2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Bravo Traditions (PPO SNP) | ||||
Location: | Collin, Texas Click to see other locations | ||||
Plan ID: | H1355 - 002 - 0 Click to see other plans | ||||
Member Services: | 1-800-291-0396 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 Bravo Traditions (PPO SNP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $25.70 (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: | 3,042 drugs | Browse the Bravo Traditions (PPO SNP) Formulary | |||
This plan has 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: | cost-sharing data not available. | ||||
• Number of Drugs per Tier: | |||||
Plan's Pharmacy Search: | http://www.mybravohealth.com | ||||
Number of Members enrolled in this plan in (H1355 - 002): | less than 10 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 | |||||
$25.7 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 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. | |||||
20% 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 www.mybravohealth.com/formulary 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 Bravo Traditions (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): | |||||
Not all drugs are available at this extended day supply. Please contact the plan for more information. | |||||
You can get drugs the following way(s): | |||||
You can get drugs the following way(s): | |||||
Not all drugs 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 Bravo Traditions (PPO SNP). | |||||
You can get drugs the following way: | |||||
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:
| |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
No plan coverage limit on the number of covered exams. | |||||
20% of the cost for routine exams. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
and routine eye exams. | |||||
$0 copay for
| |||||
$150 plan coverage limit for eye exams and eye wear every year. | |||||
0% of the cost for eye exams. | |||||
20% of the cost for eye wear. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
0% of the cost for preventive dental benefits. | |||||
0% to 20% of the cost for comprehensive dental benefits. | |||||
$800 plan coverage limit for comprehensive 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 | |||||
$25.7 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
This plan covers all Medicare-covered preventive services with zero cost sharing. | |||||
$6 700 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) | |||||
Plan covers 90 days each benefit period. | |||||
$1 100 copay for each Medicare-covered hospital stay | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 60: $0 copay per day | |||||
Days 61 - 90: $275 copay per day | |||||
Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: | |||||
Days 1 - 60: $550 copay per day | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
20% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
$1 100 copay for each Medicare-covered hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 60: $0 copay per day | |||||
Days 61 - 90: $275 copay per day | |||||
Plan covers 60 lifetime reserve days. Cost per lifetime reserve day: | |||||
Days 1 - 60: $550 copay per day | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
30% of the cost for each hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
$0 copay for SNF services | |||||
20% of the cost for each SNF stay. | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
20% for 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. | |||||
$0 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. | |||||
$0 copay for each specialist doctor visit for Medicare-covered benefits. | |||||
20% for each primary care doctor visit. | |||||
20% for each specialist visit. | |||||
Chiropractic Services | |||||
$0 copay for Medicare-covered chiropractic visits. | |||||
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. | |||||
20% of the cost for chiropractic benefits. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered podiatry visits | |||||
up to 12 routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
20% to 50% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Mental Health visits. | |||||
30% of the cost for Mental Health benefits. | |||||
30% of the cost for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered individual or group visits. | |||||
30% of the cost for outpatient substance abuse benefits. | |||||
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. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
Worldwide coverage. | |||||
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. | |||||
$0 copay for Medicare-covered Occupational Therapy visits. | |||||
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 copay for Medicare-covered Cardiac Rehab services. | |||||
20% of the cost for Occupational Therapy benefits. | |||||
20% 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 | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
30% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
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. | |||||
0% of the cost for Diabetes self-monitoring training. | |||||
0% 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 | |||||
0% of the cost for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
0% of the cost for colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
0% of the cost for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
0% of the cost for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
0% 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. | |||||
0% 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. | |||||
20% 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 www.mybravohealth.com/formulary 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 Bravo Traditions (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): | |||||
Not all drugs are available at this extended day supply. Please contact the plan for more information. | |||||
You can get drugs the following way(s): | |||||
You can get drugs the following way(s): | |||||
Not all drugs 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 Bravo Traditions (PPO SNP). | |||||
You can get drugs the following way: | |||||
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:
| |||||
Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
0% of the cost for preventive dental benefits. | |||||
0% to 20% of the cost for comprehensive dental benefits. | |||||
$800 plan coverage limit for comprehensive 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 | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$0 copay for | |||||
$0 copay for hearing aids. | |||||
$1 400 plan coverage limit for hearing aids every three years. | |||||
20% of the cost for hearing exams. | |||||
0% of the cost for hearing aids. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
and routine eye exams. | |||||
$0 copay for
| |||||
$150 plan coverage limit for eye exams and eye wear every year. | |||||
0% of the cost for eye exams. | |||||
20% of the cost for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
No plan coverage limit on the number of covered exams. | |||||
20% of the cost for routine exams. | |||||
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. | |||||
0% of the cost for Health and Wellness services. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for each one-way trip to plan-approved location. | |||||
50% of the cost for transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |