BENEFITS SUMMARY OF - Brand New Day
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SUMMARY OF
BENEFITS
2022
Brand New Day Classic Choice Plan (HMO) 33
Fresno County Sacramento County
Imperial County San Bernardino County
Kern County San Diego County
Kings County San Francisco County
Los Angeles County San Joaquin County
Madera County San Mateo County
Orange County Santa Clara County
Riverside County Tulare County
H0838_2684.210826_M2022 SUMMARY OF BENEFITS
Brand New Day Classic Choice Plan (HMO) 33
H0838, Plan 33
January 1, 2022 - December 31, 2022.
Brand New Day is an HMO with a Medicare contract. Enrollment in Brand New Day depends
on annual contract renewal.
The benefit information provided does not list every service that we cover or list every limitation
or exclusion. To get a complete list of services we cover, please access the “Evidence of
Coverage” at bndhmo.com/members/plan-details
To join Brand New Day Classic Choice Plan (HMO) you must be entitled to Medicare Part
A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the
following counties in California: Fresno, Imperial, Kern, Kings, Los Angeles, Madera, Orange,
Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo,
Santa Clara, and Tulare.
Except in emergency situations, if you use providers that are not in our network, we may not
pay for these services.
For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook.
View it online at medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227)
available 24 hours, 7 days a week including some federal holidays. TTY/TDD users should call
1-877-486-2048.
This document is available in other formats such as Braille, large print or audio.
Have questions? Please call Brand New Day Member Services Department at
1-866-255-4795, TTY 711 Monday – Friday 8 am - 8 pm between April 1 and September
30 and 7 days a week between October 1 to March 31, 8 am - 8 pm or visit our website
at bndhmo.comClassic Choice Plan (HMO) 33
PREMIUM & BENEFITS YOU PAY WHAT YOU SHOULD KNOW
Monthly Plan Premium $0 You must keep paying your
Medicare Part B premium.
Your premium may be more if you
are not receiving Extra Help.
Deductible No deductible
Maximum Out-of-Pocket No more than $0 Includes copays and other costs for
Responsibility annually medical services for the year.
(does not include Your costs may be more if your
prescription drugs) Medi-Cal does not cover cost-sharing
for Medicare covered services.
Inpatient Hospital $0 per stay Services may require authorization
and a referral.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
CLASSIC CHOICE PLAN 33
for Medicare covered services.
Outpatient Hospital $0 copay Services may require authorization
and a referral.
Please reference Evidence of
Coverage (EOC) for details on
specific services.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Ambulatory Surgery $0 copay Services may require authorization
Center and a referral.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Doctor Visits
• Primary care providers $0 copay
• Specialists $0 copay Services may require authorization
and a referral.
Preventive Care Other preventive services are
available. There are some covered
services that may have a cost.
• Flu vaccine, diabetic $0 copay Services may require authorization
screenings, etc. and a referral.
• Routine Annual Physical $0 copay Services do not require
authorization or a referral.2022 Summary of Benefits
PREMIUM & BENEFITS YOU PAY WHAT YOU SHOULD KNOW
Emergency Care $0 copay Copayment waived if admitted to
the hospital or readmitted to the ER
within 72 hours.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Worldwide $90 copay Coverage is limited to $50,000.
Emergency Care
• Urgent Care
• Emergency Room
• Emergency Transportation
Urgent Care $0 copay
Diagnostic Services/Labs/ Services may require authorization
CLASSIC CHOICE PLAN 33
Imaging and a referral.
• Diagnostic tests and $0 copay Your costs may be more if your
procedures Medi-Cal does not cover cost-sharing
for Medicare covered services.
• Lab services $0 copay
• MRI, CAT scan $0 copay Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
• X-rays $0 copay Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Hearing Services
• Routine hearing exam $0 copay One routine hearing exam annually.
• Hearing aid fittings and $0 copay One hearing aid fitting annually.
evaluations
• Hearing aid $149 per hearing aid You receive 2 hearing aids every
for the advanced 3 years.
modelClassic Choice Plan (HMO) 33
PREMIUM & BENEFITS YOU PAY WHAT YOU SHOULD KNOW
Dental Services Limitations may apply. See your
EOC for details.
