Charter + Rx (HMO) 2012
Available in Chelan, Douglas, Grant, King, Lewis, Pierce, Snohomish, Thurston and Whatcom counties.
Charter + Rx includes Part D prescription drug coverage, low copayments and lower out-of-pocket maximums.
BENEFIT |
COST |
Monthly Premium |
$94 |
Out of Pocket Maximum |
$2,250 |
Annual Physical |
$0 |
Primary Care Office Visit |
$10 |
Specialist Office Visit |
$30 |
Inpatient Hospital Care |
$200 per day for days 1-5; $0 copay per day for days 6-90; $0 copay for additional days |
Outpatient Services/Surgery |
$100 copay at ASC $150 copay at outpatient hospital facility $30 copay for O/P clinic |
Emergency RoomIncludes Worldwide Coverage |
$60 copay Copay waived if admitted within 24 hours for the same condition |
Ambulance |
$150 copay Copay waived if admitted within 24 hours for the same condition |
Diagnostic Tests, X-Rays, Lab and Radiology Services |
$0 copay for lab service, diagnostic procedures, tests and x-rays $150 copay for MRI/MRA/CT/CTA/PET/SPECT scans $30 copay for therapeutic radiology services |
Outpatient Mental Health Care |
$30 copay for individual or group therapy visit with a psychiatrist |
Prescription Drug Deductible |
$0 |
30 day supplyRetail or Mail Order |
Tier 1: $6
Tier 2: $18
Tier 3: $36
Tier 4: $60
Tier 5: 33% coinsurance
|
90 day supplyRetail |
Tier 1: $15
Tier 2: $45
Tier 3: $90
Tier 4: $150
Tier 5: 33% coinsurance
|
90 day supplyMail Order |
Tier 1: $12
Tier 2: $36
Tier 3: $72
Tier 4: $120
Tier 5: 33% coinsurance |
Additional Benefits
- Silver & Fit Fitness Benefit
- Routine Vision Care
- Individual Assistance Program
- Hearing Aid Discounts
- ChooseHealthy Affinity Program
Optional Supplemental Benefits
Dental Plan
- Through Washington Dental Services
- $63 monthly premium
- PPO Network
- Basic 100/80/20 plan
Alternative Healthcare (Chiropractic and Acupuncture)
- Through American Specialty Health
- $9 monthly premium
- 20 combined Chiropractic and Acupuncture visits
- $20 co-pay per visit
Page Last Updated: October 1, 2011
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Important Disclaimers
Soundpath Health is a health plan with a Medicare contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information contact Soundpath Health. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, 2012. You must continue to pay your Medicare Part B premium. Limitations, copayments, and restrictions may apply. Individuals must have both Part A and Part B to enroll. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid Office. Members may enroll in the plan only during specific times of the year. Contact Soundpath Health for more information. Medicare beneficiaries may enroll in Soundpath Health through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov. *Members are 30 seconds or less away from speaking to a customer service representative based on 2010 annual internal telephone statistics.