2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Sterling Option II (PFFS) | ||||
Location: | Perry, Missouri Click to see other locations | ||||
Plan ID: | H5006 - 017 - 5 Click to see other plans | ||||
Member Services: | 1-888-270-0951 TTY users 711 | ||||
— 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 Sterling Option II (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $50.70 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $200 | ||||
Health Plan Type: | PFFS | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,000 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
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: | $4.00 | $18.00 | $40.00 | 25% | |
Plan's Pharmacy Search: | http://www.sterlingplans.com | ||||
Number of Members enrolled in this plan in (H5006 - 017): | 2,999 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 | |||||
$50.7 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. | |||||
This plan does not allow providers to balance bill (charging more than your cost share amount). | |||||
$4 000 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
** 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 http://www.sterlingplans.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
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 Sterling Option II (PFFS) 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 Sterling Option II (PFFS) approves the exception you will pay Tier 3: Preferred Brand Drugs cost sharing for that drug. | |||||
$200 yearly deductible. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
After your total yearly drug costs reach $2 840 you pay 93% for all generic drugs and 100% for all brand 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 Sterling Option II (PFFS). | |||||
After you pay your yearly deductible 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: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
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. | |||||
After your total yearly drug costs reach $2 840 you pay 100% of the pharmacy's full charge for brand drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4 550. You will not be reimbursed by Sterling Option II (PFFS) for out-of-network purchases when you are in the coverage gap. However you should still submit documentation to Sterling Option II (PFFS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year. | |||||
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:
| |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye exams every year. | |||||
$200 plan coverage limit for eye wear. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
$200 plan coverage limit for preventive dental benefits every year. | |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$50.7 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. | |||||
This plan does not allow providers to balance bill (charging more than your cost share amount). | |||||
$4 000 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
Doctor and Hospital Choice | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $200 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
Inpatient Mental Health Care | |||||
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $200 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
For hospital days: | |||||
Days 91 - 190: $0 copay per day | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
3-day prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 10: $0 copay per day | |||||
Days 11 - 100: $50 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 | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$15 copay 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 | |||||
$30 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
40% of the cost for each Medicare-covered individual or group therapy visit. | |||||
Outpatient Substance Abuse Care | |||||
40% of the cost for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
15% of the cost for each Medicare-covered ambulatory surgical center visit. | |||||
15% of the cost for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
$25 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit | |||||
Outpatient Rehabilitation Services | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. | |||||
15% of the cost for Medicare-covered Occupational Therapy visits. | |||||
15% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
20% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
$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 $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
15% 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 http://www.sterlingplans.com on the web. | |||||
Different out-of-pocket costs may apply for people who
| |||||
The plan offers national in-network prescription coverage (i.e. this would include 50 states and DC). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel). | |||||
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 Sterling Option II (PFFS) 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 Sterling Option II (PFFS) approves the exception you will pay Tier 3: Preferred Brand Drugs cost sharing for that drug. | |||||
$200 yearly deductible. | |||||
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
After your total yearly drug costs reach $2 840 you pay 93% for all generic drugs and 100% for all brand 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 Sterling Option II (PFFS). | |||||
After you pay your yearly deductible 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: Generic Drugs | |||||
Tier 3: Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
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. | |||||
After your total yearly drug costs reach $2 840 you pay 100% of the pharmacy's full charge for brand drugs purchased out-of-network until your yearly out-of-pocket drug costs reach $4 550. You will not be reimbursed by Sterling Option II (PFFS) for out-of-network purchases when you are in the coverage gap. However you should still submit documentation to Sterling Option II (PFFS) so we can add the amounts you spent out-of-network to your total out-of-pocket costs for the year. | |||||
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:
| |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
$200 plan coverage limit for preventive dental benefits every year. | |||||
Separate Office Visit cost sharing of $15 to $30 [or 0% to 15% of the cost] may apply. | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$100 plan coverage limit for routine hearing tests every year. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye exams every year. | |||||
$200 plan coverage limit for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
Health/Wellness Education | |||||
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. |