• Preventive dental (e.g., oral $0 copay
exam, x-rays, cleanings)
Comprehensive dental
• Diagnostic services $0 copay
• Restorative services $0 copay
• Endodontics $0 copay
• Periodontics $0 copay
• Extractions $0 copay
• Implant Services, $0 – $350 copay Prosthodontics, other oral/
Prosthodontics, other oral/ maxillofacial surgery, other
maxillofacial surgery, other services range from $0 for surgical
services placement of implant body
CLASSIC CHOICE PLAN 33
(endosteal implant) to $350 for
implant supported crowns.
• Non-routine services $0 copay
Vision Services
• Routine eye exam $0 copay One exam per year.
• Retinal imaging $0 copay One exam per year.
• Eyeglasses (frames) $0 copay $175 allowance for frames.
• Eyeglass lenses $0 copay For standard lenses (includes
standard progressives).
• Contact lenses $0 copay $175 allowance in lieu of frames for
contact lenses every year.
• Upgrades $70 allowance for polycarb lenses
upgrade.
$89.50 allowance for premium
progressives upgrade.
Mental Health Services Services may require authorization
• Outpatient individual $0 copay and a referral.
therapy Your costs may be more if your
• Outpatient group therapy $0 copay Medi-Cal does not cover cost-sharing
for Medicare covered services.2022 Summary of Benefits
PREMIUM & BENEFITS YOU PAY WHAT YOU SHOULD KNOW
Skilled Nursing Facility $0 per stay Services may require authorization
(SNF) and a referral.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Physical Therapy $0 copay Services may require authorization
and a referral.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
Ambulance (Ground) $0 copay Services may require authorization.
Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
CLASSIC CHOICE PLAN 33
Transportation $0 copay for Services may require authorization.
unlimited one way
trips to approved
locations
Medicare Part B Drugs Services may require authorization.
• Chemotherapy drugs $0 copay Your costs may be more if your
Medi-Cal does not cover cost-sharing
for Medicare covered services.
• Other Part B drugs $0 copayClassic Choice Plan (HMO) 33
OUTPATIENT PRESCRIPTION DRUGS
Part D Deductible No deductible (Your deductible may be more if you are
not receiving Extra Help).
Retail Rx 30-day supply Mail Order 100-day supply
Initial Coverage
You are in the Initial Coverage
stage until you reach $4,430 in
drug costs (year to date).
Tier 1 – Preferred Generic $0 copay $0 copay
Tiers 2 (Generic) to $0 or $1.35 for generics. $0 or $1.35 for generics.
5 (Specialty Tier) $0 or $4 for brands. $0 or $4 for brands.
(Depending on your level (Depending on your level
of Extra Help that you of Extra Help that you
receive). receive).
CLASSIC CHOICE PLAN 33
Tier 6 – Select Care $0 copay $0 copay
Coverage Gap
You stay in this stage until your
year-to-date “out-of-pocket
costs” (your payments) reach a
total of $7,050
Tier 1 – Preferred Generic $0 copay
Tiers 2 (Generic) to $0 or $1.35 for generics. $0 or $4 for brands.
5 (Specialty Tier) (Depending on your level of Extra Help that
you receive).
Tier 6 – Select Care $0 copay
Catastrophic Coverage During this stage, the plan will pay most of the cost of your
drugs for the rest of the calendar year (through December
31, 2022).
Depending on your level of Extra Help that you receive,
$0 copay for all covered drugs or $3.95 copay or 5%
(whichever costs more) for generic drugs or a preferred
multi-source drug and $9.85 copay or 5% (whichever
costs more) for all other drugs.
Cost-Sharing may change depending on the pharmacy you choose and when you enter a
new phase of the Part D benefit.2022 Summary of Benefits
WELLNESS BENEFITS YOU PAY / RECEIVE WHAT YOU SHOULD KNOW
Over-The-Counter (OTC) Up to $820 each $205 credit every 3 months.
Items year
Healthy Foods Allowance Up to $360 each Receive a $30 monthly allowance
year for healthy to buy healthy whole foods at
foods approved grocery stores.
