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Horizon Medicare Advantage Special Needs Plan

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Exceptions Request (Part D)
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Appeals and Grievances (Part D)
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Part D - Out of Network
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Horizon Medicare Blue Solutions Details

	Horizon Medicare Blue Solutions
Eligibility	Entitled to Medicare Part A and enrolled in Medicare Part B; live in New Jersey; receive Medicaid from the state
Choice of health care specialists	Must use network health care specialists
Cost sharing and out-of-pocket limit	Cost sharing is based on level of Medicaid eligibility $3,250 out-of-pocket limit
Hospital coverage	$0 for Medicare-covered stays or $107 copay per day for days 1-10*
Outpatient services/surgery	$0 or $15 copay for Medicare-covered surgical visit; $0 or $15 copay for Medicare-covered hospital facility visit
Doctor office visits	$0 or $20 copay per primary care physician visit; $0 or $22 copay per specialist visit* (referral required)
Emergency care (worldwide)	$0 or $15 copay; copay waived if admitted within 24 hours
Transportation	Authorization rules may apply
Outpatient prescription drugs	(Deductibles and copays depend on your income and institutional status) $0 annual deductible; $0 to $2.40 copay for generic drugs (including brand drugs treated as generic); $0 to $6 copay for all other drugs up to $4,350 out-of-pocket maximum. After your out-of-pocket costs reach $4,350, you pay $0 for any drugs.*
Skilled nursing facility	$0 for Medicare-covered stay or $0 copay per day for days 1 - 5; $50 copay per day for days 6 - 20; $100 copay per day for days 21 - 100*; 100 day/benefit period; no prior hospital stay required. Prior authorization required.
Home health care	$0 or $15 copay per visit* †
Diagnostic tests, X-rays and lab services	$0 or $15 copay for lab services and diagnostic tests; $0 or $15 copay for X-rays* †
Durable medical equipment	0% or 20% of the cost for Medicare-covered items†
Routine physical exams	$20 copay for one routine exam per year
Preventive screenings available (Refer to Summary of Benefits)	100% coverage for Medicare-covered screenings
Immunizations (Flu, Pneumonia and Hepatitis B Vaccine - for those with Medicare who are at risk)	$0 copay for Flu and Pneumonia vaccines; $0 or $20 copay for Hepatitis B vaccine
Routine vision services	$0 copay for diagnosis and treatment for diseases and conditions of the eye; $0 copay for one pair of eyeglasses or contact lenses after each cataract surgery
Dental services	Not covered
Hearing services	$0 copay for diagnostic hearing exams. Routine hearing exams and hearing aids are not covered
Clinical trials	Not covered
Personal care assistant, (EPSDT) private duty nursing and medical day care	Not covered
Monthly Plan Premium^§	$31

* Cost sharing is based on your level of Medicaid eligibility
† Prior authorization may be required for some services
^§ You must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party

Last Updated: December 22, 2008