Member News

 

2019 Leon Medical Centers Health Plans – Leon Cares (HMO)

Premium: $0

Copay - Primary Care Physician: $0

Copay - Specialist Physician: $0

Medical Coverage - Included
Prescription Coverage - Included
Annual Prescription Deductible: $0
Maximum Out-of-Pocket Cost: $6,700 for services you receive from in-network providers.

Summary of Benefits
 
 

Doctors Office Visits

Primary Care Physician Office Visit

$0

Specialist Physician Office Visit

$0

Chiropractic Services (Medicare Covered)

$0

 
 

Preventive Care

Preventive Care

$0

 
 

In-Patient Care

In-Patient Cost Share

$0

Skilled Nursing Facility (SNF)

$0

 
 

Outpatient Services

Outpatient Cost Share

$0

Ambulatory Surgery Center

$0

X-ray Services

$0

Diagnostic Radiological Services

$0

Therapeutic Radiological Services

$0

Lab Services

$0

Diagnostic Procedures/Tests

$0

Physical Therapy Services

$0

 
 

Emergency and Urgent Care Services

 

Emergency Room Services

$50

Your copay will be waived if you are admitted to the hospital within 24 hours.

Emergency Transportation

$50 outside of the plans coverage area

 

Urgently Needed Services

$0 In the plans coverage area

$50 Outside of the plans coverage area

Your copay will be waived if you are admitted to the hospital within 24 hours.

Ambulance

$0

 
 

Dental Benefits

Preventive Dental Benefits

Cleaning (for up to 2 every year)

$0

Dental x-ray(s) (for up to 1 every year)

$0

Fluoride treatment (for up to 1 every year)

$0

Fluoride treatment (for up to 1 every year)

$0

Comprehensive Dental Benefits

Extraction, Erupted Tooth or Exposed tooth or forcep removal

$0

Amalgam

$0

Denture Services

$0

Resin

$0

Complete Denture 1/5 years

$0

Root Canals (Coverage for Endodontic Therapy Anterior Tooth and Endodontic Therapy Bicuspid Tooth)

$0

Crown - porcelain/ceramic substrate

$0

 

The plan pays $2,300.00 towards all covered dental services.

Services are available through network dental provider only.

Unused amounts of the annual allowance do not carry forward to future benefit years.

A referral is required for some services by your doctor or other network provider. Please contact the plan for more information.

 
 

Vision Services

Eye Exams (Medicare Covered)

$0

Eye Wear (Medicare Covered)

$0

Routine Eye Exams

$0

Contact Lenses

$0

Eyeglasses (frames and lenses)

$0

Up to 2 pairs of eyeglasses each year with value not to exceed $175 per pair of eyeglasses plus upgrades for a total benefit value of $350

or

Up to 4 boxes of soft contact lenses each year with value not to exceed $35 per box of contact lenses for a total benefit value of $140.

 
 

 Hearing Services

Hearing Exams (Medicare Covered)

$0

Routine Hearing Exams (for up to 1 every year)

$0

Hearing aid fitting/evaluation (for up to 2 every three

years)

$0

Hearing aid

$0

Our plan pays up to $1,050 every three years for hearing aids.

 

Plan will pay for the first $1,050 per ear per hearing aid for up to 2 hearing aids every three years for a total allowance of $2,100.

 
 

Prescription Drug Coverage

Initial Coverage: Your plan will pay part of the cost for your covered drugs and you will pay the other part. The amount you pay when you fill a covered prescription is called the co-payment. You pay the following until total yearly drug costs each $4,000.

You pay the following for your covered prescription drugs:

Drug Tier

Preferred retail cost-sharing (in-network)
(up to a 30-day supply)

Standard retail cost-sharing (in-network)
(up to a 30-day supply)

Preferred retail cost-sharing (in-network)
(up to a 90-day supply)

Standard retail cost-sharing (in-network)
(up to a 90-day supply)

Tier 1 (Generic drugs)

$0 copay

$5 copay

$0 copay

$15 copay

Tier 2 (Brand name drugs)

$0 copay

$10 copay

$0 copay

$30 copay

Tier 3 (Specialty drugs)

33% Coinsurance

33% Coinsurance

A long-term supply is not available for drugs in tier 3

A long-term supply is not available for drugs in tier 3

Coverage Gap: After the total yearly drug costs (paid by you and your plan) reach $4,000.

Your plan will continue to provide generic prescription drug coverage until your total out-of-pocket costs reach $5,100. Once your total out-of-pocket costs reach $5,100 you will qualify for catastrophic coverage.

Catastrophic Coverage: After your yearly out-of-pocket drug costs reach $5,100.

You pay the greater of: $3.40 copay for Generics and $8.50 copay for Brand or 5% coinsurance. For Specialty drugs you pay 5% coinsurance.

 

If you have any questions or need information, please call Leon Medical Centers Health Plans at 1-866-393-5366, TTY 711, 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.

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 (1800-633-4227). 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 Medicaid Office.

Network pharmacies must be used to access your prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply.

This information is not a complete description of benefits. Call 1-866-393-5366, TTY 711 for more information.

Leon Medical Centers Health Plans' pharmacy network offers limited lower-cost, preferred pharmacies in urban and suburban Miami-Dade County, FL. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call 1-866-393-5366, TTY users should call 711 or consult the online pharmacy directory at www.lmchealthplans.com.


LIS Premium
 
Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs.

LMC Health Plans premium includes coverage for both medical services and prescription drug coverage

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help form Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan.

This table shows you what your monthly plan premium will be if you get extra help.

Your Level of Extra Help
Monthly Premium for LMC Health Plans
100%
0
75%
0
50%
0
25%
0

You must continue to pay your Medicare Part B premium. This does not include any Medicare Part B premium you may have to pay. Please note that LMC Health Plans does not charge a plan premium.

If you aren’t getting extra help, you can see if you qualify by calling:

• 1-800-Medicare of TTY/TDD users call 1-877-486-2048 (24 hours a day/7 days a week),
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY/TDD users should call
1-800-325-0778 between 7 a.m. and 7 p.m., Monday through Friday.

If you have any questions or need information, please call Member Service 8:00 am - 8:00 pm EST, seven days a week, October 1st – March 31st and 8:00 am - 8:00 pm EST, Monday – Friday from April 1st – September 30th. Messaging service used on weekends, after hours, and on federal holidays.

   

Out of Network Coverage
 
You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Leon Medical Center Health Plans will be responsible for the costs.

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from Leon Medical Centers Health Plans - Leon Cares (HMO).

Out-of-network/non-contracted providers are under no obligation to treat Leon Medical Centers Health Plans’ 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.

   

Public Notice
Coordinated Care Plans have the opportunity to terminate their contract with the Centers for Medicare & Medicaid Services (CMS) or reduce their service area annually. Leon Medical Centers Health Plans will give you notice at least 90 days before the effective date of a termination of our contract with CMS or reduction or our service area and include a description of alternatives available for obtaining Medicare services within the service area, including alternative MA plans, Medigap options, original fee-for-service Medicare.