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2011 SmartValue Plus (PFFS) in Butts, Georgia

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the SmartValue Plus (PFFS) (H0540 - 091) in Butts, Georgia .

This plan is administered by UNICARE LIFE AND HEALTH INS. COMPANY. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the SmartValue Plus (PFFS) health and prescription benefit details in chart format

or email and view benefits chart

Plan Premium

The SmartValue Plus (PFFS) has a monthly premium of $47.00. That is $564.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $47.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a PFFS plan.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2011 is $310. This plan (SmartValue Plus (PFFS)) has no deductible.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The SmartValue Plus (PFFS)’s formulary is divided into 6 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Generic Drugs) contains 1,617 drugs and has a co-payment of $8.00.
Tier 2 (Preferred Brand Drugs) contains 563 drugs and has a co-payment of $44.00.
Tier 3 (Non-Preferred Brand Drugs) contains 1,426 drugs and has a co-payment of $85.00.
Tier 4 (Injectable Drugs) contains 554 drugs and has a co-insurance of 33% of the drug cost.
Tier 5 (Specialty Tier Drugs) contains 339 drugs and has a co-insurance of 33% of the drug cost.
Tier 6 (Supplemental Drugs) contains drugs and has a co-payment of $8.00.

Click here to browse the SmartValue Plus (PFFS) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 7% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 0% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 50% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (SmartValue Plus (PFFS)) offers Coverage for Many Generics during the Coverage Gap phase. This means that many (65% to 100%) of the generic drugs on the plans formulary (or drug list) and no brand-name drugs will be covered through the coverage gap (or donut hole).

The SmartValue Plus (PFFS) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **

Premium and Other Important Information

Balance billing means that a provider may charge and bill you more than the plan's payment amount for services. There is a limit on what providers may charge for Medicare-covered services.

$47 monthly plan premium in addition to your monthly Medicare Part B premium.

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 covers all Medicare-covered preventive services with zero cost sharing.

Providers may balance bill 0% to 15% of the plan payment amount for the following services:

Inpatient Hospital Acute
Inpatient Hospital Psychiatric
Skilled Nursing Facility (SNF)
Comprehensive Outpatient Rehabilitation Facility (CORF)
Emergency Care
Urgently Needed Care
Partial Hospitalization
Home Health Services
Primary Care Physician Services
Chiropractic Services
Occupational Therapy Services
Physician Specialist Services
Mental Health Specialty Services
Podiatry Services
Other Health Care Professional
Psychiatric Services
Physical Therapy and Speech/Language Pathology Services
Outpatient Diag Procs/Tests/Lab Services
Outpatient Diag/Therapeutic Rad Services
Outpatient Hospital Services
Ambulatory Surgical Center (ASC) Services
Out

$5 000 out-of-pocket limit.

This limit includes only Medicare-covered services.

** Doctor and Hospital Choice **

Doctor and Hospital Choice

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

** Extra Benefits **

Prescription Drugs

20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs.

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.medicarerxrewards.com 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 SmartValue Plus (PFFS) 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.

If you request a formulary exception for a drug and SmartValue Plus (PFFS) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.

$0 deductible.

Supplemental drugs don't count toward your out-of-pocket drug costs.

You pay the following until total yearly drug costs reach $2 840:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$8 copay for a one-month (30-day) supply of drugs in this tier

$44 copay for a one-month (30-day) supply of drugs in this tier

$85 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$8 copay for a one-month (30-day) supply of drugs in this tier

$24 copay for a three-month (90-day) supply of drugs in this tier

$132 copay for a three-month (90-day) supply of drugs in this tier

$255 copay for a three-month (90-day) supply of drugs in this tier

33% coinsurance for a three-month (90-day) supply of drugs in this tier

$24 copay for a three-month (90-day) supply of drugs in this tier

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$8 copay for a one-month (34-day) supply of drugs in this tier

$44 copay for a one-month (34-day) supply of drugs in this tier

$85 copay for a one-month (34-day) supply of drugs in this tier

33% coinsurance for a one-month (34-day) supply of drugs in this tier

$8 copay for a one-month (34-day) supply of drugs in this tier

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$12 copay for a three-month (90-day) supply of drugs in this tier

$110 copay for a three-month (90-day) supply of drugs in this tier

$212.50 copay for a three-month (90-day) supply of drugs in this tier

33% coinsurance for a three-month (90-day) supply of drugs in this tier

$12 copay for a three-month (90-day) supply of drugs in this tier

The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap.

You pay the following:

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$8 copay for a one-month (30-day) supply of all drugs covered in this tier

$24 copay for a three-month (90-day) supply of all drugs covered in this tier

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$8 copay for a one-month (34-day) supply of all drugs covered in this tier

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

$12 copay for a three-month (90-day) supply of all drugs covered in this tier

After your total yearly drug costs reach $2 840 you receive limited coverage by the plan on certain drugs. You will also receive a discount on brand name drugs and generally pay no more than 93% of the plan's costs for 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 following:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$2.50 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$3.25 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$8 copay for drugs in this tier

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 SmartValue Plus (PFFS).

