Western Slope Plan Highlights

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Western Slope RMHP Medicare Benefit Comparison Highlights 2012

RMHP offers plan choice! Our Medicare plans offer beneficiaries comprehensive coverage, access to quality health care, and excellent customer service.

The following grid provides a quick, at-a-glance summary of our Western Slope Medicare Cost plans available. For a detailed 2012 Summary of Benefits for plans with Part D Prescription Drug coverage, click on the link. For a detailed 2012 Summary of Benefits for the Medical-only plans, click on the link.

For the 2012 Evidence of Coverage, click on the link. This document provides more detailed information about:

Conditions associated with receipt or use of benefits, limitations and exclusions.
Out-of-network coverage
Grievance, coverage determinations, appeals procedures and exceptions process (For plans with Part D Prescription Drug coverage, see Chapter 9 of the EOC. For medical-only plans, see Chapter 7 of the EOC.)
Quality assurance policies and procedures, including medication therapy management, and drug and/or utilization management
Potential for contract termination
Beneficiaries' and plan's rights and responsibilities upon disenrollment

Click here for a Printable Western Slope RMHP Medicare Plan Highlights Grid below.

Medicare Covered Benefit	Rocky Mountain Green Plan + Rx (Cost) You Pay	Rocky Mountain Thrifty Plan + Rx (Cost) You Pay	Rocky Mountain Standard Plan + Rx (Cost) You Pay	Rocky Mountain Plus Plan + Rx (Cost) You Pay

Monthly Plan Premium Medical Only Prescription Drug Total	$8.00* $40.10 $48.10* * plus you must continue to pay Medicare Part B premium	$34.00* $40.20 $74.20* * plus you must continue to pay Medicare Part B premium	$73.40* $47.40 $120.80* * plus you must continue to pay Medicare Part B premium	$156.80* $89.40 $246.20* * plus you must continue to pay Medicare Part B premium
Medical Deductible	$500 per calendar year (annual deductible). Applies to all services except Preventive Care, Primary Care Physician and Specialist Care office visits, lab services, and Emergency room services.	$500 per calendar year (annual deductible). Applies to all services except Preventive Care, Primary Care Physician and Specialist Care office visits, lab services, and Emergency room services.	None	None
Medical Out of Pocket Maximum	$6,700 per calendar year. Amounts you pay for RMHP deductibles, copayments and coinsurance for Medicare-covered services count toward the maximum out-of-pocket amount	None	None	None
Primary Care Physician Office Visit Copayment	$15 per visit Deductible does not apply	$20 per visit Deductible does not apply	$15 per visit	$15 per visit
Specialist Care Physician Office Visit Copayment	$40 per visit Deductible does not apply	$50 per visit Deductible does not apply	$45 per visit	$35 per visit
Inpatient Hospital Copayment	After the $500 annual deductible $250 copay per day up to 7 days per admission	After the $500 annual deductible $200 copay per day up to 5 days per admission	$600 per admission	$450 per admission
Outpatient Surgery	After the $500 annual deductible $400 per visit	After the $500 annual deductible $400 per visit	$350 per visit	$250 per visit
Ambulance	$150 per trip Deductible does not apply	$200 per trip Deductible does not apply	$100 per trip	$100 per trip
Emergency Room	$65 per visit Worldwide Deductible does not apply	$50 per visit within the United States Deductible does not apply	$50 per visit Worldwide	$50 per visit Worldwide
Urgent Care	$40 per visit Worldwide Deductible does not apply	$50 per visit within the United States Deductible does not apply	$45 per visit Worldwide	$35 per visit Worldwide
Part D Prescription Drug Benefit	$125 Deductible- drugs on Tiers 3, 4 & 5 only	No deductible	No deductible	No deductible
	$2 copay Tier 1 $13 copay Tier 2 $45 copay Tier 3 $87 copay Tier 4 30% coinsurance Tier 5	$3 copay Tier 1 $12 copay Tier 2 $45 copay Tier 3 $90 copay Tier 4 33% coinsurance Tier 5	$10 copay Tiers 1 & 2 $40 copay Tier 3 $60 copay Tier 4 33% coinsurance Tier 5	$8.50 copay Tiers 1 & 2 $38 copay Tier 3 $58 copay Tier 4 33% coinsurance Tier 5
	After $2,930 in retail drug expenses, Member pays up to 86% of the price for generic drugs and 50% of the price (plus the dispensing fee) for brand name drugs until the Member's out-of-pocket drug costs reach $4,700 After the Member's out-of-pocket drug costs reach $4,700, they pay $2.60 copay generic; $6.50 copay for all other drugs; OR 5% (whichever is higher)	After $2,930 in retail drug expenses, Member pays up to 86% of the price for generic drugs and 50% of the price (plus the dispensing fee) for brand name drugs until the Member's out-of-pocket drug costs reach $4,700 After the Member's out-of-pocket drug costs reach $4,700, they pay $2.60 copay generic; $6.50 copay for all other drugs; OR 5% (whichever is higher)	After $2,930 in retail drug expenses, Member pays up to 86% of the price for generic drugs and 50% of the price (plus the dispensing fee) for brand name drugs until the Member's out-of-pocket drug costs reach $4,700 After the Member's out-of-pocket drug costs reach $4,700, they pay $2.60 copay generic; $6.50 copay for all other drugs; OR 5% (whichever is higher)	After $2,930 in retail drug expenses, Members pay either an $8.50 copayment (for a one month supply) or up to 86% of the price for generic drugs whichever is lower, and 50% of the price (plus the dispensing fee) for brand name drugs until the Member's out-of-pocket drug costs reach $4,700. After the Member's out-of-pocket drug costs reach $4,700, they pay $2.60 copay generic; $6.50 copay for all other drugs; OR 5% (whichever is higher)
Mail Order Rx	3 copays for 3 month supply	2.5 copays for 3 month supply	2.5 copays for 3 month supply	2.5 copays for 3 month supply
Annual Routine Physical Exam	$0 Deductible does not apply	$0 Deductible does not apply	$0	$0
Preventive Screening Services	$0 Deductible does not apply	$0 Deductible does not apply	$0	$0
Skilled Nursing Facility	After the $500 annual deductible $0 days 1-20 $100 days 21-100	After the $500 annual deductible $0 days 1-20 $100 days 21-100	$0 days 1-20 $95 days 21-100	$0 days 1-20 $95 days 21-100
Durable Medical Equipment	After the $500 annual deductible 20% coinsurance	After the $500 annual deductible 20% coinsurance	20% coinsurance	20% coinsurance

2011 RMHP Medicare Plan Information

For a detailed 2011 Summary of Benefits for plans with Part D Prescription Drug coverage click on the link.

For a detailed 2011 Summary of Benefits for medical-only plans, click on the link.

For the 2011 Evidence of Coverage, click on the link.

Information is current as of 10/01/11. Please call to confirm you have the most up to date information about our Medicare Plans. Full list of Medicare Disclaimers.

Medicare-approved Cost plan. H0602_1037024 MC150WEB Pending Approval