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2011 Medicare Advantage Plan Benefit Details for the Evercare Plan IP (PPO SNP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:Evercare Plan IP (PPO SNP)
Location:Butts, Georgia     Click to see other locations
Plan ID:H1108 - 001 - 0     Click to see other plans
Member Services:1-800-393-0993 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
Email a copy of the Evercare Plan IP (PPO SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$30.00 (see Plan Premium Details below)
Annual Deductible:$310
Annual Initial Coverage Limit (ICL):$2,840
Health Plan Type:Local PPO
Special Needs Plan (SNP)
Eligibility Requirement:		Institutional
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,685 drugsBrowse the Evercare Plan IP (PPO SNP) Formulary
This plan has drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		cost-sharing data not available.
• Number of Drugs per
  Tier:
Plan's Pharmacy Search:http://www.PrescriptionSolutions.com
Number of Members enrolled in this plan in (H1108 - 001):1,989 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
$30 monthly plan premium in addition to your monthly Medicare Part B premium.
This plan covers all Medicare-covered preventive services with zero cost sharing.
$5 000 out-of-pocket limit.
This limit includes only Medicare-covered services.
$10 000 out-of-pocket limit.
In-Network: This limit includes only Medicare-covered services.
Out-Of-Network: This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
** Extra Benefits **
Prescription Drugs
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.
30% of the cost for Part B drugs out-of-network.
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at EvercareHealthPlans.com/prescription_drug_coverage.jsp on the web.
Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service).
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 Evercare Plan IP (PPO SNP) 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.
$310 yearly deductible.
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 840.
You can get drugs the following way(s):
  • one-month (31-day) supply
  • three-month (90-day) supply
    • You can get drugs the following way(s):
  • one-month (31-day) supply
    • You can get drugs the following way(s):
  • three-month (90-day) supply
    • 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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    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 Evercare Plan IP (PPO SNP).
    You can get drugs the following way:
  • one-month (31-day) supply
    • After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 840.
    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.
    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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    Physical Exams
    When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests.
    $0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • 0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • $0 copay for contacts
  • $0 copay for up to 1 pair(s) of lenses every two years
  • $0 copay for up to 1 frame(s) every two years
    • $75 plan coverage limit for eye wear every two years.
    30% of the cost for eye exams.
    $0 copay for eye wear.
    Dental Services
    20% of the cost for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every six months
  • $0 copay for up to 1 cleaning(s) every six months
  • $0 copay for up to 1 dental x-ray(s) every year
    • $0 copay for preventive dental benefits.
    0% to 30% of the cost for comprehensive dental benefits.
    $250 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    ** Important Information **
    Premium and Other Important Information
    $30 monthly plan premium in addition to your monthly Medicare Part B premium.
    This plan covers all Medicare-covered preventive services with zero cost sharing.
    $5 000 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    $10 000 out-of-pocket limit.
    In-Network: This limit includes only Medicare-covered services.
    Out-Of-Network: This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    No referral required for network doctors specialists and hospitals.
    You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits.
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    You will not be charged additional cost sharing for professional services.
    $0 copay for each additional hospital day.
    30% of the cost for each hospital stay.
    Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care')
    30% of the cost for each hospital stay.
    Skilled Nursing Facility (SNF)
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For Medicare-covered SNF stays:
    Days 1 - 100: $0 copay per day
    30% of the cost for each SNF stay.
    Home Health Care
    $0 copay for each Medicare-covered home health visit.
    30% for home health visits.
    Hospice
    You must get care from a Medicare-certified hospice.
    ** Outpatient Care **
    Doctor Office Visits
    $0 copay for each primary care doctor visit for Medicare-covered benefits.
    20% of the cost for each in-area network urgent care Medicare-covered visit.
    0% to 20% of the cost for each specialist visit for Medicare-covered benefits.
    30% for each primary care doctor visit.
    30% for each specialist visit.
    Chiropractic Services
    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.
    30% of the cost for chiropractic benefits.
    Podiatry Services
    20% of the cost for each Medicare-covered visit.
