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2013 Medicare Advantage Plan Benefit Details for the Humana Gold Plus H6622-003 (HMO-POS)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2013 Medicare Advantage Plan Details
Medicare Plan Name:Humana Gold Plus H6622-003 (HMO-POS)
Location:Jackson, Wisconsin     Click to see other locations
Plan ID:H6622 - 003 - 0     Click to see other plans
Member Services:1-800-457-4708 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 Humana Gold Plus H6622-003 (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$32.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,970
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Additional Gap Coverage?Few Generics,
Few Brands
Total Number of Formulary Drugs:3,906 drugsBrowse the Humana Gold Plus H6622-003 (HMO-POS) 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:		$5.00$40.00$80.0033% 
• Number of Drugs per
  Tier:		11998671495373
Plan's Pharmacy Search:http://www.humana.com/Medicare/medicare_prescription_drugs
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in (H6622 - 003):1,133 members
Plan’s Summary Star Rating: 5 out of 5 Stars.  
This plan qualifies for the 5-star rating Special Enrollment period. Read more.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 4 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
$32 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.
$6 700 out-of-pocket limit for Medicare-covered services.
$6 700 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.
** 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.
Point of Service
Authorization rules may apply.
Point of Service coverage is available for the following benefits:
Medicare-covered
  • Inpatient Hospital Acute
  • Inpatient Hospital Psychiatric
  • Skilled Nursing Facility (SNF)
  • Cardiac Rehabilitation Services
  • Intensive Cardiac Rehabilitation Services
  • Pulmonary Rehabilitation Services
  • Partial Hospitalization
  • Home Health Services
  • Primary Care Physician Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Other Health Care Professional
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
Supplemental
  • Outpatient Blood Services
  • Over-the-Counter (OTC) Items
  • Meal Benefit
  • Annual Physical Exam
  • Supplemental Education/Wellness Programs
  • Eye Exams
You may need a referral for the following Point-of-service benefits:
Medicare-covered
  • Inpatient Hospital Acute
  • Inpatient Hospital Psychiatric
  • Skilled Nursing Facility (SNF)
  • Partial Hospitalization
  • Home Health Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
  • Outpatient Substance Abuse
  • Outpatient Blood Services
  • Ambulance Services
  • End-Stage Renal Disease
  • Diabetes Self-Management Training
  • Comprehensive Dental
  • Eye Ex
50% of the cost per hospital stay.
50% of the cost per Inpatient Psychiatric Hospital stay.
50% of the cost for each SNF stay.
50% of the cost for Medicare-covered
  • Cardiac Rehabilitation Services
  • Intensive Cardiac Rehabilitation Services
  • Pulmonary Rehabilitation Services
  • Partial Hospitalization
  • Home Health Services
  • Primary Care Physician Services
  • Chiropractic Services
  • Occupational Therapy Services
  • Physician Specialist Services
  • Mental Health Specialty Services
  • Podiatry Services
  • Other Health Care Professional
  • Psychiatric Services
  • Physical Therapy and Speech-Language Pathology Services
  • Outpatient Diagnostic Procedures/Tests/Lab Services
  • Diagnostic Radiological Services
  • Therapeutic Radiological Services
  • Outpatient X-Rays
  • Outpatient Hospital Services
  • Ambulatory Surgical Center (ASC) Services
  • Outpatient Substance Abuse
  • Durable Medical Equipment (DME)
  • Prostheti
$200 copay for Medicare-covered
  • Ambulance Services
20% of the cost for Medicare-covered
  • End-Stage Renal Disease
$0 copay for Medicare-covered
  • Outpatient Blood Services
  • Eye Wear
Supplemental
  • Outpatient Blood Services
  • Eye Exams
0% to 50% of the cost for Medicare-covered
  • Medicare-covered Preventive Services
Transportation
This plan does not cover supplemental routine transportation.
** Important Information **
Premium and Other Important Information
$32 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.
