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

2012 Anthem Medicare Preferred Select (PPO) in Scott, Kentucky

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Anthem Medicare Preferred Select (PPO) (H5530 - 004) in Scott, Kentucky .

This plan is administered by ANTHEM HEALTH PLANS OF KENTUCKY, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Anthem Medicare Preferred Select (PPO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Anthem Medicare Preferred Select (PPO) has a monthly premium of $59.00. That is $708.00 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 $59.00 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 Local PPO plan.

Plan Membership and Plan Ratings
The Anthem Medicare Preferred Select (PPO) (H5530 - 004) currently has 3,372 members.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 2 stars. The detail CMS plan carrier ratings are as follows:
  • Customer Service Rating of 2 out of 5 stars
  • Member Experience Rating of 3 out of 5 stars
  • Drug Cost Information Accuracy Rating of 2 out of 5 stars
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $60 deductible. So, you are 100% responsible for the first $60 in medication costs. After you have met the deductible, the Anthem Medicare Preferred Select (PPO) will share the costs of your medications with you (see cost-sharing below). The maximum deductible for 2012 is $320, but this plan (Anthem Medicare Preferred Select (PPO)) has a $60. 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 following information is about the Anthem Medicare Preferred Select (PPO) formulary (or drug list). There are 4669 drugs on the Anthem Medicare Preferred Select (PPO) formulary. Click here to browse the Anthem Medicare Preferred Select (PPO) Formulary.
 
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 $60, 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 Anthem Medicare Preferred Select (PPO)’s formulary is divided into 6 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 contains 1,684 drugs and has a co-payment of $7.00.
  • Tier 2 contains 451 drugs and has a co-payment of $43.00.
  • Tier 3 contains 1,496 drugs and has a co-payment of $85.00.
  • Tier 4 contains 604 drugs and has a co-insurance of 33% of the drug cost.
  • Tier 5 contains 434 drugs and has a co-insurance of 33% of the drug cost.
  • Tier 6 contains drugs and has a co-payment of $7.00.
Click here to browse the Anthem Medicare Preferred Select (PPO) 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 14% 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 (Anthem Medicare Preferred Select (PPO)) offers Coverage for Many Generics during the Coverage Gap phase. This means that many (65% to 100%) of the generic drugs on the plans formulary (or drug list) and no brand-name drugs will be covered through the coverage gap (or donut hole).

