2011 Medicare Advantage Plan Details | |||||
---|---|---|---|---|---|
Medicare Plan Name: | Amerivantage Classic + Rx (HMO) | ||||
Location: | Fort Bend, Texas Click to see other locations | ||||
Plan ID: | H5817 - 010 - 0 Click to see other plans | ||||
Member Services: | 1-866-805-4589 TTY users 1-800-855-2880 | ||||
— 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 |
||||
Email a copy of the Amerivantage Classic + Rx (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,025 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 3,033 drugs | Browse the Amerivantage Classic + Rx (HMO) Formulary | |||
This plan has 5 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: | 0% | 0% | $30.00 | $70.00 | 33% |
• Number of Drugs per Tier: | 340 | 1410 | 825 | 248 | 210 |
Plan's Pharmacy Search: | https://www.amerigroupcorp.com/members/amerivantage/ | ||||
Number of Members enrolled in this plan in (H5817 - 010): | 2,401 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 — |