$6 700 out-of-pocket limit for Medicare-covered services.
$6 700 out-of-pocket limit for Medicare-covered services.
Doctor and Hospital Choice
No referral required for network doctors specialists and hospitals.
** 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: $255 copay per day
  • Days 8 - 60: $0 copay per day
  • Days 61 - 90: $100 copay per day
    • $0 copay for each additional hospital day.
    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.
    For Medicare-covered hospital stays:
    • Days 1 - 7: $205 copay per day
  • Days 8 - 90: $0 copay per day
    • 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.
    For SNF stays:
    • Days 1 - 20: $50 copay per day
  • Days 21 - 100: $150 copay per day
    • 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.
    $5 copay for each Medicare-covered primary care doctor visit.
    $35 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    Authorization rules may apply.
    $20 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.
    $35 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.
    $35 copay for each Medicare-covered individual therapy visit
    $35 copay for each Medicare-covered group therapy visit
    $35 copay for each Medicare-covered individual therapy visit with a psychiatrist
    $35 copay for each Medicare-covered group therapy visit with a psychiatrist
    $35 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $100 copay for Medicare-covered individual substance abuse outpatient treatment visits
    $100 copay for Medicare-covered group substance abuse outpatient treatment visits
    Outpatient Services
    Authorization rules may apply.
    $205 copay for each Medicare-covered ambulatory surgical center visit
    $5 to $255 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $200 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $65 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
    50% of the cost for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $35 copay for Medicare-covered Occupational Therapy visits
    $35 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.
    20% of the cost for Medicare-covered durable medical equipment
    You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
    Prosthetic Devices
    Authorization rules may apply.
    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% to 20% of the cost for Medicare-covered Diabetes monitoring supplies
    0% of the cost for Medicare-covered Therapeutic shoes or inserts
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 to $35 copay for Medicare-covered lab services
    $0 to $35 copay for Medicare-covered diagnostic procedures and tests
    $5 to $35 copay for Medicare-covered X-rays
    $5 to $255 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost for Medicare-covered therapeutic radiology services
    ** 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
    $35 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.
    $0 copay for an annual physical exam
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • Nursing Hotline
    • Kidney Disease and Conditions
    Authorization rules may apply.
    20% of the cost for Medicare-covered renal dialysis
    $0 copay for Medicare-covered kidney disease education services
    Outpatient Prescription Drugs
    20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.humana.com/members/tools/prescription_tools/medicare_drug_list.asp 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 Humana Gold Plus H6622-003 (HMO-POS) 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.
    The plan charges a minimum cost sharing amount for certain low-cost drugs.
    If you request a formulary exception for a drug and Humana Gold Plus H6622-003 (HMO-POS) approves the exception you will pay Tier 3: Non-Preferred Brand cost sharing for that drug.
    $0 deductible.
    You pay the following until total yearly drug costs reach $2 970:
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 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
  • $15 copay for a three-month (90-day) supply of drugs in this tier
  • $120 copay for a three-month (90-day) supply of drugs in this tier
  • $240 copay for a three-month (90-day) supply of drugs in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (31-day) supply of drugs in this tier
  • $40 copay for a one-month (31-day) supply of drugs in this tier
  • $80 copay for a one-month (31-day) supply of drugs in this tier
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
    • 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.
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $0 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $0 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $110 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $230 copay for a three-month (90-day) supply of drugs in this tier from a preferred mail order pharmacy.
  • $5 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $40 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $80 copay for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • 33% coinsurance for a one-month (30-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $15 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $120 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
  • $240 copay for a three-month (90-day) supply of drugs in this tier from a non-preferred mail order pharmacy.
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier 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.
    The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
    The plan offers additional coverage in the gap for the following tiers. You pay the following:
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $80 copay for a one-month (30-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier
  • $120 copay for a three-month (90-day) supply of select drugs covered in this tier
  • $240 copay for a three-month (90-day) supply of select drugs covered in this tier
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (31-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (31-day) supply of select drugs covered in this tier
  • $80 copay for a one-month (31-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (31-day) supply of select drugs covered in this tier
    • 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.
