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Soundpath Health 2018 Benefit Plans

Charter + Rx, Sound + Rx, and Peak + Rx offer comprehensive medical coverage and Medicare Part D prescription drug coverage along with worldwide emergency coverage. 
Alpine offers comprehensive medical coverage along with worldwide emergency coverage This plan has no prescription drug coverage. 
Please note: Beneficiaries who don't enroll in a Medicare Prescription Drug Plan when they are first eligible may have to pay a late enrollment penalty to enroll in a plan later if they don't maintain creditable coverage.

What follows is a partial list of benefits.

Benefit*

Alpine

(HMO)

Sound+Rx

(HMO)

Charter+Rx

(HMO)

Peak+Rx

(HMO)

 Service Area Chelan, Douglas, Grant, King, Pierce, Snohomish, Thurston and Whatcom Counties in Washington
Chelan, Douglas, Grant, King, Pierce, Snohomish, Thurston and Whatcom Counties in Washington
Chelan, Douglas, Grant, King, Pierce, Snohomish, Thurston and Whatcom Counties in Washington
Chelan, Douglas, Grant, King, Pierce, Snohomish, Thurston and Whatcom Counties in Washington
 
Monthly Premium $42 per month. In addition, you must keep paying your Medicare Part B premium. $40 per month. In addition, you must keep paying your Medicare Part B premium.
$146 per month. In addition, you must keep paying your Medicare Part B premium. $0 per month. In addition, you must keep paying your Medicare Part B premium.
Out of Pocket Maximum
$6,500 out-of-pocket limit every year for all member cost sharing excluding Part D pharmacy. 

Non-Medicare covered preventive dental, eyewear, eye exam, fitness and hearing aid cost sharing does not count towards the out of pocket maxumum amount, as applicable.
$6,500 out-of-pocket limit every year for all member cost sharing excluding Part D pharmacy. 

Non-Medicare covered preventive dental, eyewear, eye exam, fitness and hearing aid cost sharing does not count towards the out of pocket maximum amount, as applicable.

$4,900 out-of-pocket limit every year for all member cost sharing excluding Part D pharmacy. 

Non-Medicare covered preventive dental, eyewear, eye exam, fitness and hearing aid cost sharing does not count towards the out of pocket maximum amount, as applicable.
$6,700 out-of-pocket limit every year for all member cost sharing excluding Part D pharmacy.

Non-Medicare covered preventive dental, eyewear, eye exam, fitness and hearing aid cost sharing does not count towards the out of pocket maximum amount, as applicable.
Doctor Office Visits
Primary Care Provider: $10 copay

Annual Physical: $0 copay 

Specialist: $50 copay
Primary Care Provider: $10 copay

Annual Physical: $0 copay 

Specialist: $50 copay
Primary Care Provider: $10 copay

Annual Physical: $0 copay 

Specialist: $35 copay
Primary Care Provider: $15 copay

Annual Physical: $0 copay

Specialist: $50 copay
Emergency Care 
 (You may go to any emergency room if you reasonably believe you need emergency care)

$80 copay; waived if admitted within 24 hours for same condition
$80 copay; waived if admitted within 24 hours for same condition
$80 copay; waived if admitted within 24 hours for same condition
$80 copay; waived if admitted within 24 hours for same condition
Ambulance Services 
 (Medically necessary ambulance services)
$265 copay; not waived if admitted

Prior authorization is required for non-emergency ambulance transportation.*
$265 copay; not waived if admitted 

Prior authorization is required for non‐emergency ambulance transportation.*
$315 copay; not waived if admitted

Prior authorization is required for non-emergency ambulance
transportation.*
$315 copay; not waived if admitted 

Prior authorization is required for non-emergency ambulance transportation.*
Urgently Needed Services 
(This is NOT emergency care)
$50 copay, not waived if admitted
$50 copay, not waived if admitted 
$50 copay, not waived if admitted
$50 copay, not waived if admitted
Inpatient Hospital Care
 (Includes Substance Abuse & Rehabilitation Services)
$595 copay per day for days 1-4
$0 copay per day for days 5-90
$0 copay for additional days 