The Anthem Medicare Preferred Select (PPO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **
Premium and Other Important Information
$59 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
$3 400 out-of-pocket limit for Medicare-covered services.
$3 400 out-of-pocket limit for Medicare-covered services.
** 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.
Plan covers you when you travel in the U.S.
** 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
$59 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
$3 400 out-of-pocket limit for Medicare-covered services.
$3 400 out-of-pocket limit for Medicare-covered services.
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.
Plan covers you when you travel in the U.S.
** 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 - 7: $175 copay per day
Days 8 - 90: $0 copay per day
$0 copay for additional hospital days
$1 225 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.
For hospital stays:
Days 1 - 7: $250 copay per day
Days 8 and beyond: $0 copay per day
Inpatient Mental Health Care
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.
For Medicare-covered hospital stays:
Days 1 - 7: $175 copay per day
Days 8 - 90: $0 copay per day
$0 copay for additional hospital days
The maximum out-of-pocket limit is covered under 'Inpatient Hospital Care'.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
For hospital stays:
Days 1 - 7: $250 copay per day
Days 8 and beyond: $0 copay per day
Skilled Nursing Facility (SNF)
Authorization rules may apply.
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: $146 copay per day
25% of the cost for each SNF stay.
Home Health Care
Authorization rules may apply.
$0 copay for each Medicare-covered home health visit
$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
$10 copay for each primary care doctor visit for Medicare-covered benefits.
$15 copay for each in-area network urgent care Medicare-covered visit
$15 copay for each specialist visit for Medicare-covered benefits.
$15 copay for each primary care doctor visit
$25 copay for each specialist visit
Chiropractic Services
Authorization rules may apply.
$10 copay 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.
$25 copay for chiropractic benefits.
Podiatry Services
$15 copay for each Medicare-covered visit
Medicare-covered podiatry benefits are for medically-necessary foot care.
$25 copay for podiatry benefits.
Outpatient Mental Health Care
Authorization rules may apply.
$40 copay for each Medicare-covered individual therapy visit
$40 copay for each Medicare-covered group therapy visit
$40 copay for each Medicare-covered individual therapy visit with a psychiatrist
$40 copay for each Medicare-covered group therapy visit with a psychiatrist
$40 copay for Medicare-covered partial hospitalization program services
$50 copay for Mental Health benefits with a psychiatrist
$50 copay for Mental Health benefits
$50 copay for partial hospitalization program services
Outpatient Substance Abuse Care
Authorization rules may apply.
$40 copay for Medicare-covered individual visits
$40 copay for Medicare-covered group visits
$50 copay for outpatient substance abuse benefits.
Outpatient Services/Surgery
Authorization rules may apply.
$0 to $150 copay for each Medicare-covered ambulatory surgical center visit
$0 to $150 copay for each Medicare-covered outpatient hospital facility visit
$25 to $225 copay for outpatient hospital facility benefits.
$225 copay for ambulatory surgical center benefits.
Ambulance Services
Authorization rules may apply.
$100 copay for Medicare-covered ambulance benefits.
$100 copay for ambulance benefits.
Emergency Care
$60 copay for Medicare-covered emergency room visits
Worldwide coverage.
If you are admitted to the hospital within 72-hour(s) for the same condition you pay $0 for the emergency room visit.
Urgently Needed Care
$15 copay for Medicare-covered urgently-needed-care visits
Outpatient Rehabilitation Services
Authorization rules may apply.
$30 copay for Medicare-covered Occupational Therapy visits
$30 copay for Medicare-covered Physical and/or Speech and Language Therapy visits
$50 copay for Physical and/or Speech and Language Therapy visits
$50 copay for Occupational Therapy benefits.
** Outpatient Medical Services and Supplies **
Durable Medical Equipment
Authorization rules may apply.
20% of the cost for Medicare-covered items
25% of the cost for durable medical equipment
Prosthetic Devices
Authorization rules may apply.
20% of the cost for Medicare-covered items
25% of the cost for prosthetic devices.
Diabetes Programs and Supplies
$0 copay for Diabetes self-management training
$0 copay for Diabetes monitoring supplies
$0 copay for Therapeutic shoes or inserts
$0 copay for Diabetes self-management training
25% of the cost for Diabetes monitoring supplies
25% 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
$0 to $125 copay for Medicare-covered diagnostic procedures and tests
$75 copay for Medicare-covered X-rays
$75 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays)
20% of the cost 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 $10 to $15 may apply
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $15 may apply
20% of the cost for therapeutic radiology services
25% of the cost for outpatient X-rays
25% of the cost for diagnostic radiology services
0% to 25% of the cost for diagnostic procedures tests and lab services
** Preventive Services **
Cardiac and Pulmonary Rehabilitation Services
$0 copay for Medicare-covered Cardiac Rehabilitation Services
$0 copay for Medicare-covered Intensive Cardiac Rehabilitation Services
$0 copay for Medicare-covered Pulmonary Rehabilitation Services
$0 copay for Cardiac Rehabilitation Services
$0 copay for Intensive Cardiac Rehabilitation Services
$0 copay 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:
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • $0 copay for Medicare-covered preventive services