Meals and Nutritional Receive 14 meals Meal programs include: Diabetes,
Counseling each month, for congestive heart failure (CHF),
12 months in the cardiovascular disorders, dementia,
calendar year (168 chronic and disabling mental health
total meals) conditions, kidney disease, and
hypertension.
Also includes a nutritional
consultation with a registered
dietician to develop a healthy
eating plan.
CLASSIC CHOICE PLAN 33
Acupuncture Services may require authorization
• Medicare-covered $0 copay and a referral.
acupuncture
• Routine acupuncture $0 copay For up to 30 visits every year
combined with Routine Chiropractic
services.
Chiropractic Services Services may require authorization
• Medicare-covered $0 copay and a referral.
chiropractic care
• Routine chiropractic care $0 copay For up to 30 visits every
year combined with Routine
Acupuncture services.
Gym Membership $0 copay SilverSneakers gym membership
is available to you at no cost
with access to fitness facilities, or
SilverSneakers Steps at-home kits
for members who are unable to
exercise in a fitness facility or prefer
to work out at home.
24/7 Doctor Advice Line $0 copay A Doctor is available at no cost to
you 24 hours a day, 7 days a week
by web, mobile app, or phone
at: (800) 835-2362. Doctors can
diagnose and prescribe medications
if medically necessary.
Personal Emergency $0 copay Mobile PERS device with GPS and
Response System (PERS) fall detection; 24/7/365 monitoring.ADDITIONAL BENEFITS
BEYOND
ORIGINAL
MEDICARE
Brand New Day offers you additional benefits beyond what
Original Medicare alone provides. Brand New Day has
partnered with specialized companies for these added benefits.
Benefit may vary by plan, to get a complete list of services we cover, call us and ask for the “Evidence of
Coverage.” You can also see the Evidence of Coverage on our website bndhmo.com.
Brand New Day is an HMO/SNP with a Medicare Contract. Enrollment in Brand New Day depends on
contract renewal.
H0838_2699.210826_MADDITIONAL BENEFITS BEYOND ORIGINAL MEDICARE
ADDITIONAL BENEFITS CLASSIC CARE I CLASSIC CHOICE PART B SAVINGS
PROVIDER PLAN 25 PLAN 33 PLAN 49
ACUPUNCTURE & CHIROPRACTIC
$0 copay
$0 copay 12 treatments when
1-800-678-9133,
TTY 1-800-735-2922 30 treatments when combined with Routine combined with Routine
Monday – Friday, 5 am - 8 pm Chiropractic or Routine Acupuncture services. Chiropractic or Routine
ashlink.com/ash/brandnewday Acupuncture services.
DENTAL BENEFITS
1-844-282-7638,
TTY 1-877-855-8039
Monday – Sunday, 8 am - 8 pm Deep Cleaning Deep Cleaning Deep Cleaning
(October 1 - March 31) $35 – $60 copay $0 copay $35 – $60 copay
Monday – Friday, 8 am - 8 pm Crowns Crowns Crowns
(April 1 - September 30) $275 – $400 copay $0 copay $275 – $400 copay
Medicare: www1.deltadentalins.
com/brand-new-day-medicare Implants Implants Implants
Medi-Medi: www1.deltadentalins. $0 – $1,110 copay $0 – $350 copay $0 – $1,110 copay
com/brand-new-day-medi-cal- Dentures Dentures Dentures
medicare $450 copay $0 – $150 copay $450 copay
1-855-203-5900, TTY 711
Monday – Friday, 8 am - 5 pm Limitations may apply. See your EOC for details.
westerndental.com
GYM MEMBERSHIP
$0 copay
Fitness facility programs
1-888-423-4632, TTY 711 Healthy aging program
Monday – Friday, 5 am - 5 pm
silversneakers.com SilverSneakers steps at-home kits
HEARING AID
Advanced model Advanced model
1-866-202-1182, TTY 711 $149 copay $149 copay Not covered
Monday – Friday, 8 am - 8 pm per aid. per aid.