    $0 copay for up to 6 routine visit(s) every year
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    30% of the cost for podiatry benefits.
    Outpatient Mental Health Care
    20% of the cost for each Medicare-covered individual or group therapy visit.
    30% of the cost for Mental Health benefits.
    30% of the cost for Mental Health benefits with a psychiatrist.
    Outpatient Substance Abuse Care
    20% of the cost for Medicare-covered individual or group visits.
    30% of the cost for outpatient substance abuse benefits.
    Outpatient Hospital Services
    20% of the cost for each Medicare-covered ambulatory surgical center visit.
    20% of the cost for each Medicare-covered outpatient hospital facility visit.
    30% of the cost for ambulatory surgical center benefits.
    30% of the cost for outpatient hospital facility benefits.
    Emergency Care
    $50 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
    $0 copay for Medicare-covered Occupational Therapy visits.
    $0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    20% of the cost for Medicare-covered Cardiac Rehab services.
    30% of the cost for Occupational Therapy benefits.
    30% of the cost for Physical and/or Speech and Language Therapy visits.
    30% of the cost for Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered items.
    30% of the cost for durable medical equipment.
    Prosthetic Devices
    20% of the cost for Medicare-covered items.
    30% of the cost for prosthetic devices.
    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.
    30% of the cost for Diabetes self-monitoring training.
    30% of the cost for Nutrition Therapy for Diabetes.
    30% of the cost for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement.
    30% of the cost for Medicare-covered bone mass measurement.
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    30% of the cost for colorectal screenings.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    No referral needed for Flu and pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    $0 copay for immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
    30% of the cost for pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for Medicare-covered prostate cancer screening.
    30% of the cost for prostate cancer screening.
    ** Additional Benefits **
    Dialysis
    20% of the cost for renal dialysis
    $0 copay for Nutrition Therapy for End-Stage Renal Disease.
    20% of the cost for renal dialysis.
    30% of the cost 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.
    30% of the cost for Part B drugs out-of-network.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at EvercareHealthPlans.com/prescription_drug_coverage.jsp on the web.
    Different out-of-pocket costs may apply for people who
    • have limited incomes
    • live in long term care facilities or
    • have access to Indian/Tribal/Urban (Indian Health Service).
    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 Evercare Plan IP (PPO SNP) 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.
    $310 yearly deductible.
    After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 840.
    You can get drugs the following way(s):
  • one-month (31-day) supply
  • three-month (90-day) supply
    • You can get drugs the following way(s):
  • one-month (31-day) supply
    • You can get drugs the following way(s):
  • three-month (90-day) supply
    • 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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    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 Evercare Plan IP (PPO SNP).
    You can get drugs the following way:
  • one-month (31-day) supply
    • After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 840.
    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.
    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:
    • A $ 2.50 copay for generic (including brand drugs treated as generic) and a $ 6.30 copay for all other drugs or
    • 5% coinsurance.
    Dental Services
    20% of the cost for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every six months
  • $0 copay for up to 1 cleaning(s) every six months
  • $0 copay for up to 1 dental x-ray(s) every year
    • $0 copay for preventive dental benefits.
    0% to 30% of the cost for comprehensive dental benefits.
    $250 plan coverage limit for dental benefits every year. This limit applies to both in-network and out-of-network benefits.
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    Hearing Services
    In general routine hearing exams and hearing aids not covered.
  • 20% of the cost for Medicare-covered diagnostic hearing exams
    • 30% of the cost for hearing exams.
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • 0% to 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • $0 copay for contacts
  • $0 copay for up to 1 pair(s) of lenses every two years
  • $0 copay for up to 1 frame(s) every two years
    • $75 plan coverage limit for eye wear every two years.
    30% of the cost for eye exams.
    $0 copay for eye wear.
    Physical Exams
    When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests.
    $0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.
    Health/Wellness Education
    $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.
    30% of the cost for Health and Wellness services.
    Transportation
    $0 copay for up to 24 one-way trip(s) to plan approved location every year.
    50% of the cost for transportation.
    Acupuncture
    This plan does not cover Acupuncture.




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