    $0 copay for supplemental education/wellness programs
    Kidney Disease and Conditions
    20% of the cost 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
    20% 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 www.anthem.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) 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 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 Anthem Medicare Preferred Select (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.
    You pay $0 the first time you fill a prescription for certain drugs. These drugs will be listed as 'free first fill' on the plan?s website formulary printed materials and on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If you request a formulary exception for a drug and Anthem Medicare Preferred Select (PPO) approves the exception you will pay Tier 3: Non-Preferred Brand Drugs cost sharing for that drug.
    $60 deductible on all drugs except Tier 1: Generic Drugs Tier 4: Injectable Drugs Tier 5: Specialty Tier Drugs Tier 6: Supplemental Drugs.
    Supplemental drugs don't count toward your out-of-pocket drug costs.
    After you pay your yearly deductible you pay the following until total yearly drug costs reach $2 930:
    Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Injectable Drugs
    Tier 5: Specialty Tier Drugs
    Tier 6: Supplemental Drugs
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $43 copay for a one-month (30-day) supply of drugs in this tier
  • $85 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $21 copay for a three-month (90-day) supply of drugs in this tier
  • $129 copay for a three-month (90-day) supply of drugs in this tier
  • $255 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
  • $21 copay for a three-month (90-day) supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Injectable Drugs
    Tier 5: Specialty Tier Drugs
    Tier 6: Supplemental Drugs
  • $7 copay for a one-month (34-day) supply of drugs in this tier
  • $43 copay for a one-month (34-day) supply of drugs in this tier
  • $85 copay for a one-month (34-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (34-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (34-day) supply of drugs in this tier
  • $7 copay for a one-month (34-day) supply of drugs in this tier
    • Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Injectable Drugs
    Tier 5: Specialty Tier Drugs
    Tier 6: Supplemental Drugs
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $10.50 copay for a three-month (90-day) supply of drugs in this tier
  • $107.50 copay for a three-month (90-day) supply of drugs in this tier
  • $212.50 copay for a three-month (90-day) supply of drugs in this tier
  • 33% coinsurance for a three-month (90-day) supply of drugs in this tier
  • $10.50 copay for a three-month (90-day) supply of drugs in this tier
    • The plan covers many formulary generics (65%-99% of formulary generic drugs) through the coverage gap.
    You pay the following:
    Tier 1: Generic Drugs
    Tier 6: Supplemental Drugs
  • $7 copay for a one-month (30-day) supply of all drugs covered in this tier
  • $7 copay for a one-month (30-day) supply of all drugs covered in this tier
  • $21 copay for a three-month (90-day) supply of all drugs covered in this tier
  • $21 copay for a three-month (90-day) supply of all drugs covered in this tier
    • Tier 1: Generic Drugs
    Tier 6: Supplemental Drugs
  • $7 copay for a one-month (34-day) supply of all drugs covered in this tier
  • $7 copay for a one-month (34-day) supply of all drugs covered in this tier
    • Tier 1: Generic Drugs
    Tier 6: Supplemental Drugs
  • $10.50 copay for a three-month (90-day) supply of all drugs covered in this tier
  • $10.50 copay for a three-month (90-day) supply of all drugs covered in this tier
    • 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.
    Tier 6: Supplemental Drugs
    After your yearly out-of-pocket drug costs reach $4 700 you pay the greater of:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
  • $7 copay for drugs in this tier
    • 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 Anthem Medicare Preferred Select (PPO).
    After you pay your yearly deductible you will be reimbursed up to the plan's cost of the drug minus the following for drugs purchased out-of-network until your total yearly drug costs reach $2 930:
    Tier 1: Generic Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Injectable Drugs
    Tier 5: Specialty Tier Drugs
    Tier 6: Supplemental Drugs
  • $7 copay for a one-month (30-day) supply of drugs in this tier
  • $43 copay for a one-month (30-day) supply of drugs in this tier
  • $85 copay for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier
  • $7 copay for a one-month (30-day) supply of drugs in this tier
    • 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: Generic Drugs
    Tier 6: Supplemental Drugs
    Tier 2: Preferred Brand Drugs
    Tier 3: Non-Preferred Brand Drugs
    Tier 4: Injectable Drugs
    Tier 5: Specialty Tier Drugs
  • $7 copay for a one-month (30-day) supply of all drugs covered in this tier
  • $7 copay for a one-month (30-day) supply of all drugs covered in this tier
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until 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 total yearly out-of-pocket drug costs reach $4 700.
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until 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 total yearly out-of-pocket drug costs reach $4 700.
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until 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 total yearly out-of-pocket drug costs reach $4 700.
  • You will be reimbursed up to 14% of the plan allowable cost for generic drugs purchased out-of-network until 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 total yearly out-of-pocket drug costs reach $4 700.
