Contracted Health Plans
| OUTPATIENT SERVICES |
Secure Horizons Medicare Complete Plan 1 | Secure Horizons Medicare Complete Plan 2 | Secure Horizons Medicare Complete Plan 3 | Secure Horizons Medicare Complete Value Plan | Secure Horizons Medicare Complete Essential | Secure Horizons Evercare (Medi-Medi) |
| Monthly Premium | $0 | $40 | $0 | $0 | $0 | $0 |
| PCP Office Visits | $10 | $10 | $0 | $10 | $0 | $0 |
| Specialist Office Visits | $10 | $20 | $0 | $10 | $0 | $0 |
| Dialysis Treatment | $0 | $0 | $0 | $0 | $0 | 20% Copayment based on the 2006 Medicare fee schedule (1) |
| Durable Medical Equipment | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) |
| Diabetes Monitoring Supplies |
$0 | $0 | $0 | $0 | $0 | $0 |
| Home Health | $0 | $0 | $0 | $0 | $0 | $0 |
| Covered Injectable Drugs Self-administered | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) |
| Covered Injectable Drugs Physician -administered | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) |
| OUTPATIENT SERVICES | Secure Horizons Medicare Complete Plan 1 | Secure Horizons Medicare Complete Plan 2 | Secure Horizons Medicare Complete Plan 3 | Secure Horizons Medicare Complete Value Plan | Secure Horizons Medicare Complete Essential | Secure Horizons Evercare (Medi-Medi) |
| Radiation Therapy | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | $20.00 for each Medicare Covered |
| Simple Radiology | $0 | $0 | $0 | $0 | $0 | $0 |
| Complex Radiology | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) | 20% Copayment based on the 2006 Medicare fee schedule (1) |
| Rehabilitation - Speech, Occupational, Physical |
$0 for visits (1 - 12) $30 per visit for (13 or more) |
$0 for visits (1 - 12) $30 per visit for (13 or more) |
$0 for visits (1 - 12) $30 per visit for (13 or more) |
$0 for visits (1 - 12) $30 per visit for (13 or more) |
$0 for visits (1 - 12) $30 per visit for (13 or more) |
$0 |
| HOSPITAL SERVICES | ||||||
| Ambulance | $100 (per trip) | $100 (per trip) | $75 (per trip) | $100 (per trip) | $75 (per trip) | $50 (per trip) |
| Emergency Room | $50 (not waived if admitted) | $50 (not waived if admitted) | $50 (not waived if admitted) | $50 (not waived if admitted) | $50 (not waived if admitted) | $50 (not waived if admitted) |
| Inpatient Hospital | $250 per admit | $400 per admit | $50 per day for days 1-5 | $150 per admit | $50 per day for days 1-5 | $0 per admit |
| Inpatient Mental Health | $912 per admit | $912 per admit | $912 per admit | $912 per admit | $912 per admit | $812 copay; $0 per day, days 1 - 60 |
| Outpatient Surgery | $150 per visit | $175 per visit | $50 per visit | $100 per visit | $50 per visit | $0 |
| Skilled Nursing Facility | $0 for days 1-20 $100 per day, days 21 - 100 |
$0 for days 1-20 $100 per day, days 21 - 100 |
$0 for days 1-20 $120 per day, days 21 - 100 |
$0 for days 1-20 $100 per day, days 21 - 100 |
$0 for days 1-20 $100 per day, days 21 - 100 |
$0 for days 1 - 20 $150 per day, days 21 - 100 |
| PRESCRIPTION DRUG BENEFITS |
Secure Horizons Medicare Complete Plan 1 | Secure Horizons Medicare Complete Plan 2 | Secure Horizons Medicare Complete Plan 3 | Secure Horizons Medicare Complete Value Plan | Secure Horizons Medicare Complete Essential | Secure Horizons Evercare (Medi-Medi) |
| (P) Preferred (NP) Non Preferred | ||||||
| Part D Premium /Deductible | None | $8.70 | None | Not Covered | None | |
| (P) Generics Retail 30 days /Mail 90 days | $5.00/ $5.00 | $5.00/ $5.00 | $5.00/ $5.00 | $5.00/ $5.00 | Not Covered | $1.00 or $2.15 or 15% |
| (P) Brand Retail/Mail | $29.00/ $77.00 | $29.00/ $77.00 | $29.00/ $77.00 | $29.00/ $77.00 | Not Covered | $3.00/ $5.00 |
| (NP) Generic /Brand Retail /Mail | $60.00/ $170.00 | $60.00/ $170.00 | $60.00/ $170.00 | $60.00/ $170.00 | Not Covered | 25% |
| Specialty Drugs Retail/Mail | 33% | 33% | 33% | 33% | Not Covered | 33% |
| PRESCRIPTION DRUG BENEFITS |
Secure Horizons Medicare Complete Plan 1 | Secure Horizons Medicare Complete Plan 2 | Secure Horizons Medicare Complete Plan 3 | Secure Horizons Medicare Complete Value Plan | Secure Horizons Medicare Complete Essential | Secure Horizons Evercare (Medi-Medi) |
| Initial Coverage Limit | $2,400 (*) | $2,400 (*) | $2,400 | $3,000 | Not Covered | $2,400 |
| Coverage Gap | Not Covered | Not Covered | $10.00 / $10.00 generics $45.00/ $125.00 brand |
$10.00 / $10.00 generics $29.00/ $77.00 brand |
Not Covered | Covered |
| Catastrophic Coverage Level TrOOP Threshold | $3,850 | $3,850 | $3,850 | $3,850 | Not Covered | $3,850 |
| (P) Generics Retail 30 days /Mail 90 days | Greater of 5% or $2.15 | Greater of 5% or $2.15 | Greater of 5% or $2.15 | Greater of 5% or $2.15 | Not Covered | Greater of 5% or $2.15 |
| (P) Brand Retail /Mail | Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Not Covered | Greater of 5% or $5.35 |
| (NP) Generic /Brand Retail /Mail | Greater of 5% or $2.15/ $5.35 |
Greater of 5% or $2.15/ $5.35 |
Greater of 5% or $2.15/ $5.35 |
Greater of 5% or $2.15/ $5.35 |
Not Covered | Greater of 5% or $2.15/ $5.35 |
(1) Coinsurance for Secure Horizons members is based on the 2006 Medicare Allowable rates from the Quarter 1 2006 Medicare Fee Schedule.