Prior authorization is required for non-urgent and nonemergent admissions. Urgent and/or emergent facility stays
requires the treating provider to notify the health plan within 24 hours of initiation of services in order for the
health plan to coordinate the care that you receive.*
$595 copay per day for days 1-4
$0 copay per day for days 5-90
$0 copay for additional days 

Prior authorization is required for non-urgent and nonemergent admissions. Urgent and/or emergent facility stays
requires the treating provider to notify the health plan within 24 hours of initiation of services in order for the
health plan to coordinate the care that you receive.*
$450 copay per day for days 1-4
$0 copay per day for days 5-90
$0 copay for additional days 

Prior authorization is required for non-urgent and nonemergent admissions. Urgent and/or emergent facility stays requires the treating provider to notify the health plan within 24 hours of initiation of services in order for the health plan to coordinate the care that you receive.*
$595 copay per day for days 1-3
$0 copay per day for days 4-90
$0 copay for additional days 

Prior authorization is required for non-urgent and nonemergent admissions. Urgent and/or emergent facility stays requires the treating provider to notify the health plan within 24 hours of initiation of services in order for the health plan to coordinate the care that you receive.*
Outpatient Services/Surgery
Ambulatory Surgery Center: $395 copay
Outpatient Hospital Facility: $495 copay
Outpatient Clinic $50 copay 

Prior authorization is required for certain services.* 

Ambulatory Surgery Center: $395 copay 
Outpatient Hospital Facility: $495 copay
Outpatient Clinic $50 copay 

Prior authorization is required for certain services.*
Ambulatory Surgery Center: $190 copay
Outpatient Hospital Facility: $290 copay
Outpatient Clinic: $35 copay 

Prior authorization is required for certain 
services.*
Ambulatory Surgery Center: $395 copay
Outpatient Hospital Facility: 20% coinsurance
Outpatient Clinic: $50 copay 

Prior authorization is required for certain services.*
Outpatient Rehabilitation Services
Occupational Therapy, Physical Therapy, Speech & Language Therapy: $40 copay for each visit

Prior authorization is required.*
Occupational Therapy: Physical Therapy, Speech & Language Therapy: $40 copay for each visit 

Prior authorization is required.*
Occupational Therapy, Physical Therapy, Speech & Language Therapy: $35 copay for each visit

Prior authorization is required.*

Occupational Therapy, Physical Therapy, Speech & Language Therapy: $40 copay for each visit

Prior authorization is required.*
Skilled Nursing Facility
 (In a Medicare-certified skilled nursing facility)
$0 copay per day for days 1-20
$167.50 copay per day for days 21-59
$0 copay per day for days 60-100
100 days per benefit period; no prior hospital stay is required 

Prior authorization is required.*
$0 copay per day for days 1-20
$167.50 copay per day for days 21-59
$0 copay per day for days 60-100 
100 days per benefit period; no prior hospital stay is required 

Prior authorization is required*
$0 copay per day for days 1-20
$167.50 copay per day for days 21-50
$0 copay per day for days 51-100
100 days per benefit period; no prior hospital stay is required 

Prior authorization is required.*
$0 copay per day for days 1-20
$167.50 copay per day for days 21-60
$0 copay per day for days 61-100
100 days per benefit period; no prior hospital stay is required 

Prior authorization is required.*
Outpatient Mental Health Care
Individual or Group Therapy:
Visit: $40 copay
Partial Hospitalization Program Services: $55 copay per day
Prior authorization is required for certain services.*
Individual or Group Therapy Visit: $40 copay
Partial Hospitalization Program Services: $55 copay per day
Prior authorization is required for certain services.*
Individual or Group Therapy Visit: $40 copay 
Partial Hospitalization Program Services: $55 copay per day
Prior authorization is required for certain services.*
Individual or Group Therapy Visit: $40 copay
Partial Hospitalization Program Services: $55 copay per day
Prior authorization is required for certain services.*
Diagnostic Tests,
X-Rays, 
Lab Services & 
Radiology Services

