2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medicare Masterpiece (HMO-POS) | ||||
Location: | Montgomery, Texas Click to see other locations | ||||
Plan ID: | H6642 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-866-690-4842 TTY users 1-800-617-0177 | ||||
— 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 Medicare Masterpiece (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,056 drugs | Browse the Medicare Masterpiece (HMO-POS) 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% | $10.00 | $45.00 | $70.00 | 33% |
• Number of Drugs per Tier: | 578 | 1188 | 922 | 190 | 178 |
Plan's Pharmacy Search: | http://www.univhc.com | ||||
Number of Members enrolled in this plan in (H6642 - 001): | 1,027 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 | |||||
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 does not cover all Medicare-covered preventive services with zero cost sharing. | |||||
Universal HMO of Texas Inc. will reduce your monthly Medicare Part B premium by up to $ 60.00. | |||||
** Important Information ** | |||||
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 does not cover all Medicare-covered preventive services with zero cost sharing. | |||||
Universal HMO of Texas Inc. will reduce your monthly Medicare Part B premium by up to $ 60.00. | |||||
** Additional Benefits ** | |||||
Point of Service | |||||
Authorization rules may apply. | |||||
Point of Service coverage is available for the following benefits:
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$50 000 plan coverage limit every year for the following POS Benefits:
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$200 copay per hospital stay. | |||||
For hospital stays: | |||||
Days 1 - 7: $200 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
$200 per Inpatient Psychiatric Hospital stay. | |||||
For Inpatient Psychiatric Hospital stays: | |||||
Days 1 - 7: $200 copay per day | |||||
Days 8 - 90: $0 copay per day | |||||
For each SNF stay: | |||||
Days 1 - 10: $0 copay per SNF day | |||||
Days 11 - 100: $100 copay per SNF day | |||||
$0 to $100 copay [or 0% to 25% of the cost] for
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$25 copay for
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