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2012 Medicare Advantage Plan Benefit Details for the Care Improvement Plus Dual Advantage (Regional PPO SNP) - R3444-011-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2012 Medicare Advantage Plan Details
Medicare Plan Name:Care Improvement Plus Dual Advantage (Regional PPO SNP)
Location:Taney, Missouri     Click to see other locations
Plan ID:R3444 - 011 - 0     Click to see other plans
Member Services:1-800-204-1002 TTY users 711
— 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
Email a copy of the Care Improvement Plus Dual Advantage (Regional PPO 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:Regional PPO
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:3,412 drugsBrowse the Care Improvement Plus Dual Advantage (Regional PPO SNP) Formulary
This plan has 4 drug tiers. See cost-sharing highlights below.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$10.00$45.00$95.0027% 
• Number of Drugs per
  Tier:		2008933196275
Plan's Pharmacy Search:http://www.careimprovementplus.com/members/formulary--medicare-drug-plan-coverage.aspx
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in (R3444 - 011):10,356 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 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*
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
$0 annual deductible.*
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
$0 annual deductible.**
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.**
$0 annual deductible.*
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
Referral required for network specialists (for certain benefits).
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
Authorization rules may apply.
$0 copay for up to 34 one-way trip(s) to plan approved location every year
$0 copay for 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*
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
$0 annual deductible.*
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
$0 annual deductible.**
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.**
$0 annual deductible.*
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
Doctor and Hospital Choice
Referral required for network specialists (for certain benefits).
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
Plan covers 90 days each benefit period.
You will not be charged additional cost sharing for professional services
$0 annual deductible*
$0 copay*
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.
$0 annual deductible*
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care')
Skilled Nursing Facility (SNF)
Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
$0 annual deductible*
$0 copay for SNF services*
You will not be charged additional cost sharing for professional services
For Non-Medicare Supplemental SNF stays: Days 1 - 20: $___ per day Days 21 - 100: $___ per day
Home Health Care
Authorization rules may apply.
$0 copay for Medicare-covered home health visits*
$0 copay 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*
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
Authorization rules may apply.
$0 copay for Medicare-covered Mental Health visits*
$0 copay for each Medicare-covered visit with a psychiatrist*
$0 copay for Medicare-covered partial hospitalization program services*
40% of the cost for Mental Health benefits with a psychiatrist**
40% 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*
40% of the cost for outpatient substance abuse 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*
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*
Worldwide coverage.
If you are admitted to the hospital within 24-hour(s) 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.
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits.
$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
Authorization rules may apply.
$0 copay for Medicare-covered items*
20% of the cost for durable medical equipment**
Prosthetic Devices
Authorization rules may apply.
$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:
  • Diabetes monitoring supplies*
  • Therapeutic shoes or inserts*
    • $0 copay 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'
    Authorization rules may apply.
    $0 copay for Medicare-covered:
  • lab services*
  • diagnostic procedures and tests*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • therapeutic radiology services*
    • 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
    Authorization rules may apply.
    $0 copay for:
  • Medicare-covered Cardiac Rehabilitation Services*
  • Medicare-covered Intensive Cardiac Rehabilitation Services*
  • Medicare-covered Pulmonary Rehabilitation Services*
    • 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:
  • Abdominal Aortic Aneurysm screening
  • Bone Mass Measurement
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine
  • HIV Screening
  • Breast Cancer Screening (Mammogram)
  • Medical Nutrition Therapy Services
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine
  • Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
  • Smoking Cessation (Counseling to stop smoking)
  • Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
    • 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:
  • Written health education materials including Newsletters
  • Additional Smoking Cessation
  • Nursing Hotline
    • $0 copay for Medicare-covered preventive services**
    $0 copay for supplemental education/wellness programs
    Kidney Disease and Conditions
    $0 copay for renal dialysis*
    $0 copay for kidney disease education services*
    $0 copay for kidney disease education services**
    20% of the cost for renal dialysis**
    Outpatient Prescription Drugs
    $0 annual deductible for Part B-covered drugs.*
    $0 copay 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.careimprovementplus.com/members/formulary--medicare-drug-plan-coverage.aspx 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) providers.
    • 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 Care Improvement Plus Dual Advantage (Regional PPO 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.
    If you request a formulary exception for a drug and Care Improvement Plus Dual Advantage (Regional PPO SNP) approves the exception you will pay the generic cost share for generic drugs and the brand cost share for brand drugs.
    You pay a $0 annual deductible.
    Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.10 copay or
  • A $2.60 copay For all other drugs either:
  • A $0 copay or
  • A $3.30 copay or
  • A $6.50 copay.
    • You pay a $0 copay.
    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 Care Improvement Plus Dual Advantage (Regional PPO SNP).
    Depending on your income and institutional status you will be reimbursed by Care Improvement Plus Dual Advantage (Regional PPO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.10 copay or
  • A $2.60 copay For all other drugs purchased out-of-network either:
  • A $0 copay or
  • A $3.30 copay or
  • A $6.50 copay.
    • You will be reimbursed in full for drugs purchased out-of-network.
    Dental Services
    Authorization rules may apply.
    $0 copay for Medicare-covered dental benefits*
    $0 copay for an office visit that includes:
  • up to 1 oral exam(s) every year
  • up to 1 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • 20% of the cost for comprehensive dental benefits**
    $0 copay for preventive dental benefits
    Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits.
    Hearing Services
    In general supplemental routine hearing exams and hearing aids not covered.
    $0 copay for Medicare-covered diagnostic hearing exams*
    20% of the cost for hearing exams.**
    ** Additional Benefits **
    Vision Services
    $0 copay for diagnosis and treatment for diseases and conditions of the eye*
    $0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery *
  • 0% of the cost for up to 1 supplemental routine eye exam(s) every year
  • 0% of the cost for glasses
  • 0% of the cost for contacts
    • 20% of the cost for eye exams.**
    0% to 20% of the cost for eye wear.**
    $200 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
    Authorization rules may apply.
    $0 copay for up to 34 one-way trip(s) to plan approved location every year
    $0 copay for transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    ** Inpatient Care **
    Inpatient Hospital Care
    Plan covers 90 days each benefit period.
    You will not be charged additional cost sharing for professional services
    $0 annual deductible*
    $0 copay*
    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.*
    20% of the cost for each primary care doctor visit**
    20% of the cost for each specialist visit**
    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*
    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
    Authorization rules may apply.
    $0 copay for Medicare-covered items*
    20% of the cost for durable medical equipment**
    'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services'
    Authorization rules may apply.
    $0 copay for Medicare-covered:
  • lab services*
  • diagnostic procedures and tests*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • therapeutic radiology services*
    • 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
    Authorization rules may apply.
    $0 copay for up to 34 one-way trip(s) to plan approved location every year
    $0 copay for transportation.




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