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $0 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $80 copay for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $0 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $110 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $230 copay for a three-month (90-day) supply of select drugs covered in this tier from a preferred mail order pharmacy
  • $5 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $80 copay for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $15 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $120 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
  • $240 copay for a three-month (90-day) supply of select drugs covered in this tier from a non-preferred mail order pharmacy
    • Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Not all drugs on this tier are available at this extended day supply. Please contact the plan for more information.
    Please contact the plan for a complete list of drugs covered through the gap.
    After your yearly out-of-pocket drug costs reach $4 750 you pay the greater of:
    • 5% coinsurance or
    • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copay for all other drugs.
    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 Humana Gold Plus H6622-003 (HMO-POS).
    You will be reimbursed up to the plan’s cost of the drug minus the following for drugs purchased out-of-network until total yearly drug costs reach $2 970:
    Tier 1: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (30-day) supply of drugs in this tier
  • $40 copay for a one-month (30-day) supply of drugs in this tier
  • $80 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
    • 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 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).
    The plan covers few formulary generics (less than 10% of formulary generic drugs) few formulary brands (less than 10% of formulary brand drugs) through the coverage gap.
    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: Preferred Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $5 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $40 copay for a one-month (30-day) supply of select drugs covered in this tier
  • $80 copay for a one-month (30-day) supply of select drugs covered in this tier
  • 33% coinsurance for a one-month (30-day) supply of select drugs covered 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.
    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:
    • 5% coinsurance or
    • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 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.
    Dental Services
    This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.")
    $35 copay for Medicare-covered dental benefits
    Hearing Services
    Authorization rules may apply.
    In general supplemental routine hearing exams and hearing aids not covered.
    $35 copay for Medicare-covered diagnostic hearing exams
    ** Additional Benefits **
    Vision Services
    $0 copay for
    • one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
    • $0 to $35 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
    • $40 plan coverage limit for eye exams every year.
    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
    This plan does not cover supplemental routine transportation.
    Acupuncture
    This plan does not cover Acupuncture.
    Point of Service
    Authorization rules may apply.
    Point of Service coverage is available for the following benefits:
    Medicare-covered
    • Inpatient Hospital Acute
    • Inpatient Hospital Psychiatric
    • Skilled Nursing Facility (SNF)
    • Cardiac Rehabilitation Services
    • Intensive Cardiac Rehabilitation Services
    • Pulmonary Rehabilitation Services
    • Partial Hospitalization
    • Home Health Services
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Other Health Care Professional
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Outpatient Diagnostic Procedures/Tests/Lab Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    Supplemental
    • Outpatient Blood Services
    • Over-the-Counter (OTC) Items
    • Meal Benefit
    • Annual Physical Exam
    • Supplemental Education/Wellness Programs
    • Eye Exams
    You may need a referral for the following Point-of-service benefits:
    Medicare-covered
    • Inpatient Hospital Acute
    • Inpatient Hospital Psychiatric
    • Skilled Nursing Facility (SNF)
    • Partial Hospitalization
    • Home Health Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Outpatient Diagnostic Procedures/Tests/Lab Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • Outpatient Substance Abuse
    • Outpatient Blood Services
    • Ambulance Services
    • End-Stage Renal Disease
    • Diabetes Self-Management Training
    • Comprehensive Dental
    • Eye Ex
    50% of the cost per hospital stay.
    50% of the cost per Inpatient Psychiatric Hospital stay.
    50% of the cost for each SNF stay.
