2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | SeniorCare Sr Select - Basic Rx (Cost) | ||||
Location: | Coke, Texas Click to see other locations | ||||
Plan ID: | H4564 - 003 - 0 Click to see other plans | ||||
Member Services: | 1-866-334-3141 TTY users 1-800-735-2989 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the SeniorCare Sr Select - Basic Rx (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $75.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 2,599 drugs | Browse the SeniorCare Sr Select - Basic Rx (Cost) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $7.00 | $35.00 | $64.00 | 33% | |
• Number of Drugs per Tier: | 1512 | 508 | 421 | 158 | |
Plan's Pharmacy Search: | http://www.swhp.org | ||||
Number of Members enrolled in this plan in (H4564 - 003): | 1,249 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$75 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
Referral required for network hospitals and specialists (for certain benefits). | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.swhp.org on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from SeniorCare Sr Select - Basic Rx (Cost) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and SeniorCare Sr Select - Basic Rx (Cost) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
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 SeniorCare Sr Select - Basic Rx (Cost). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Physical Exams | |||||
Authorization rules may apply. | |||||
$30 copay for routine exams. | |||||
No plan coverage limit on the number of covered exams. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$75 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B and Part D premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
Doctor and Hospital Choice | |||||
Referral required for network hospitals and specialists (for certain benefits). | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
Plan covers 90 days each benefit period. | |||||
$700 copay for each Medicare-covered hospital stay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
$700 copay for each Medicare-covered hospital stay. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $100 copay per day | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
Authorization rules may apply. | |||||
$30 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$40 copay for each in-area network urgent care Medicare-covered visit. | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
20% of the cost for each Medicare-covered individual or group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit. | |||||
20% of the cost for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$200 copay for Medicare-covered emergency room visits. | |||||
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. | |||||
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. | |||||
20% of the cost for Medicare-covered Occupational Therapy visits. | |||||
20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
20% of the cost for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
20% of the cost for Diabetes supplies. | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
Colorectal Screening Exams | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
Immunizations | |||||
Authorization rules may apply. | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
Pap Smears and Pelvic Exams | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
Prostate Cancer Screening Exams | |||||
Authorization rules may apply. | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. | |||||
Authorization rules may apply. | |||||
20% of the cost for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
Prescription Drugs | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.swhp.org on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
Your in-network prescription coverage may be limited to the plan's service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. | |||||
Total yearly drug costs are the total drug costs paid by both you and the plan. | |||||
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from SeniorCare Sr Select - Basic Rx (Cost) for certain drugs. | |||||
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. | |||||
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. | |||||
If you request a formulary exception for a drug and SeniorCare Sr Select - Basic Rx (Cost) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 840 you receive a discount on brand name drugs and pay 93% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 550. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you pay the greater of:
| |||||
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 SeniorCare Sr Select - Basic Rx (Cost). | |||||
You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
You will be reimbursed up to 7% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 550. | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
After your yearly out-of-pocket drug costs reach $ 4 550 you will be reimbursed for drugs purchased out-of-network up to the full cost of the drug minus your cost share which is the greater of:
| |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
Hearing Services | |||||
Authorization rules may apply. | |||||
In general routine hearing exams and hearing aids not covered. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
Physical Exams | |||||
Authorization rules may apply. | |||||
$30 copay for routine exams. | |||||
No plan coverage limit on the number of covered exams. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Separate Office Visit cost sharing of $30 may apply. | |||||
Health/Wellness Education | |||||
Authorization rules may apply. | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |