2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Fidelis Secure Liberty (HMO SNP) | ||||
Location: | Macomb, Michigan Click to see other locations | ||||
Plan ID: | H2323 - 012 - 0 Click to see other plans | ||||
Member Services: | 1-877-372-8085 TTY users 1-888-844-5530 | ||||
— 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 Fidelis Secure Liberty (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): | $2,970 | ||||
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: | 3,800 drugs | Browse the Fidelis Secure Liberty (HMO SNP) 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: | 1798 | 531 | 1050 | 456 | |
Plan's Pharmacy Search: | http://www.fidelissc.com/pharmacy/index.asp | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in (H2323 - 012): | 541 members | ||||
Plan’s Summary Star Rating: | Insufficient data to rate this plan. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• 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 | |||||
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* | |||||
$6 700 out-of-pocket limit. All plan services included.* | |||||
$325 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 12 round trip(s) to plan-approved location every year | |||||
** 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 | |||||
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* | |||||
$6 700 out-of-pocket limit. All plan services included.* | |||||
$325 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
Plan covers 90 days each benefit period. | |||||
You will not be charged additional cost sharing for professional services. | |||||
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. | |||||
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. | |||||
You will not be charged additional cost sharing for professional 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 | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered primary care doctor visit.* | |||||
0% or 20% of the cost for each Medicare-covered specialist visit.* | |||||
Chiropractic Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost 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. | |||||
0% or 20% of the cost for each Medicare-covered podiatry visit* | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for each Medicare-covered individual therapy visit* | |||||
0% or 20% of the cost for each Medicare-covered group therapy visit* | |||||
0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist* | |||||
0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist* | |||||
0% or 20% of the cost for Medicare-covered partial hospitalization program services* | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits* | |||||
0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits* | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* | |||||
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered ambulance benefits.* | |||||
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits* | |||||
Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. | |||||
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% or 20% of the cost 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. | |||||
0% or 20% of the cost for Medicare-covered Occupational Therapy visits* | |||||
0% or 20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered durable medical equipment* | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
0% or 20% 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* | |||||
0% or 20% of the cost for Medicare-covered Diabetes monitoring supplies* | |||||
0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts* | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered lab services* | |||||
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests* | |||||
0% or 20% of the cost for Medicare-covered X-rays* | |||||
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* | |||||
0% or 20% of the cost for Medicare-covered therapeutic radiology services* | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services* | |||||
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* | |||||
0% or 20% of the cost 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. | |||||
This plan does not cover supplemental education/wellness programs. | |||||
$0 copay for Additional Rehabilitation Services. Contact plan for details. | |||||
$0 copay for Personal Emergency Response System. Contact plan for details. | |||||
Kidney Disease and Conditions | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered renal dialysis* | |||||
$0 copay for Medicare-covered kidney disease education services* | |||||
Outpatient Prescription Drugs | |||||
$0 yearly deductible for Medicare Part B drugs.* | |||||
0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.* | |||||
$0 copay for home infusion drugs that would normally be covered under Part D. This cost-sharing amount will also cover the supplies and services associated with home infusion of these drugs. | |||||
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.fidelissc.com/pdfs/2012/mi/2012_Liberty_and_Liberty_Select_Formulary_MI_only.pdf on the web. | |||||
Different out-of-pocket costs may apply for people who
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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 Fidelis Secure Liberty (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. | |||||
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:
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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 yearly out-of-pocket drug costs reach $4 750 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 Fidelis Secure Liberty (HMO SNP). | |||||
You can get out-of-network drugs the following way: | |||||
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Depending on your income and institutional status you will be reimbursed by Fidelis Secure Liberty (HMO 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:
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After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits* | |||||
$0 copay for the following preventive dental benefits: | |||||
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Plan offers additional comprehensive dental benefits. | |||||
$400 plan coverage limit for dental benefits every year | |||||
Hearing Services | |||||
$0 copay for: | |||||
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$0 copay for hearing aids. | |||||
0% or 20% of the cost for Medicare-covered diagnostic hearing exams* | |||||
$325 plan coverage limit for supplemental routine hearing exams. | |||||
$325 plan coverage limit for hearing aids. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for
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$325 plan coverage limit for eye exams | |||||
$325 plan coverage limit for eye wear | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 12 round trip(s) to plan-approved location every year | |||||
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. | |||||
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. | |||||
$0 copay for each Medicare-covered primary care doctor visit.* | |||||
0% or 20% of the cost for each Medicare-covered specialist visit.* | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit* | |||||
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit* | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost 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. | |||||
0% or 20% of the cost for Medicare-covered durable medical equipment* | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
0% or 20% of the cost for Medicare-covered lab services* | |||||
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests* | |||||
0% or 20% of the cost for Medicare-covered X-rays* | |||||
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* | |||||
0% or 20% of the cost for Medicare-covered therapeutic radiology services* | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 12 round trip(s) to plan-approved location every year |