You will be reimbursed up to the full cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 840:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$8 copay for a one-month (30-day) supply of drugs in this tier

$44 copay for a one-month (30-day) supply of drugs in this tier

$85 copay for a one-month (30-day) supply of drugs in this tier

33% coinsurance for a one-month (30-day) supply of drugs in this tier

$8 copay for a one-month (30-day) supply of drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

You will be reimbursed for these drugs purchased out-of-network up to the full cost of the drug minus the following:

Tier 1: Generic Drugs

Tier 6: Supplemental Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

$8 copay for a one-month (30-day) supply of all drugs covered in this tier

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 drug costs reach $4 550.

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

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 the following:

Tier 1: Generic Drugs

Tier 2: Preferred Brand Drugs

Tier 3: Non-Preferred Brand Drugs

Tier 4: Injectable Drugs

Tier 5: Specialty Tier Drugs

Tier 6: Supplemental Drugs

$2.50 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$3.25 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$6.30 copay or 5% coinsurance [whichever costs more] for drugs in this tier

$8 copay for drugs in this tier

You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.

Physical Exams

$0 copay for routine exams.

Limited to 1 exam(s) every year.

$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 $35 copay for exams to diagnose and treat diseases and conditions of the eye.

$35 copay for up to 1 routine eye exam(s) every year

Dental Services

In general preventive dental benefits (such as cleaning) not covered.

$0 copay for Medicare-covered dental benefits.

** Important Information **

Premium and Other Important Information

Balance billing means that a provider may charge and bill you more than the plan's payment amount for services. There is a limit on what providers may charge for Medicare-covered services.

$47 monthly plan premium in addition to your monthly Medicare Part B premium.

This plan covers all Medicare-covered preventive services with zero cost sharing.

Providers may balance bill 0% to 15% of the plan payment amount for the following services:

Inpatient Hospital Acute
Inpatient Hospital Psychiatric
Skilled Nursing Facility (SNF)
Comprehensive Outpatient Rehabilitation Facility (CORF)
Emergency Care
Urgently Needed Care
Partial Hospitalization
Home Health Services
Primary Care Physician Services
Chiropractic Services
Occupational Therapy Services
Physician Specialist Services
Mental Health Specialty Services
Podiatry Services
Other Health Care Professional
Psychiatric Services
Physical Therapy and Speech/Language Pathology Services
Outpatient Diag Procs/Tests/Lab Services
Outpatient Diag/Therapeutic Rad Services
Outpatient Hospital Services
Ambulatory Surgical Center (ASC) Services
Out

$5 000 out-of-pocket limit.

This limit includes only Medicare-covered services.

Doctor and Hospital Choice

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

** Inpatient Care **

Inpatient Hospital Care (Acute)

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies.

No limit to the number of days covered by the plan each benefit period.

For Medicare-covered hospital stays:

Days 1 - 7: $225 copay per day

Days 8 - 90: $0 copay per day

$0 copay for additional hospital days

Inpatient Mental Health Care

You get up to 190 days in a Psychiatric Hospital in a lifetime.

For Medicare-covered hospital stays:

Days 1 - 7: $225 copay per day

Days 8 - 90: $0 copay per day

Skilled Nursing Facility (SNF)

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

Days 1 - 20: $0 copay per day

Days 21 - 100: $128 copay per day

Home Health Care

$0 copay for each Medicare-covered home health visit.

Hospice

You must get care from a Medicare-certified hospice.

** Outpatient Care **

Doctor Office Visits

You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.

See 'Welcome to Medicare; and Annual Wellness Visit' for more information.

$20 copay for each primary care doctor visit for Medicare-covered benefits.

$35 copay for each specialist visit for Medicare-covered benefits.

Chiropractic Services

$10 copay 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.

Podiatry Services

$35 copay for each Medicare-covered visit.

Medicare-covered podiatry benefits are for medically-necessary foot care.

Outpatient Mental Health Care

$40 copay for each Medicare-covered individual or group therapy visit.

Outpatient Substance Abuse Care

$40 copay for Medicare-covered individual or group visits.

Outpatient Hospital Services

20% of the cost for each Medicare-covered ambulatory surgical center visit.

$35 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit.

Emergency Care

$50 copay for Medicare-covered emergency room visits.

Worldwide coverage.

If you are admitted to the hospital within 72-hour(s) for the same condition you pay $0 for the emergency room visit

Outpatient Rehabilitation Services

$35 to $50 copay for Medicare-covered Occupational Therapy visits.

$35 to $50 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.

$35 copay for Medicare-covered Cardiac Rehab services.

** Outpatient Medical Services and Supplies **

Durable Medical Equipment

20% of the cost for Medicare-covered items.

Prosthetic Devices

20% of the cost for Medicare-covered items.

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.

** Preventive Services **

Bone Mass Measurement

$0 copay for Medicare-covered bone mass measurement.

Colorectal Screening Exams

$0 copay for Medicare-covered colorectal screenings.

Immunizations

$0 copay for Flu and Pneumonia vaccines.

$0 copay for Hepatitis B vaccine.

Pap Smears and Pelvic Exams

$0 copay for Medicare-covered pap smears and pelvic exams

Prostate Cancer Screening Exams

$0 copay for Medicare-covered prostate cancer screening.

** Additional Benefits **

Dialysis

20% of the cost for renal dialysis

$0 copay 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.

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.medicarerxrewards.com 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).