    • 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:
  • 5% coinsurance or
  • $2.60 copay for generic (including brand drugs treated as generic) and a $6.50 copay for all other drugs.
    • You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan's In-Network allowable amount.
    Tier 6: Supplemental Drugs
  • $7 copay for drugs in this tier
    • Dental Services
    $0 copay for Medicare-covered dental benefits
    $0 copay for an office visit that includes:
  • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
    • $0 copay for comprehensive dental benefits
    20% of the cost for preventive dental benefits
    20% of the cost for preventive dental benefits
    Hearing Services
    Hearing aids not covered.
  • $15 copay for Medicare-covered diagnostic hearing exams
  • $15 copay for up to 1 supplemental routine hearing exam(s) every year
    • $25 copay for hearing exams.
    $100 plan coverage limit for supplemental routine hearing exams every year. This limit applies to both in-network and out-of-network benefits.
    ** Additional Benefits **
    Vision Services
  • $0 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
  • $0 copay for up to 1 pair(s) of glasses every year
  • $0 copay for up to 1 pair(s) of contacts every year
    • $160 plan coverage limit for eye glasses (lenses and frames) every year.
    $80 plan coverage limit for contact lenses every year.
    $0 copay for eye exams.
    $0 copay for eye wear.
    $69 plan coverage limit for supplemental routine eye exams every year. This limit applies to both in-network and out-of-network benefits.
    $160 plan coverage limit for eye glasses (lenses and frames) every year. This limit applies to both in-network and out-of-network benefits.
    $80 plan coverage limit for contact lenses 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
    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.
    For Medicare-covered hospital stays:
    Days 1 - 7: $175 copay per day
    Days 8 - 90: $0 copay per day
    $0 copay for additional hospital days
    $1 225 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.
    For hospital stays:
    Days 1 - 7: $250 copay per day
    Days 8 and beyond: $0 copay per day
    ** Outpatient Care **
    Doctor Office Visits
    $10 copay for each primary care doctor visit for Medicare-covered benefits.
    $15 copay for each in-area network urgent care Medicare-covered visit
    $15 copay for each specialist visit for Medicare-covered benefits.
    $15 copay for each primary care doctor visit
    $25 copay for each specialist visit
    Outpatient Services/Surgery
    Authorization rules may apply.
    $0 to $150 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $150 copay for each Medicare-covered outpatient hospital facility visit
    $25 to $225 copay for outpatient hospital facility benefits.
    $225 copay for ambulatory surgical center benefits.
    Ambulance Services
    Authorization rules may apply.
    $100 copay for Medicare-covered ambulance benefits.
    $100 copay for ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered items
    25% 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
    $0 to $125 copay for Medicare-covered diagnostic procedures and tests
    $75 copay for Medicare-covered X-rays
    $75 to $125 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost 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 $10 to $15 may apply
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $10 to $15 may apply
    20% of the cost for therapeutic radiology services
    25% of the cost for outpatient X-rays
    25% of the cost for diagnostic radiology services
    0% to 25% 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
    This plan does not cover supplemental routine transportation.




    Medicare Supplements
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    Original Medicare
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    » Medicare Supplement FAQs





    Pets are Family Too!
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    » Learn more about savings on Pet Medications
    • No enrollment fee and no limits on usage
    • Everyone in your household can use the same card, including your pets
    Your drug discount card is available to you at no cost.


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    Tips & Disclaimers
    • Q1Medicare®, Q1Rx®, and Q1Group® are registered Service Marks of Q1Group LLC and may not be used in any advertising, publicity, or for commercial purposes without the express authorization of Q1Group.
    • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
    • Medicare has neither reviewed nor endorsed the information on our site.
    • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
    • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
    • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDPCompare.com and MACompare.com provide highlights of annual plan benefit changes.
    • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
    • Limitations, copayments, and restrictions may apply.
    • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
      Statement required by Medicare:
      "We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options."
    • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
    • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
    • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
    • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
    • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
    • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
    • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
    • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
    • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
    • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
    • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
    • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
    .