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2011 Medicare Advantage Plan Benefit Details for the Evercare Plan IP (PPO SNP) - H1108-001-0


2011 Medicare Advantage Plan Details
Medicare Plan Name:Evercare Plan IP (PPO SNP)
Location:Butts, Georgia
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:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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.




    Tips & Disclaimers
    • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
    • Medicare has neither reviewed nor endorsed the information on our site.
    • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
    • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
    • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
    • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
    • Limitations, copayments, and restrictions may apply.
    • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
    • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
    • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
    • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
    • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
    • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
    • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.