2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medica Clear Solution with Part D Option 1 (PPO) | ||||
Location: | Mille Lacs, Minnesota Click to see other locations | ||||
Plan ID: | H3283 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-800-234-8755 TTY users 1-800-855-2880 | ||||
— 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 Medica Clear Solution with Part D Option 1 (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $262.70 (see Plan Premium Details below) | ||||
Annual Deductible: | $320 | ||||
Annual Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $2,500 | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 5,156 drugs | Browse the Medica Clear Solution with Part D Option 1 (PPO) Formulary | |||
This plan has 4 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: | 25% | 25% | 25% | 25% | |
• Number of Drugs per Tier: | 2122 | 693 | 1904 | 437 | |
Plan's Pharmacy Search: | http://www.medica.com/C12/DrugFormularyPartD/default.aspx | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H3283 - 001): | less than 10 members | ||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||
• Customer Service Rating: | New plan - not yet rated. | ||||
• Member Experience Rating: | New plan - not yet rated. | ||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||
— 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 | |||||
$262.7 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. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$2 500 out-of-pocket limit. All plan services included. | |||||
$4 000 out-of-pocket limit. All plan services included. | |||||
** 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 ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$0 copay for up to 6 round trip(s) to plan-approved location every year | |||||
$0 copay for transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$262.7 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. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$2 500 out-of-pocket limit. All plan services included. | |||||
$4 000 out-of-pocket limit. All plan services included. | |||||
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 | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
20% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
$0 copay | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
20% 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. | |||||
$0 copay for SNF services | |||||
For each SNF stay: | |||||
Days 1 - 20: $0 copay per SNF day | |||||
Days 21 - 100: $50 copay per SNF day | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits | |||||
20% of the cost for home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$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% of the cost for each primary care doctor visit | |||||
20% of the cost for each specialist visit | |||||
Chiropractic Services | |||||
$0 copay for: Medicare-covered chiropractic visits | |||||
supplemental routine 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 | |||||
$0 copay for Medicare-covered podiatry benefits. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
20% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
$0 copay for Medicare-covered Mental Health visits | |||||
$0 copay for Medicare-covered partial hospitalization program services | |||||
20% of the cost for Mental Health benefits with a psychiatrist | |||||
20% of the cost for Mental Health benefits | |||||
20% of the cost for partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
$0 copay for Medicare-covered visits | |||||
20% of the cost for outpatient substance abuse benefits. | |||||
Outpatient Services/Surgery | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
20% of the cost for ambulance benefits. | |||||
Emergency Care | |||||
$0 copay for Medicare-covered emergency room visits | |||||
$20 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
Urgently Needed Care | |||||
$0 copay for Medicare-covered urgently-needed-care visits | |||||
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 Physical and/or Speech and Language Therapy visits | |||||
20% of the cost for Occupational Therapy benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
$0 copay for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
Prosthetic Devices | |||||
$0 copay for Medicare-covered items | |||||
20% of the cost for prosthetic devices. | |||||
Diabetes Programs and Supplies | |||||
$0 copay for Diabetes self-management training | |||||
$0 copay for: | |||||
20% of the cost for Diabetes self-management training | |||||
20% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$0 copay for Medicare-covered: | |||||
20% of the cost for therapeutic radiology services | |||||
20% of the cost for outpatient X-rays | |||||
20% of the cost for diagnostic radiology services | |||||
20% of the cost for diagnostic procedures tests and lab services | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$0 copay for: | |||||
20% of the cost for Cardiac Rehabilitation Services | |||||
20% of the cost for Intensive Cardiac Rehabilitation Services | |||||
20% of the cost for Pulmonary Rehabilitation Services | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
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. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
20% of the cost for Medicare-covered preventive services | |||||
20% of the cost for supplemental education/wellness programs | |||||
Kidney Disease and Conditions | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
20% of the cost for kidney disease education services | |||||
20% of the cost for renal dialysis | |||||
Outpatient Prescription Drugs | |||||
10% 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 http://www.medica.com/C12/DrugFormularyPartD/default.aspx 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 the District of Columbia). 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 a Part D 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 Medica Clear Solution with Part D Option 1 (PPO) 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. | |||||
$320 annual deductible. | |||||
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 930. | |||||
You can get drugs the following way(s): | |||||
You can get drugs the following way(s): | |||||
You can get drugs the following way(s): | |||||
After your total yearly drug costs reach $2 930 you receive a discount on brand name drugs and pay 86% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $4 700. | |||||
After your yearly out-of-pocket drug costs reach $4 700 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 Medica Clear Solution with Part D Option 1 (PPO). | |||||
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 $2 930. | |||||
You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. You will be reimbursed up to the discounted price for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 700. | |||||
After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed for drugs purchased out-of-network up to the plan's cost of the drug minus your cost share which is the greater of: | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
20% of the cost for comprehensive dental benefits | |||||
Hearing Services | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$0 copay for | |||||
$0 copay for hearing aids. | |||||
20% of the cost for hearing exams. | |||||
20% of the cost for hearing aids. | |||||
$1 000 plan coverage limit for supplemental routine hearing exams and hearing aids every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
and supplemental routine eye exams. | |||||
$0 copay for | |||||
20% of the cost for eye exams. | |||||
20% of the cost for eye wear. | |||||
$250 plan coverage limit for eye wear every year. This limit applies to both in-network and out-of-network benefits. | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$0 copay for up to 6 round trip(s) to plan-approved location every year | |||||
$0 copay for transportation. | |||||
Acupuncture | |||||
$0 copay for up to 12 visit(s) every year | |||||
20% of the cost for acupuncture visits | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
20% of the cost for each hospital stay. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$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% of the cost for each primary care doctor visit | |||||
20% of the cost for each specialist visit | |||||
Outpatient Services/Surgery | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
20% of the cost for ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
$0 copay for Medicare-covered items | |||||
20% of the cost for durable medical equipment | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$0 copay for Medicare-covered: | |||||
20% of the cost for therapeutic radiology services | |||||
20% of the cost for outpatient X-rays | |||||
20% of the cost for diagnostic radiology services | |||||
20% of the cost for diagnostic procedures tests and lab services | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
$0 copay for up to 6 round trip(s) to plan-approved location every year | |||||
$0 copay for transportation. |