Lab Services:
$15 copay per day, per visit

X-rays:
$20 copay per day maximum

Diagnostic Radiology Services (not including X-rays):
20% coinsurance

Therapeutic Radiology Services:
20% coinsurance

Prior authorization is required for certain services.*

Lab Services:
$15 copay, per day, per visit

X-rays:
$20 copay per day maximum

Diagnostic Radiology Services (not including X-rays):
20% coinsurance

Therapeutic Radiology Services:
20% coinsurance

Prior authorization is required for certain services.*

Lab Services:
$7 copay per day, per visit

X-rays:
$20 copay per day maximum

Diagnostic Radiology Services (not including X-rays):
20% coinsurance

Therapeutic Radiology Services:
20% coinsurance

Prior authorization is required for certain services.*

Lab Services:
$15 copay per day, per visit

X-rays:
$20 copay per day maximum

Diagnostic Radiology Services (not including X-rays):
20% coinsurance

Therapeutic Radiology Services:
20% coinsurance 

Prior authorization is required for certain services.*
Limited Dental Services
 (Medicare covered dental benefits)
$50 copay
$50 copay
$35 copay
$50 copay
Dental-Preventive
Not covered
$20 copay per visit, through plan vendor
One exam every 6 months 
One x-ray every 6 months 
One cleaning every 6 months
$20 copay per visit through plan vendor 
One Exam every 6 months 
One X-Ray every 6 months 
One Cleaning every 6 months
Not covered

Hearing Services
Medicare-covered diagnostic hearing exams: $0-$50 copay; $0 copay through plan vendor; higher
copay applies to exams performed by all other providers

One routine hearing exam every year: $0-$50 copay

$1,000 Annual Hearing Aid Discount (per ear) 
Medicare-covered diagnostic hearing exams: $0 - $50 copay. $0 copay through plan vendor; higher
copay applies to exams performed by all other providers

One routine hearing exam every year: $0 - $50 copay 

$1,000 Annual Hearing Aid Discount (per ear)
Medicare-covered diagnostic hearing exams: $0-$35 copay: $0 copay through plan vendor; higher copay applies to exams performed by all other providers

One routine hearing exam every year: $0-$35 copay

$1,000 Annual Hearing Aid Discount (per ear)
Medicare-covered diagnostic hearing exams: $0 - $50 copay; $0 copay through plan vendor; higher copay applies to exams performed by all other providers 

One routine hearing exam every year: $0 - $50 copay

$1,000 Annual Hearing Aid Allowance (per ear)
 Health Club Membership & Fitness Classes
American Specialty Health Silver&Fit program including membership to local gyms, exercise classes, and online support to achieve fitness goals: $0 copay
American Specialty Health Silver&Fit program including membership to local gyms, exercise classes, and online support to achieve fitness goals: $0 copay
American Specialty Health Silver&Fit program including membership to local gyms, exercise classes, and online support to achieve fitness goals: $0 copay
American Specialty Health Silver&Fit program including membership to local gyms, exercise classes, and online support to achieve fitness goals: $0 copay

 
Vision Services
One standard pair of eyeglasses 
or contact lenses after cataract surgery: $0 copay

Exams to diagnose and treat diseases and conditions of the eye: $0 - $50 copay; $0 copay through plan
vendor; $0 copay for Medicare-covered Glaucoma test; higher copay applies to all other Medicare covered
eye exams.

One routine eye exam every year through plan vendor: $20 copay

One pair of eyeglasses or contact lenses through plan vendor, every 24 months: $30 copay

Plan coverage limit for eye wear: $120 every 24 months
One standard pair of eyeglasses or contact lenses after cataract surgery: $0 copay

Exams to diagnose and treat diseases and conditions of the eye: $0-$50 copay. $0 copay through plan vendor; $0 copay for Medicare-covered Glaucoma test; higher copay applies to all other Medicare covered eye exams.