All Health Plan products are offered in all service areas, with the following exceptions:
The Secure Horizons Medicare Complete Plan 2 and Plan 3 are the only Secure Horizons product available in Santa Clarita service area.
SCAN is not available in Santa Clarita Valley.
Blue Cross I Senior Secure is available in Central Valley only. Blue Cross II Senior Secure is available in all other service areas.
(*) After the total yearly drug costs (paid by both member and health plan) reaches Initial Coverage Limit, member pays 100% of prescription drug costs until their yearly out-of-pocket drug costs reaches $3,850.Unless the member has coverage through the gap.
TrOOP is True out-of-pocket costs for Part D prescription drugs for a beneficiary, which include the member's copayment and/or coinsurance.
Disclaimer: This data was summarized from information provided by each health plan based on their interpretation.
| OUTPATIENT SERVICES | Blue Shield 65 Plus | SCAN | Health Net Seniority Plus | Blue Cross I Senior Secure | Blue Cross II Senior Secure |
| Monthly Premium | $0 | $0 | $0 | $0 | $0 |
| PCP Office Visits | $5 | $5 | $7 | $5 | $30 |
| Specialist Office Visits | $10 | $10 | $10 | $10 | $30 |
| Dialysis Treatment | Copayment: 10% of the Medicare allowable amount for each session | $0 | Copayment: $25.00 per session | Copayment: 20% of the Medicare allowable amount for each session | Copayment: 20% of the Medicare allowable amount for each session |
| Durable Medical Equipment | Copayment: 20% of the Medicare allowable cost for each Medicare-covered item | Copayment: 10% of the Medicare allowable cost for each Medicare-covered item $100.00 or over (4) | Copayment: 20% of the Medicare allowable cost for each Medicare-covered item | Copayment: 20% of the Medicare allowable amount for each Medicare-covered item | Copayment: 20% of the Medicare allowable amount for each Medicare-covered item |
| OUTPATIENT SERVICES | Blue Shield 65 Plus | SCAN | Health Net Seniority Plus | Blue Cross I Senior Secure | Blue Cross II Senior Secure |
| Diabetes Monitoring Supplies | Copayment: 20% of the Medicare allowable cost for each Medicare-covered Diabetes Supply items (7) | $0 | $0 | Copayment: 20% of the Medicare each Medicare-covered Diabetes Supply | Copayment: 20% of the Medicare each Medicare-covered Diabetes Supply |
| Home Health | $0 | $0 | $0 | $0 | $0 |
| Covered Injectable Drugs Self-administered | Copayment: 20% based on Blue Shield's contracted rate | Copayment: 20% of the Medicare Allowable | Copayment: 20% based on Health Net's contracted rate | Copayment: 20% of the Medicare Allowable | Copayment: 20% of the Medicare Allowable |
| Covered Injectable Drugs Physician-administered | Copayment: 20% based on Blue Shield's contracted rate | Copayment: 25% of the Medicare Allowable | Copayment: 20% based on Health Net's contracted rate | Copayment: 20% of the Medicare Allowable | Copayment: 20% of the Medicare Allowable |
| OUTPATIENT SERVICES | Blue Shield 65 Plus | SCAN | Health Net Seniority Plus | Blue Cross I Senior Secure | Blue Cross II Senior Secure |
| Radiation Therapy | $0 | Copayment: 20% of the Medicare Allowable | Medicare Allowable (Approved) Cost Cost: $0 -$999 Copayment: $0 per day Cost:$1000+ Copayment: $275 per day |
Copayment: 20% of the Medicare allowable amount | Copayment: 20% of the Medicare allowable amount |
| Simple Radiology | $0 | $0 | Medicare Allowable (Approved) Cost Cost: $0 -$999 Copayment: $0 per day Cost:$1000+ Copayment: $275 per day |
$0 | $1 |
| Complex Radiology | $0 | $0 | Medicare Allowable (Approved) Cost Cost: $0 -$999 Copayment: $0 per day Cost:$1000+ Copayment: $275 per day |
Copayment: 20% of the Medicare allowable amount | Copayment: 20% of the Medicare allowable amount |
| Rehabilitation - Speech, Occupational, Physical | $10 | $10 | $0 | $20 | $30 |
| HOSPITAL SERVICES | |||||
