2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medicare y Mucho Mas - ELITE (HMO-POS) | ||||
Location: | Rio Grande, Puerto Rico Click to see other locations | ||||
Plan ID: | H4003 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-866-333-5470 TTY users 1-866-333-5469 | ||||
— 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 y Mucho Mas - ELITE (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,250 | ||||
Additional Rx Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 2,728 drugs | Browse the Medicare y Mucho Mas - ELITE (HMO-POS) 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: | $5.00 | $29.00 | $50.00 | 25% | |
• Number of Drugs per Tier: | 1820 | 567 | 59 | 282 | |
Plan's Pharmacy Search: | http://www.mmm-pr.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H4003 - 001): | 3,496 members | ||||
Plan’s Summary Star Rating: | 2.5 out of 5 Stars. | ||||
• Customer Service Rating: | 2 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 2 out of 5 Stars. | ||||
— 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 | |||||
$0 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. | |||||
$3 250 out-of-pocket limit. All plan services included. | |||||
$3 250 out-of-pocket limit. All plan services included. | |||||
$3 250 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. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Point of Service | |||||
Authorization rules may apply. | |||||
Point of Service coverage is available for the following benefits: | |||||
$10 000 plan coverage limit every year for the following POS Benefits: | |||||
20% of the cost per hospital stay. | |||||
20% of the cost per Inpatient Psychiatric Hospital stay. | |||||
20% of the cost for each SNF stay. | |||||
20% of the cost for | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 8 one-way trip(s) to any location every year | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$0 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. | |||||
$3 250 out-of-pocket limit. All plan services included. | |||||
$3 250 out-of-pocket limit. All plan services included. | |||||
$3 250 out-of-pocket limit. All plan services included. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $25 copay per day | |||||
Days 5 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
$3 250 out-of-pocket limit every year. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Inpatient Mental Health Care | |||||
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. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $25 copay per day | |||||
Days 5 - 90: $0 copay per day | |||||
$3 250 out-of-pocket limit every year. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 4: $25 copay per day | |||||
Days 5 - 100: $0 copay per day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered 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. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$10 copay for each Medicare-covered visit | |||||
$15 copay for up to 10 supplemental routine visit(s) every year | |||||
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 | |||||
Authorization rules may apply. | |||||
$15 copay for each Medicare-covered visit | |||||
$15 copay for up to 3 supplemental routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$10 copay for each Medicare-covered individual therapy visit | |||||
$10 copay for each Medicare-covered group therapy visit | |||||
$10 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$10 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$15 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$10 copay for Medicare-covered individual visits | |||||
$10 copay for Medicare-covered group visits | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$25 copay for each Medicare-covered ambulatory surgical center visit | |||||
$25 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 1-day for the same condition you pay $0 for the emergency room visit. | |||||
Urgently Needed Care | |||||
$0 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$4 copay for Medicare-covered Occupational Therapy visits | |||||
$4 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-management training | |||||
0% to 20% of the cost for Diabetes monitoring supplies | |||||
0% to 20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
0% to 10% of the cost for Medicare-covered lab services | |||||
$0 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 copay for Medicare-covered X-rays | |||||
$0 to $40 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $0 to $15 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $15 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$10 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered 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: | |||||
Kidney Disease and Conditions | |||||
Authorization rules may apply. | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
$0 copay for Part B-covered drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.mmm-pr.com 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 Medicare y Mucho Mas - ELITE (HMO-POS) 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 Medicare y Mucho Mas - ELITE (HMO-POS) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug. | |||||
$0 deductible. | |||||
You pay the following until total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap. | |||||
You pay the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 1: Preferred Generic Drugs | |||||
Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 930 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 86% of the plan's costs for generic drugs until your yearly out-of-pocket drug costs reach $4 700. | |||||
Please contact the plan for a complete list of drugs covered through the gap. | |||||
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 Medicare y Mucho Mas - ELITE (HMO-POS). | |||||
You will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 930: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
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 plan's cost of the drug minus the following: | |||||
Tier 1: Preferred Generic Drugs | |||||
Tier 2: Preferred Brand Drugs | |||||
Tier 3: Non-Preferred Brand Drugs | |||||
Tier 4: Specialty Tier Drugs | |||||
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 $4 700 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: | |||||
You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
50% of the cost for Medicare-covered dental benefits | |||||
$5 copay for an office visit that includes: | |||||
Plan offers additional comprehensive dental benefits. | |||||
Hearing Services | |||||
Authorization rules may apply. | |||||
$0 copay for hearing aids. | |||||
$200 plan coverage limit for hearing aids every three years. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for | |||||
$225 plan coverage limit for eye wear every two years. | |||||
Plan offers additional vision benefits. Contact plan for details. | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 8 one-way trip(s) to any location every year | |||||
Acupuncture | |||||
Authorization rules may apply. | |||||
$15 copay per visit up to 10 visit(s). | |||||
Point of Service | |||||
Authorization rules may apply. | |||||
Point of Service coverage is available for the following benefits: | |||||
$10 000 plan coverage limit every year for the following POS Benefits: | |||||
20% of the cost per hospital stay. | |||||
20% of the cost per Inpatient Psychiatric Hospital stay. | |||||
20% of the cost for each SNF stay. | |||||
20% of the cost for | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 4: $25 copay per day | |||||
Days 5 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
$3 250 out-of-pocket limit every year. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
** 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. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$25 copay for each Medicare-covered ambulatory surgical center visit | |||||
$25 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% to 20% of the cost for Medicare-covered items | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
0% to 10% of the cost for Medicare-covered lab services | |||||
$0 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 copay for Medicare-covered X-rays | |||||
$0 to $40 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $0 to $15 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $15 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 8 one-way trip(s) to any location every year |