2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | SeniorCare Sr VIP - Value Rx (Cost) | ||||
Location: | Bosque, Texas Click to see other locations | ||||
Plan ID: | H4564 - 019 - 0 Click to see other plans | ||||
Member Services: | 1-866-334-3141 TTY users 1-800-735-2989 | ||||
— 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 SeniorCare Sr VIP - Value Rx (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $193.90 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $325 | ||||
Annual Rx Initial Coverage Limit (ICL): | $2,970 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 2,880 drugs | Browse the SeniorCare Sr VIP - Value Rx (Cost) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | 25% | 25% | 25% | 25% | |
• Number of Drugs per Tier: | 1722 | 486 | 458 | 214 | |
Plan's Pharmacy Search: | http://www.swhp.org | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H4564 - 019): | less than 10 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 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 | |||||
$193.9 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 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. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
Referral required for network hospitals and specialists (for certain benefits). | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** 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 | |||||
$193.9 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 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. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
Doctor and Hospital Choice | |||||
Referral required for network hospitals and specialists (for certain benefits). | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$100 copay for each Medicare-covered hospital stay | |||||
$0 copay for additional hospital days | |||||
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. | |||||
$100 copay for each Medicare-covered hospital stay. | |||||
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 | |||||
For Medicare-covered SNF stays: | |||||
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Home Health Care | |||||
$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 | |||||
Authorization rules may apply. | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$5 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
$5 copay for each Medicare-covered chiropractic 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. | |||||
Podiatry Services | |||||
Authorization rules may apply. | |||||
$5 copay for each Medicare-covered podiatry visit | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$5 copay for each Medicare-covered individual therapy visit | |||||
$5 copay for each Medicare-covered group therapy visit | |||||
$5 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$5 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$5 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$5 copay for Medicare-covered individual substance abuse outpatient treatment visits | |||||
$5 copay for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$50 copay for each Medicare-covered ambulatory surgical center visit | |||||
$5 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$50 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$100 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 | |||||
$40 copay for Medicare-covered urgently-needed-care visits | |||||
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. | |||||
$5 copay for Medicare-covered Occupational Therapy visits | |||||
$5 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered prosthetic devices | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
10% of the cost for Medicare-covered Diabetes monitoring supplies | |||||
10% of the cost for Medicare-covered Therapeutic shoes or inserts | |||||
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $5 may apply | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 to $5 copay for Medicare-covered lab services | |||||
$0 to $5 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 to $5 copay for Medicare-covered X-rays | |||||
$0 to $5 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 to $5 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 $5 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$5 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$5 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$5 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. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. | |||||
$5 copay for an annual physical exam | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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Kidney Disease and Conditions | |||||
Authorization rules may apply. | |||||
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. | |||||
$5 copay for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
$0 copay for Medicare Part B drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.swhp.org on the web. | |||||
Different out-of-pocket costs may apply for people who
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Your in-network prescription coverage may be limited to the plan’s service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. | |||||
Total yearly drug costs are the total drug costs paid by both you and a Part D plan. | |||||
Some drugs have quantity limits. | |||||
Your provider must get prior authorization from SeniorCare Sr VIP - Value Rx (Cost) 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. | |||||
$325 annual deductible. | |||||
After you pay your yearly deductible you pay 25% until total yearly drug costs reach $2 970. | |||||
You can get drugs the following way(s): | |||||
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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): | |||||
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Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. | |||||
You can get drugs the following way(s): | |||||
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Not all drugs are available at this extended day supply. Please contact the plan for more information. | |||||
After your total yearly drug costs reach $2 970 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 47.5% for the plan’s costs for brand drugs and 79% of the plan’s costs for generic drugs until your yearly out-of-pocket drug costs reach $4 750. | |||||
After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
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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 SeniorCare Sr VIP - Value Rx (Cost). | |||||
You can get out-of-network drugs the following way: | |||||
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After you pay your yearly deductible you will be reimbursed up to 75% of the actual cost for drugs purchased out-of-network until your total yearly drug costs reach $2 970. | |||||
You will be reimbursed up to 21% of the plan allowable cost for generic drugs purchased out-of-network until total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). You will be reimbursed up to 52.5% of the plan allowable cost for brand name drugs purchased out-of-network until your total yearly out-of-pocket drug costs reach $4 750. Please note that the plan allowable cost may be less than the out-of-network pharmacy price paid for your drug(s). | |||||
After your yearly out-of-pocket drug costs reach $4 750 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:
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Dental Services | |||||
$0 copay for Medicare-covered dental benefits | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
Hearing Services | |||||
Authorization rules may apply. | |||||
Hearing aids not covered. | |||||
$5 copay for Medicare-covered diagnostic hearing exams | |||||
$5 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
Authorization rules may apply. | |||||
$0 copay for
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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. | |||||
$100 copay for each Medicare-covered hospital stay | |||||
$0 copay for additional hospital days | |||||
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 | |||||
Authorization rules may apply. | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$5 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$50 copay for each Medicare-covered ambulatory surgical center visit | |||||
$5 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$50 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
10% of the cost for Medicare-covered durable medical equipment | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 to $5 copay for Medicare-covered lab services | |||||
$0 to $5 copay for Medicare-covered diagnostic procedures and tests | |||||
$0 to $5 copay for Medicare-covered X-rays | |||||
$0 to $5 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 to $5 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 $5 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. |