Generally, the higher the tier, the more you pay for the drug. You can find our formulary in the back pocket of this book. Some prescriptions require step therapy (for you to try a lower tier first), preauthorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary. Emergency Care: The amount you pay for emergency care, like a trip to the emergency room. Inpatient Hospital Care: The amount you pay for a stay in an in-network hospital.*
Medicare Advantage
Medicare Supplement
Comfort of having an in-network primary care provider to oversee all your care
Generally gives you the flexibility to see any doctor who accepts Original Medicare
Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.
Replaces Original Medicare
Supplements Original Medicare
Primary Care Provider (PCP) Visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.*
May cover benefits that Original Medicare doesn't
Only covers expenses covered by Original Medicare
No medical underwriting
Medical underwriting (except for guaranteed issue plans)
Lower premiums than Medicare Supplement plans
Higher premiums than Medicare Advantage plans
Who pays in what order: Health plan, you
Who pays in what order: Original Medicare, health plan, you
Not age- or tobacco-rated
Age- and tobacco-rated
Outpatient Surgery: What you pay for an outpatient procedure. Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare. For more information turn to the Perks tab.
Skilled Nursing Facility (SNF): What you pay for an approved stay at a SNF. Specialist Visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent Care: The amount you pay for urgent or convenient care.
Lab: What you pay for lab services, like blood tests. Medical Deductible: What you pay out-of-pocket before your coverage starts.
You get more out of Medicare with Medicare Advantage.
Yearly Limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum.
Medical Tier - The cost group a provider, hospital or facility belongs to. Two medical tiers make up the provider network. • Tier 1 – Most OSF HealthCare providers, hospitals and facilities. • Tier 2 – Other chosen providers, hospitals and facilities in the counties OSF MedAdvantage plans are offered. *Review the provider directory at OSFMedAdvantage.org for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You are not covered out of network unless it’s for emergency or urgent care. With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You will save money by staying in network, though.
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF Med Advantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Health Alliance Medicare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted. Llame 1-800-965-4022 (TTY: 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 1-800-965-4022 (TTY: 711). Out-of-network/non-contracted providers are under no obligation to treat OSF MedAdvantage 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.
MDMKOS21-foldguide-0420 H1463_21_86002_M
2021 MEDICARE ADVANTAGE Key Benefits Guide
Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan. (877) 633-2531 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1-September 30 OSFMedAdvantage.org