    50% of the cost for Medicare-covered
    • Cardiac Rehabilitation Services
    • Intensive Cardiac Rehabilitation Services
    • Pulmonary Rehabilitation Services
    • Partial Hospitalization
    • Home Health Services
    • Primary Care Physician Services
    • Chiropractic Services
    • Occupational Therapy Services
    • Physician Specialist Services
    • Mental Health Specialty Services
    • Podiatry Services
    • Other Health Care Professional
    • Psychiatric Services
    • Physical Therapy and Speech-Language Pathology Services
    • Outpatient Diagnostic Procedures/Tests/Lab Services
    • Diagnostic Radiological Services
    • Therapeutic Radiological Services
    • Outpatient X-Rays
    • Outpatient Hospital Services
    • Ambulatory Surgical Center (ASC) Services
    • Outpatient Substance Abuse
    • Durable Medical Equipment (DME)
    • Prostheti
    $200 copay for Medicare-covered
    • Ambulance Services
    20% of the cost for Medicare-covered
    • End-Stage Renal Disease
    $0 copay for Medicare-covered
    • Outpatient Blood Services
    • Eye Wear
    Supplemental
    • Outpatient Blood Services
    • Eye Exams
    0% to 50% of the cost for Medicare-covered
    • Medicare-covered Preventive Services
    ** 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: $255 copay per day
  • Days 8 - 60: $0 copay per day
  • Days 61 - 90: $100 copay per day
    • $0 copay for each additional hospital day.
    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.
    $35 copay for each Medicare-covered specialist visit.
    Outpatient Services
    Authorization rules may apply.
    $205 copay for each Medicare-covered ambulatory surgical center visit
    $5 to $255 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    Authorization rules may apply.
    $200 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    20% of the cost for Medicare-covered durable medical equipment
    You may pay less if you purchase these items from the plan’s preferred manufacturers/vendors. Contact the plan for a list of non-preferred and preferred manufacturers/vendors.
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 to $35 copay for Medicare-covered lab services
    $0 to $35 copay for Medicare-covered diagnostic procedures and tests
    $5 to $35 copay for Medicare-covered X-rays
    $5 to $255 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    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
    This plan does not cover supplemental routine transportation.
    ** Cost **
    Premium and Other Important Information
    Package: 1 - MyOption Dental - Low PPO:
    $14 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 000 plan coverage limit every year for these benefits.
    ** Important Information **
    Package: 1 - MyOption Dental - Low PPO:
    $14 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $1 000 plan coverage limit every year for these benefits.
    ** Preventive Services **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • $1 000 plan coverage limit for dental benefits every year
    ** Cost **
    Premium and Other Important Information
    Package: 2 - MyOption Plus:
    $23 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    • Eye Exams
    • Eye Wear
    ** Important Information **
    Package: 2 - MyOption Plus:
    $23 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    • Eye Exams
    • Eye Wear
    ** Preventive Services **
    Dental Services
    Plan offers additional comprehensive dental benefits.
  • up to 2 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • $1 000 plan coverage limit for dental benefits every year
    ** Additional Benefits **
    Vision Services
    • $0 copay for up to 1 pair(s) of contacts every year
  • $0 copay for up to 1 pair(s) of glasses every year
  • $0 copay for up to 1 supplemental routine eye exam(s) every year
    • $40 plan coverage limit for eye exams every year.
    $290 plan coverage limit for eye wear every year.
    ** Cost **
    Premium and Other Important Information
    Package: 3 - MyOption Platinum Dental:
    $33 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $2 000 plan coverage limit every year for these benefits.
    ** Important Information **
    Package: 3 - MyOption Platinum Dental:
    $33 monthly premium in addition to your $32 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
    • Preventive Dental
    • Comprehensive Dental
    $2 000 plan coverage limit every year for these benefits.
    ** Preventive Services **
    Dental Services
    Plan offers additional comprehensive dental benefits.
    • up to 3 oral exam(s) every year
  • up to 2 cleaning(s) every year
  • up to 1 dental x-ray(s) every year
    • $2 000 plan coverage limit for dental benefits every year




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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.
    .