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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Today's Options Premier 850F powered by CCRx (PFFS) in Pierce, Georgia

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Today's Options Premier 850F powered by CCRx (PFFS) (H5421 - 075) in Pierce, Georgia .

This plan is administered by THE PYRAMID LIFE INSURANCE COMPANY.  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Today's Options Premier 850F powered by CCRx (PFFS) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Today's Options Premier 850F powered by CCRx (PFFS) has a monthly premium of $100.00. That is $1,200.00 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 $100.00 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 has a $310 deductible. So, you are 100% responsible for the first $310 in medication costs. After you have met the deductible, the Today's Options Premier 850F powered by CCRx (PFFS) will share the costs of your medications with you -- see cost-sharing below. $310 is the maximum deductible for 2011. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 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. Once you have spent $310, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Today's Options Premier 850F powered by CCRx (PFFS)’s formulary is divided into 4 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 and Preferred Brand Drugs) contains 1,490 drugs and has a co-payment of $4.00.
  • Tier 2 (Non-Preferred Generic and Preferred Brand Drugs) contains 677 drugs and has a co-payment of $40.00.
  • Tier 3 (Non-Preferred Generic and Non-Preferred Brand Drug) contains 404 drugs and has a co-payment of $80.00.
  • Tier 4 (Specialty Tier Drugs) contains 275 drugs and has a co-insurance of 25% of the drug cost.
    •   
Click here to browse the Today's Options Premier 850F powered by CCRx (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 (Today's Options Premier 850F powered by CCRx (PFFS)) offers No Coverage during the Coverage Gap phase.

The Today's Options Premier 850F powered by CCRx (PFFS) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **
Premium and Other Important Information
$100 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.
This plan does not allow providers to balance bill (charging more than your cost share amount).
$6 700 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.todaysoptions.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 Today's Options Premier 850F powered by CCRx (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 Today's Options Premier 850F powered by CCRx (PFFS) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug.
$310 yearly deductible.
After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840:
Tier 1: Generic and Preferred Brand Drugs
Tier 2: Non-Preferred Generic and Preferred Brand Drugs
Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 25% 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
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $240 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Generic and Preferred Brand Drugs
    Tier 2: Non-Preferred Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (34-day) supply of drugs in this tier
  • $40 copay for a one-month (34-day) supply of drugs in this tier
  • $80 copay for a one-month (34-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (34-day) supply of drugs in this tier
    • 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 Today's Options Premier 850F powered by CCRx (PFFS).
    After you pay your yearly deductible 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 and Preferred Brand Drugs
    Tier 2: Non-Preferred Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (30-day) supply of drugs 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 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
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    Vision Services
  • $20 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s) every year
    • Dental Services
    $0 copay for Medicare-covered dental benefits.
    In general preventive dental benefits (such as cleaning) not covered.
    ** Important Information **
    Premium and Other Important Information
    $100 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.
    This plan does not allow providers to balance bill (charging more than your cost share amount).
    $6 700 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 - 6: $265 copay per day
    Days 7 - 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 - 6: $265 copay per day
    Days 7 - 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: $135 copay per day
    Home Health Care
    0% of the cost 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.
    $25 copay for each primary care doctor visit for Medicare-covered benefits.
    $50 copay for each specialist visit for Medicare-covered benefits.
    Chiropractic Services
    50% 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.
    Podiatry Services
    $50 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    Outpatient Mental Health Care
    45% of the cost for each Medicare-covered individual or group therapy visit.
    Outpatient Substance Abuse Care
    45% of the cost for Medicare-covered individual or group visits.
    Outpatient Hospital Services
    $163 copay for each Medicare-covered ambulatory surgical center visit.
    $0 to $325 copay for each Medicare-covered outpatient hospital facility visit.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    $20 000 plan coverage limit for emergency services outside the U.S. every year.
    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
    There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits.
    $45 copay for Medicare-covered Occupational Therapy visits.
    $45 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $45 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.
    0% to 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
    $25 copay 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.todaysoptions.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 Today's Options Premier 850F powered by CCRx (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 Today's Options Premier 850F powered by CCRx (PFFS) approves the exception you will pay Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs cost sharing for that drug.
    $310 yearly deductible.
    After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 840:
    Tier 1: Generic and Preferred Brand Drugs
    Tier 2: Non-Preferred Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 25% 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
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $240 copay for a three-month (90-day) supply of drugs in this tier
  • 25% coinsurance for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Generic and Preferred Brand Drugs
    Tier 2: Non-Preferred Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (34-day) supply of drugs in this tier
  • $40 copay for a one-month (34-day) supply of drugs in this tier
  • $80 copay for a one-month (34-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (34-day) supply of drugs in this tier
    • 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 Today's Options Premier 850F powered by CCRx (PFFS).
    After you pay your yearly deductible 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 and Preferred Brand Drugs
    Tier 2: Non-Preferred Generic and Preferred Brand Drugs
    Tier 3: Non-Preferred Generic and Non-Preferred Brand Drugs
    Tier 4: Specialty Tier Drugs
  • $4 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 copay for a one-month (30-day) supply of drugs in this tier
  • 25% coinsurance for a one-month (30-day) supply of drugs 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 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
    $0 copay for Medicare-covered dental benefits.
    In general preventive dental benefits (such as cleaning) not covered.
    Hearing Services
    Hearing aids not covered.
  • $20 copay for Medicare-covered diagnostic hearing exams
  • $20 copay for up to 1 routine hearing test(s) every year
    • Vision Services
  • $20 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s) every year
    • Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Nursing Hotline
  • Other Wellness 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.
    Transportation
    This plan does not cover routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.




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    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
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    .