| Ambulance | $100 (per trip) | $50 (per trip) | $125 (per trip) | $100 (per trip)(5) | |
| Emergency Room | $50 (6) | $50 (6) | $50 (6) | $50 (5) | |
| Inpatient Hospital | $55 per day for days 1-10 (3) | $50 per day for days 1-8 | $100 per day for days 1-4 | $100 per day for days 1-21 (5) | $200 per day for days 1-10 (5) |
| Inpatient Mental Health | $55 per day for days 1-10 (3) | $50 per day for days 1-8 | $900 For each Medicare-covered stay | $100 for days 1-21 $0 per day, days 22-90 (5) |
$200 for days 1-10 $0 per day, days 11-90 (5) |
| Outpatient Surgery | $50 per visit | $50 per visit | $100.00 per visit | $100.00 per visit | $200.00 per visit |
| Skilled Nursing Facility | $0 for days 1-20 $65 per day, days 21-100 |
$0 for days 1-20 $20 per day, days 21-100 |
$0 for days 1-20 $75 per day, days 21-100 |
$0 for days 1-20 $95 per day, days 21-100 |
$0 for days 1-20 $25 per day, days 21-100 |
| PRESCRIPTION DRUG BENEFITS | Blue Shield 65 Plus | SCAN | Health Net Seniority Plus | Blue Cross I Senior Secure | Blue Cross II Senior Secure |
| (P) Preferred (NP) Non Preferred |
On Formulary | On Formulary | On Formulary | On Formulary | On Formulary |
| Deductible | None | None | None | None | $250.00 Deductible |
| Generics Retail 30 days/Mail 90 days (P) | $6.00/ $12.00 | $5.00/ $10.00 | $5.00/ $15.00 | $10.00/ $15.00 | $5.00/ $7.50 |
| Brand Retail/Mail 90 days (P) | $25.00/ $50.00 | $28.00/ $56.00 | $29.00/ $58.00 | $30.00/ $75.00 | $27.00/ $67.50 |
| Generic/Brand Retail 30 days/ Mail 90 days (NP) | $45.00/ $90.00 | $50.00/ $100.00 (Generic does not apply) | $58.00/ $145.00 | $60.00/ $150.00(Generic does not apply) | $60.00/ $150.00(Generic does not apply) |
| PRESCRIPTION DRUG BENEFITS | Blue Shield 65 Plus | SCAN | Health Net Seniority Plus | Blue Cross I Senior Secure | Blue Cross II Senior Secure |
| Mail Order 90 days Generic/Brand/NP | $90.00 | N/A | $10.00/ $58.00/ $145.00 | N/A | |
| Specialty Drugs Retail/Mail | 25% Copay (1) | 25% Copay | 33% Copay | 30% Copay | 25% Copay |
| Initial Coverage Limit | $2,400 | $4,000 | $2,250 (*) | $2,400 (*) | $2,400 (*) |
| Coverage Gap | Covered | $5.00 genericsbrand Not Covered | Not Covered | $10.00 genericsbrand Not Covered | Not Covered |
| Catastrophic Coverage Level TrOOP Threshold | $3,850 | $3,850 | $3,850 | $3,850 | $3,850 |
| Generics/Preferred Brand | Greater of 5% or $2.15 |
Greater of 5% or $2.15 |
Greater of 5% or $2.15 |
Greater of 5% or $2.15 |
Greater of 5% or $2.15 |
| All other Drugs | Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
Greater of 5% or $5.35 |
(3) $550 Annual Copayment Maximum
(4) Item $99.00 or less have $0 Copayment
- All Health Plan products are offered in all service areas, with the following exceptions:
- The Secure Horizons Medicare Complete Plan 2 and Plan 3 are the only Secure Horizons product available in Santa Clarita service area.
- SCAN is not available in Santa Clarita Valley.
- Blue Cross I Senior Secure is available in Central Valley only. Blue Cross II Senior Secure is available in all other service areas.
(5) Applies to Out of Pocket Maximum (Plan I $500 and Plan II $2,000)
(6) Waived if admitted within 24 hours
(7) Includes glucose monitors, test strips, lancets, and self management training
(1) Unique High Cost Drugs and Self injectables with a cost greater than $500.00
(*) After the total yearly drug costs (paid by both member and health plan) reaches Initial Coverage Limit, member pays 100% of prescription drug costs until their yearly out-of-pocket drug costs reaches $3,850.Unless the member has coverage through the gap.
TrOOP is True out-of-pocket costs for Part D prescription drugs for a beneficiary, which include the member's copayment and/or coinsurance.
Disclaimer: This data was summarized from information provided by each health plan based on their interpretation.
© 2008 All rights reserved. Lakeside HealthCare, Inc., 777A Flower Street, Glendale, CA 91201