2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Premier Preferred (HMO SNP) | ||||
Location: | Loiza, Puerto Rico Click to see other locations | ||||
Plan ID: | H4004 - 048 - 0 Click to see other plans | ||||
Member Services: | 1-866-516-7700 TTY users 1-866-516-7701 | ||||
— 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 Premier Preferred (HMO SNP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) | ||||
Annual Deductible: | $0 for people who qualify for both Medicare and Medicaid. | ||||
Annual Initial Coverage Limit (ICL): | $2,930 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Dual-Eligible | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 2,669 drugs | Browse the Premier Preferred (HMO SNP) Formulary | |||
This plan has 2 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: | 15% | 15% | |||
• Number of Drugs per Tier: | 1820 | 567 | |||
Plan's Pharmacy Search: | http://www.pmcpr.org | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H4004 - 048): | 29,213 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 | |||||
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services | |||||
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* | |||||
Preferred Medicare Choice Inc. will reduce your monthly Medicare Part B premium by up to $ 15.00. | |||||
$3 250 out-of-pocket limit. All plan services included.* | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
Referral required for network specialists (for certain benefits). | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services | |||||
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* | |||||
Preferred Medicare Choice Inc. will reduce your monthly Medicare Part B premium by up to $ 15.00. | |||||
$3 250 out-of-pocket limit. All plan services included.* | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
Referral required for network specialists (for certain benefits). | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
$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 | |||||
$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. | |||||
$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. | |||||
$0 copay for SNF services | |||||
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.* | |||||
$0 copay for each specialist doctor visit for Medicare-covered benefits.* | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered chiropractic 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. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered podiatry benefits.* | |||||
up to 1 supplemental routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Mental Health visits* | |||||
$0 copay for Medicare-covered partial hospitalization program services* | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered visits* | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit* | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit* | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered ambulance benefits.* | |||||
Emergency Care | |||||
$0 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. | |||||
$0 copay for Medicare-covered Occupational Therapy visits* | |||||
$0 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% or 0% to 20% of the cost for Medicare-covered items* | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
0% or 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% or 0% to 20% of the cost for Diabetes monitoring supplies* | |||||
0% or 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 copay for Medicare-covered: | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$0 copay for: | |||||
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. | |||||
$0 annual deductible for Part B-covered drugs.* | |||||
$0 copay 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.pmcpr.org 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 you the plan and Medicare. | |||||
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 Premier Preferred (HMO SNP) 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. | |||||
In 2012 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) $0 for prescription drugs Deductible Level 1 (Low Income Threshold 51% - 100%) $0.50 for prescription drugs | |||||
You can get drugs the following way(s): | |||||
Not all drugs are available at this extended day supply. Please contact the plan for more information. | |||||
You can get drugs the following way(s): | |||||
You can get drugs the following way(s): | |||||
Not all drugs are available at this extended day supply. Please contact the plan for more information. | |||||
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 Premier Preferred (HMO SNP). | |||||
You can get drugs the following way: | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
$0 copay for the following preventive dental benefits: | |||||
0% of the cost for Medicare-covered dental benefits* | |||||
Plan offers additional comprehensive dental benefits. | |||||
$500 plan coverage limit for comprehensive dental benefits every year | |||||
Hearing Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered diagnostic hearing exams* | |||||
$0 copay for | |||||
$0 copay for hearing aids. | |||||
$200 plan coverage limit for hearing aids every three years. | |||||
** 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 | |||||
$190 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 | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
$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.* | |||||
$0 copay for each specialist doctor visit for Medicare-covered benefits.* | |||||
Outpatient Services/Surgery | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit* | |||||
$0 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% or 0% to 20% of the cost for Medicare-covered items* | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. |