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

2013 Day Break (HMO) in Miami-Dade, Florida 33142

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Day Break (HMO) (H4199 - 002) in Miami-Dade, Florida 33142.

This plan is administered by FLORIDA HEALTHCARE PLUS, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Day Break (HMO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings
The Day Break (HMO) (H4199 - 002) currently has 626 members.

The Centers for Medicare and Medicaid Services (CMS) is not yet able to calculate a summary rating for this plan carrier. The detail CMS plan carrier ratings are as follows:
  • Customer Service Rating of 3 out of 5 stars
  • Member Experience Rating not available
  • Drug Cost Information Accuracy Rating not available
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2013 is $325. This plan (Day Break (HMO)) has no deductible.

The following information is about the Day Break (HMO) formulary (or drug list). There are 2709 drugs on the Day Break (HMO) formulary. Click here to browse the Day Break (HMO) Formulary.
 
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Day Break (HMO)’s formulary is divided into 4 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Generic) contains 1,689 drugs and has a co-payment of $0.00.
  • Tier 2 (Preferred Brand) contains 301 drugs and has a co-payment of $0.00.
  • Tier 3 (Non-Preferred Brand) contains 660 drugs and has a co-payment of $20.00.
  • Tier 4 (Specialty Tier) contains 237 drugs and has a co-insurance of 33% of the drug cost.
    •   
Click here to browse the Day Break (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 21% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 2.5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 52.5% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Day Break (HMO)) offers Coverage for All Generics during the Coverage Gap phase. This means that all generic drugs on the plans formulary (or drug list) and no brand-name drugs will be covered through the coverage gap (or donut hole).

The Day Break (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** 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.
FLORIDA HEALTHCARE PLUS will reduce your monthly Medicare Part B premium by up to $ 99.90.
$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
Authorization rules may apply.
$0 copay for each one-way trip to plan-approved location.
** 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.
FLORIDA HEALTHCARE PLUS will reduce your monthly Medicare Part B premium by up to $ 99.90.
$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
No limit to the number of days covered by the plan each hospital stay.
$0 copay
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 - 5: $100 copay per day
  • Days 6 - 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 - 5: $0 copay per day
  • Days 6 - 100: $50 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
    $0 copay for each Medicare-covered primary care doctor visit.
    $0 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    $0 copay for: Medicare-covered chiropractic visits
    up to 12 supplemental routine chiropractic visit(s) every year
    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
    $0 copay for Medicare-covered podiatry visits
    up to 12 supplemental routine podiatry visit(s) every year
    Medicare-covered podiatry visits are for medically-necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $0 copay for:
    • each Medicare-covered individual therapy visit
  • each Medicare-covered group therapy visit
    • $0 copay for:
    • each Medicare-covered individual therapy visit with a psychiatrist
  • each Medicare-covered group therapy visit with a psychiatrist
    • $0 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    $0 copay for:
    • each Medicare-covered individual substance abuse outpatient treatment visit
  • each Medicare-covered group substance abuse outpatient treatment visit
    • Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $100 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    $50 copay for Medicare-covered ambulance benefits.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits
    $50 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.
    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 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $0 copay for Medicare-covered Occupational Therapy visits
    $0 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% 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
    $0 copay for Medicare-covered Diabetes self-management training
    $0 copay for Medicare-covered:
    • Diabetes monitoring supplies
  • Therapeutic shoes or inserts
    • Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • lab services
  • diagnostic procedures and tests
    • $0 copay for Medicare-covered X-rays
    $150 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $0 copay for Medicare-covered therapeutic radiology services
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    Authorization rules may apply.
    $0 copay for:
    • Medicare-covered Cardiac Rehabilitation Services
  • Medicare-covered Intensive Cardiac Rehabilitation Services
  • 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.
    The plan covers the following supplemental education/wellness programs:
    • Health Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • 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.floridahealthcareplus.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 Day Break (HMO) 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.
    If you request a formulary exception for a drug and Day Break (HMO) 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 $4 000:
    Tier 1: 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
  • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $20 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
  • $0 copay for a three-month (90-day) supply of drugs in this tier
  • $60 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: 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
  • 33% coinsurance for a one-month (31-day) supply of drugs in this tier
  • $0 copay for a one-month (31-day) supply of drugs in this tier
  • $20 copay 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: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $0 copay for a three-month (90-day) supply of drugs in this tier
  • $0 copay for a three-month (90-day) supply of drugs in this tier
  • $60 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 $4 000 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 all formulary generics (100% of formulary generic drugs) through the coverage gap.
    The plan offers additional coverage in the gap for the following tiers. You pay the following:
    Tier 1: 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: 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: Generic
    • $0 copay for a three-month (90-day) supply of all drugs covered in this tier
    Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    After your yearly out-of-pocket drug costs reach $4 750 you pay the following:
    • $0 copay for drugs in this tier
  • 5% coinsurance for drugs in this tier
  • 5% coinsurance for drugs in this tier
  • 5% coinsurance for drugs in this tier
    • Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Day Break (HMO).
    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 $4 000:
    Tier 1: 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
  • $0 copay for a one-month (30-day) supply of drugs in this tier
  • $20 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 all formulary generics (100% of formulary generic 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: 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 the following:
    You will not be reimbursed for the difference between the Out-of-Network Pharmacy charge and the plan’s In-Network allowable amount.
    Tier 1: Generic
    Tier 2: Preferred Brand
    Tier 3: Non-Preferred Brand
    Tier 4: Specialty Tier
    • $0 copay for drugs in this tier
  • 5% coinsurance for drugs in this tier
  • 5% coinsurance for drugs in this tier
  • 5% coinsurance for drugs in this tier
    • Dental Services
    $0 copay for Medicare-covered dental benefits
    $0 copay for the following preventive dental benefits:
    • up to 1 oral exam(s) every six months
  • up to 1 cleaning(s) every six months
  • up to 1 fluoride treatment(s) every six months
  • up to 1 dental x-ray(s) every year
    • Plan offers additional comprehensive dental benefits.
    Hearing Services
    $0 copay for Medicare-covered diagnostic hearing exams
    $0 copay for :
    • supplemental routine hearing exams
  • fitting-evaluations for a hearing aid
    • $0 copay for hearing aids.
    $1 000 plan coverage limit for hearing aids every year.
    ** Additional Benefits **
    Vision Services
    $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye
    $0 copay for up to 2 supplemental routine eye exam(s) every year
    $0 copay for
    • one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
    • up to 2 pair(s) of glasses every year
  • up to 1 pair(s) of contacts every year
    • $500 plan coverage limit for eye wear 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
    Authorization rules may apply.
    $0 copay for each one-way trip to plan-approved location.
    Acupuncture
    Authorization rules may apply.
    $0 copay per acupuncture visit.
    ** Inpatient Care **
    Inpatient Hospital Care
    No limit to the number of days covered by the plan each hospital stay.
    $0 copay
    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
    $0 copay for each Medicare-covered primary care doctor visit.
    $0 copay for each Medicare-covered specialist visit.
    Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit
    $0 to $100 copay for each Medicare-covered outpatient hospital facility visit
    Ambulance Services
    $50 copay for Medicare-covered ambulance benefits.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    0% 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
  • diagnostic procedures and tests
    • $0 copay for Medicare-covered X-rays
    $150 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    $0 copay 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 each one-way trip to plan-approved location.




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    .