2019BENEFIT HIGHLIGHTS2020BENEFIT HIGHLIGHTS

BND_8876

Brand New Day Embrace Care Plan (HMO CSNP) 39-2

Brand New Day Embrace Choice Plan (HMO CSNP) 40-2

H0838_1422.2020Hilit.39.2.40.2. 191111_M

PLAN DETAILSBRAND NEW DAY

EMBRACE CARE PLAN (HMO CSNP) 39-2

BRAND NEW DAYEMBRACE CHOICE PLAN

(HMO CSNP) 40-2

Monthly Plan Premium

Deductible Maximum Out-of-Pocket (MOOP)

$0

No Deductible

You pay no more than $999

$32

No Deductible

You pay no more than $6,700

COMPREHENSIVE PLAN 39-2PLAN 40-2

Medi-Cal will pay the following cost-shares for you if you remain

eligible and have no share of cost.

Primary Care Providers

Specialists1

Endocrinologist1

Urgently Needed Services

Diagnostic tests and procedures1

Lab Services1

MRI, CAT Scan1

X-rays1

Therapeutic Radiology1

Durable Medical Equipment1

Prosthetics / Medical Supplies1

Diabetic Supplies1

Diabetic Shoe Inserts1

Physical Therapy1

Occupational Therapy1

Dialysis1

Podiatry Services1

$0 copay

$10 copay$0 copay

$0 per visit

$0 copay

$0 copay $0 copay $0 copay

20% of the cost

$0 copay for items less than $10020% of the cost for items over $100

$0 copay for items less than $100 20% of cost for items over $100

$0 copay

$0 copay

$10 copay

$10 copay

20% of the cost

$0 copay

20% of the cost

20% of the cost20% of the cost

$0 per visit

20% of the cost

$0 copay20% of the cost20% of the cost20% of the cost

20% of the cost

20% of the cost

$0 copay

$0 copay

$40 copay

$40 copay

20% of the cost

20% of the cost

1Services may require authorization and/or a referral2Copayment/share of cost waived if you are admitted to a hospital within 72 hours.

3Emergency transportation must be provided by a licensed emergency transportation vehicle.1Services may require authorization and/or a referral2Copayment/share of cost waived if you are admitted to a hospital within 72 hours.

HOSPITAL & EMERGENCY CARE

BRAND NEW DAY EMBRACE CARE PLAN

(HMO CSNP) 39-2

BRAND NEW DAYEMBRACE CHOICE PLAN

(HMO CSNP) 40-2Medi-Cal will pay the following

cost-shares for you if you remain eligible and have

no share of cost.

Inpatient Hospital1

Outpatient Hospital1

Emergency Care2 Worldwide Emergency3

Ambulance

$100 copay for days 1-4 $0 copay for days 5-90

$75 copay for surgery and $100 copay for other services

$100 per visit$0 copay

$125 copay per ride

$1,340 Deductible$0 copay for days 1-60

$335 copay per day for days 61-90

20% of the cost for surgery and20% of the cost for other services

$90 per visit20% of the cost

20% of the cost

PRESCRIPTION DRUG COVERAGE PLAN 39-2

PLAN 40-2If you receive “Extra Help”

to pay your prescription drugs, this payment stage does not

apply to you.

Part D Deductible

Initial Coverage Tier 1- Preferred GenericTier 2 - GenericTier 3 - Preferred BrandTier 4 - Non-Preferred DrugTier 5 - Specialty TierTier 6 - Select Care Drugs

You are in the Initial Coverage stage until you reach $4,020 in drug costs (year to date).

Coverage GapYou stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $6,350.

No Deductible

Retail Rx 30-day Supply$0 copay$12 copay$47 copay$90 copay

33% of the cost$0 copay

$0 copay for Tier 1 – Preferred Generic and Tier - 6 Select Care

Drugs during this stage.

For all other tiers, you pay 25% of the cost for brand name drugs (plus a portion of the dispensing

fee) and 25% of the cost for generic drugs.

$435You don’t pay a deductible for Tier 1 - Preferred Generic and

Tier - 6 Select Care Drugs

Retail Rx 30-day Supply$0 copay

25% of the cost25% of the cost25% of the cost25% of the cost

$0 copay

25% of the cost for brand name drugs (plus a portion of the

dispensing fee) and 25% of the cost for generic drugs.

ADDITIONAL BENEFITS & SERVICES

BRAND NEW DAY EMBRACE CARE PLAN

(HMO CSNP) 39-2

BRAND NEW DAYEMBRACE CHOICE PLAN

(HMO CSNP) 40-2

Routine Eye Exam

Frames and lenses or Contacts

Oral exam and cleaning

$0 copay, one exam per year

$175 allowance every year towards your purchase

$0 copay for oral exams up to 2 per year

$0 copay every 6 months for cleanings, up to 2 per year$55 copay if more frequent

$0 copay, one exam per year

$175 allowance every year towards your purchase

$0 copay for oral examsup to 2 per year

$0 copay for cleanings up to 2 per year

Hearing AidYou must call TruHearing to use this benefit

Transportation1

Over-The-Counter (OTC) Items

Viagra

Chiropractic1

Acupuncture1

$699 per aid for theAdvanced Model

$999 per aid Premium Model2 hearing aids per year

$0 copay unlimited plan-approved trips

$50 allowance every three (3) months for OTC supplies

$12 copay

$0 copay

Not Covered

$149 per aid for the Advanced Model

2 hearing aids every 3 years

$0 copay unlimited plan-approved trips

$40 allowance every three (3) months for OTC supplies

25% of the cost

$0 copay

$0 copay24 treatments

WELLNESS PROGRAMS PLAN 39-2 PLAN 40-2

Gym Membership1

Personal Care Plan1

$0 copay

$0 copay

$0 copay

$0 copay

3Emergency transportation must be provided by a licensed emergency transportation vehicle.

Brand New Day Embrace Care Plan (HMO CSNP) 39-2 is a good choice for anyone who doesn’t qualify for Medi-Cal with a diagnosis of Cardiovascular Disease and or Diabetes. This plan reduces the cost of prescription drugs while adding additional services and benefits.

• For Fresno, Imperial, Kings, San Mateo, Santa Clara, and Tulare Counties

Brand New Day Embrace Choice Plan (HMO CSNP) 40-2 is a good choice for individuals who require assistance coordinating with other health insurance coverage. An individual can qualify for this plan with a diagnosis of Cardiovascular Disease and or Diabetes.

• For Fresno, Imperial, Kings, San Mateo, Santa Clara, and Tulare Counties

THERE ARE TWO DIFFERENT HEALTH INSURANCE BENEFIT PLANS. FIND THE ONE THAT IS RIGHT FOR YOU:

Brand New Day is an HMO SNP with a Medicare Contract. Enrollment in Brand New Day depends on contract renewal. Calling the agent/broker number will direct an individual to a licensed insurance agent/broker. For accommodations of persons with special needs at meetings call 1-866-255-4795, TTY 711. You must continue paying your Medicare Part B premium.

P.O. Box 93122 Long Beach, CA 90809-9871 1-866-255-4795 | TTY 711

WWW.BNDHMO.COM

CALL TO CONTACT AN AUTHORIZED BRAND NEW DAY REPRESENTATIVE TODAY!

Phone 1-866-255-4795TTY 711

Or visit us at www.bndhmo.com

Hours:Year RoundMonday - Friday, 8 am - 8 pmOctober 1 - March 31Monday - Sunday, 8 am - 8 pm