One routine eye exam every year through plan vendor: $20 copay

One pair of eyeglasses or contacts lenses through plan vendor, every 24 months: $30 copay 

Plan coverage limit for eye wear: $120 every 24 months
One standard pair of eyeglasses or contact lenses after cataract surgery: $0 copay

Exams to diagnose and treat diseases and conditions of the eye: $0-$35 copay $0 copay through plan vendor; $0 copay for Medicare-covered Glaucoma test; higher copay applies to all other Medicare covered eye exams.

One routine eye exam every year through plan vendor: $20 copay

One pair of eyeglasses or contacts lenses through plan vendor, every 24 months: $30 copay

Plan coverage limit for eye wear: $120 every 24 months
One standard pair of eyeglasses or contact lenses after cataract surgery: $0 copay

Exams to diagnose and treat diseases and conditions of the eye: $0-$50 copay; $0 copay through plan vendor; $0 copay for Medicare-covered Glaucoma test; higher copay applies to all other Medicare covered eye exams

One routine eye exam every year through plan vendor: $20 copay.

One pair of eyeglasses or contact lenses through plan vendor, every 24 months: $30 copay

Plan coverage limit for eye wear: $120 every 24 months 
 
Part D Deductible
Not covered

$0 per year on Tier 1 and Tier 2, $160 per year on Tier 3, Tier 4 and Tier 5
$0 per year on Tier 1 and Tier 2, $160 per year on Tier 3, Tier 4 and Tier 5

$0 per year on Tier 1 and Tier 2, $160 per year on Tier 3, Tier 4 and Tier 5

 

 

Prescription Drug 31-day Supply Retail

Not covered

Tier 1: $2 copay
Tier 2: $12 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance

Tier 1: $2 copay
Tier 2: $12 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance
Tier 1: $3 copay
Tier 2: $14 copay
Tier 3: $47 copay
Tier 4: 50% coinsurance 
Tier 5: 30% coinsurance
 

 

Prescription Drug 62-day supply Retail

Not covered
Tier 1: $4 copay
Tier 2: $24 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered
Tier 1: $4 copay
Tier 2: $24 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered
Tier 1: $6 copay
Tier 2: $28 copay
Tier 3: $94 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Prescription Drug 93-day Supply Retail

Not covered

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

Tier 1: $7.50 copay
Tier 2: $35 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered
 

Prescription Drug 93-day Supply Mail Order

Not covered
Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered
Tier 1: $5 copay
Tier 2: $30 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered
Tier 1: $7.50 copay
Tier 2: $35 copay
Tier 3: $117.50 copay
Tier 4: 50% coinsurance 
Tier 5: Not Covered

 

* For complete information about your benefits, and about limitations or restrictions to your medical or drug benefits, please see Chapters 4, 5, and 6 in your Evidence of Coverage (EOC) document

Note: Members of our plan generally must use network pharmacies to receive plan coverage. You may choose to have your prescription drugs shipped to your home through the network mail order delivery program. For refills, please contact your pharmacy before you run out of the prescription drugs you have on hand. Usually, a mail-order pharmacy order will get to you within 14 days. If your mail order prescription drug is delayed, we recommend you contact the mail-order pharmacy directly. If you have questions or concerns, the Customer Service phone number is listed on your ID card. Quantity limitations and restrictions may apply.




Benefit 
Plan Information

Download Plan Information :

2018 Alpine Evidence of Coverage (EOC) Download
2018 Peak + Rx Evidence of Coverage (EOC)
Download 
2018 Charter + Rx Evidence of Coverage (EOC)
Download
2018 Sound + Rx Evidence of Coverage (EOC)
Download
2018 Alpine Summary of Benefits (SB) DOWNLOAD
2018 Peak +Rx, Charter + Rx, & Sound + Rx Summary of Benefits (SB) 
Download
2018 Soundpath Health Prescription Drug Transition Policy Download
2018 Comprehensive Formulary Download
Appeals and Grievances Information
 View Page 
Multi-Language Sheet Download
Soundpath Health Star Rating Information Download




Page Last Updated: October 02, 2017