truhearing.com
MEALS AND NUTRITIONAL COUNSELING
Receive 15 meals Receive 15 meals
each week for 6 weeks Receive 14 meals each each week for 6 weeks
with a $0 copay (90 month, for 12 months with a $0 copay (90
1-866-255-4795, TTY 711 total meals). Meal in the calendar year total meals). Meal
Monday – Friday, 8 am - 8 pm delivery is included (168 total meals). delivery is included
bndhmo.com/eatinghealthy 1 time per week. 1 time per week.ADDITIONAL BENEFITS BEYOND ORIGINAL MEDICARE
ADDITIONAL BENEFITS CLASSIC CARE I CLASSIC CHOICE PART B SAVINGS
PROVIDER PLAN 25 PLAN 33 PLAN 49
OVER-THE-COUNTER
You get $40 You get $205 You get $35
1-877-280-6207, TTY 711 every month to every 3 months to every month to
24/7/365 spend on OTC spend on OTC spend on OTC
NationsOTC.com/BND
PERSONAL EMERGENCY RESPONSE SYSTEM (PERS)
$0 copay
1-888-256-3227, TTY 711
Monday – Friday, 6 am - 6 pm Mobile PERS device with GPS and fall detection,
Saturday – Sunday, 7 am - 4 pm 24/7/365 monitoring.
aloecare.com/brandnewday
TRANSPORTATION
Routine Transportation: $0 copay
1-855-804-3340, TTY 711 Unlimited transportation Not covered
Medical Transportation: for plan-approved trips.
1-855-804-3484, TTY 711
Monday – Friday, 8 am - 8 pm
VISION
Routine Eye Exam $0 copay
1-800-511-1486, Frames up to $175
TTY 1-844-230-6498
Monday – Saturday, 5 am - 8 pm Standard lenses $0 copay
Sunday, 8 am - 5 pm Upgrade allowance up to $159.50
member.eyemedvisioncare.com/
brandnewday
24/7 DOCTOR ADVICE LINE
$0 copay
1-800-835-2362, Request a visit with a doctor 24 hours a day, 7 days a week,
TTY 1-855-636-1578 by web, phone or mobile app. Talk to the doctor, take as
24 hours a day, 7 days a week much time as you need.
teladoc.com
24/7 NURSE ADVICE LINE
$0 copay
1-888-687-7321, TTY 711 Speak with a Brand New Day registered
24 hours a day, 7 days a week nurse 24 hours a day 7 days a week.
bndhmo.comSAVE MONE Y ON YOUR PRESCR I P TI ON DRUGS!
Lower Copayments for Prescriptions!
Tiers 1 and 6 at $0 Copay even through the coverage gap! If you are filling
a prescription for medications on Tier 1 or 6 you will not have a Copayment.
Mail Order Savings!
Tiers 1, 2, 3, 4 and 6 Special! Pay for 2 months of a 100-day prescription and get
the third month at no extra cost. This applies to members when they use Mail Order
to fill their 100-day, Tiers 1, 2, 3, 4 and 6 prescription. It is easy to save on prescription
drugs with MedImpact Direct!
More Savings!
Extra Help - from Medicare
You may qualify for Extra Help with your prescription drug costs. If you don’t qualify for
Medi-Cal but you have a limited income, you can apply for Extra Help. To apply, call:
• Brand New Day at 1-866-255-4795, TTY 711 and talk to a Member Services
representative; or call
• Social Security at 1-800-772-1213; TTY users call 1-800-325-0778;
• Or apply online at ssa.gov/prescriptionhelp
If you qualify for Extra Help, Medicare will pay all or part of your Part D premium and you
will have lower copays at the pharmacy.
Other Ways to Save
Generic vs. Brand Name
Generic medications have the exact same ingredients as the brand name drugs, but you
aren’t paying for the “name.” Always ask the pharmacy for generic instead of brand name.
Brand New Day is an HMO with a Medicare contract. Enrollment in Brand New Day
depends on annual contract renewal. This information is not a complete description of
benefits. Call 1-866-255-4795, TTY 711 for more information Monday - Friday, 8 am - 8
pm and 7 days a week 8 am - 8 pm from October 1 - March 31.You can also read
