** Cost ** |
Premium and Other Important Information |
$0 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. |
$3 400 out-of-pocket limit for Medicare-covered services. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** 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 |
$0 copay for up to 8 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
$0 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. |
$3 400 out-of-pocket limit for Medicare-covered services. |
Doctor and Hospital Choice |
You must go to network doctors specialists and hospitals. |
Referral required for network hospitals and specialists (for certain benefits). |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
For Medicare-covered hospital stays: |
- Days 1 - 7: $95 copay per day
|
Days 8 - 90: $0 copay per day |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve 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: $95 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 Medicare-covered SNF stays: |
- Days 1 - 8: $0 copay per day
|
Days 9 - 100: $95 copay per day |
Home Health Care |
Authorization rules may apply. |
$0 copay for each Medicare-covered home health visit |
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. |
$20 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. |
$20 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. |
$20 copay for each Medicare-covered individual therapy visit |
$20 copay for each Medicare-covered group therapy visit |
$20 copay for each Medicare-covered individual therapy visit with a psychiatrist |
$20 copay for each Medicare-covered group therapy visit with a psychiatrist |
$95 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
$15 to $200 copay for Medicare-covered individual substance abuse outpatient treatment visits |
$15 to $200 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 |
$200 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$50 copay for Medicare-covered emergency room visits |
$25 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year. |
Urgently Needed Care |
$10 copay for Medicare-covered urgently-needed-care visits |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
$20 copay for Medicare-covered Occupational Therapy visits |
$20 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. |
0% to 20% of the cost for Medicare-covered durable medical equipment |
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 |
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 copay for Medicare-covered lab services |
$0 copay for Medicare-covered diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$25 to $100 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 $0 to $20 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $20 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$15 to $200 copay for Medicare-covered Cardiac Rehabilitation Services |
$15 to $200 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$15 to $200 copay for Medicare-covered Pulmonary Rehabilitation Services |
Preventive Services and Wellness/Education Programs |
Authorization rules may apply. |
$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. |
Authorization rules may apply. |
The plan covers the following supplemental education/wellness programs: |
- Health Club Membership/Fitness Classes
|
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 www.freedomhealth.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 Freedom VIP Care COPD (HMO SNP) for certain drugs. |
The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
If you request a formulary exception for a drug and Freedom VIP Care COPD (HMO SNP) approves the exception you will pay Tier 3: Non-Preferred Brand cost sharing for that drug. |
$0 deductible. |
Supplemental drugs don’t count toward your out-of-pocket drug costs. |
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 |
- $0 copay for a one-month (30-day) supply of drugs in this tier
|
$5 copay for a one-month (30-day) supply of drugs in this tier |
$60 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 |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$15 copay for a three-month (90-day) supply of drugs in this tier |
$180 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 |
Tier 1: Preferred Generic |
Tier 2: Preferred Brand |
Tier 3: Non-Preferred Brand |
Tier 4: Specialty Tier |
- $0 copay for a one-month (31-day) supply of drugs in this tier
|
$5 copay for a one-month (31-day) supply of drugs in this tier |
$60 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
|
$5 copay for a one-month (30-day) supply of drugs in this tier |
$60 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 |
$0 copay for a three-month (90-day) supply of drugs in this tier |
$10 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 |
33% coinsurance for a three-month (90-day) supply of drugs in this tier |
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 offers additional coverage in the gap for the following tiers. You pay the following: |
Tier 1: Preferred Generic |
- $0 copay for a one-month (30-day) supply of all drugs covered in this tier
|
$0 copay for a three-month (90-day) supply of all drugs covered in this tier |
Tier 1: Preferred Generic |
- $0 copay for a one-month (31-day) supply of all 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 |
- $0 copay for a one-month (30-day) supply of all drugs covered in this tier
|
$0 copay for a three-month (90-day) supply of all drugs covered in this tier |
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 Freedom VIP Care COPD (HMO SNP). |
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 |
- $0 copay for a one-month (30-day) supply of drugs in this tier
|
$5 copay for a one-month (30-day) supply of drugs in this tier |
$60 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). |
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 |
- $0 copay for a one-month (30-day) supply of all 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 |
$0 copay for Medicare-covered dental benefits |
- $0 copay for up to 1 oral exam(s) every year
|
$0 copay for up to 2 cleaning(s) every year |
$0 copay for up to 2 fluoride treatment(s) every year |
$0 to $75 copay for up to 1 dental x-ray(s) |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams |
$0 copay for: |
- up to 1 supplemental routine hearing exam(s) every two years
|
$0 copay for up to 1 hearing aid fitting-evaluation(s) every two years |
$0 copay for up to 1 hearing aid(s) every two years |
$500 plan coverage limit for hearing aids every two years. |
** Additional Benefits ** |
Vision Services |
- $15 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
|
$0 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 |
$15 copay for up to 1 pair(s) of glasses every year |
$15 copay for up to 1 pair(s) of contacts every year |
$100 plan coverage limit for eye wear every year. |
Plan offers additional vision benefits. Contact plan for details. |
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 |
$0 copay for up to 8 one-way 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. |
For Medicare-covered hospital stays: |
- Days 1 - 7: $95 copay per day
|
Days 8 - 90: $0 copay per day |
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve 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. |
$0 copay for each Medicare-covered primary care doctor visit. |
$20 copay for each Medicare-covered specialist visit. |
Outpatient Services |
Authorization rules may apply. |
$50 copay for each Medicare-covered ambulatory surgical center visit |
$200 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
Authorization rules may apply. |
$100 copay for Medicare-covered ambulance benefits. |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% to 20% of the cost for Medicare-covered durable medical equipment |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered lab services |
$0 copay for Medicare-covered diagnostic procedures and tests |
$0 copay for Medicare-covered X-rays |
$25 to $100 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 $0 to $20 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $20 may apply |
** 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 |
$0 copay for up to 8 one-way trip(s) to plan-approved location every year |