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

2013 Sunshine State Health Plan (HMO SNP) in MIAMI-DADE, Florida 33142

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Sunshine State Health Plan (HMO SNP) (H5190 - 001) in MIAMI-DADE, Florida 33142.

This plan is administered by SUNSHINE STATE HEALTH PLAN, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Sunshine State Health Plan (HMO SNP) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Sunshine State Health Plan (HMO SNP) has a monthly premium of $24.00. That is $288.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $24.00 montly premium is in addition to 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
The Sunshine State Health Plan (HMO SNP) (H5190 - 001) currently has less than 10 members.

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $325 deductible. So, you are 100% responsible for the first $325 in medication costs. After you have met the deductible, the Sunshine State Health Plan (HMO SNP) will share the costs of your medications with you -- see cost-sharing below. $325 is the maximum deductible for 2013. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the Sunshine State Health Plan (HMO SNP) formulary (or drug list). There are 2876 drugs on the Sunshine State Health Plan (HMO SNP) formulary. Click here to browse the Sunshine State Health Plan (HMO SNP) 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. Once you have spent $325, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Sunshine State Health Plan (HMO SNP)’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 1,665 drugs and has a co-payment of $0.00.
  • Tier 2 (Preferred Brand) contains 665 drugs and has a co-payment of $45.00.
  • Tier 3 (Non-Preferred Brand) contains 79 drugs and has a co-payment of $95.00.
  • Tier 4 (Injectable Drugs) contains 612 drugs and has a co-payment of $95.00.
    •   
Click here to browse the Sunshine State Health Plan (HMO SNP) 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 (Sunshine State Health Plan (HMO SNP))offers Coverage for during the Coverage Gap phase.

The Sunshine State Health Plan (HMO SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** 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.*
$3 400 out-of-pocket limit. All plan services included.*
** 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 up to 12 one-way 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.*
$3 400 out-of-pocket limit. All plan services included.*
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.
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% or 0% to 20% of the cost 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 40% of the cost for each Medicare-covered individual therapy visit*
0% or 40% of the cost for each Medicare-covered group therapy visit*
0% or 40% of the cost for each Medicare-covered individual therapy visit with a psychiatrist*
0% or 40% 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 0% to 40% of the cost for Medicare-covered individual substance abuse outpatient treatment visits*
0% or 0% to 40% of the cost for Medicare-covered group substance abuse outpatient treatment visits*
Outpatient Services
Authorization rules may apply.
0% or 0% to 20% of the cost for each Medicare-covered ambulatory surgical center visit*
0% or 0% to 20% of the cost for each Medicare-covered outpatient hospital facility visit*
Ambulance Services
Authorization rules may apply.
0% or 0% to 20% of the cost 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 3-day(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*
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*
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.
0% or 20% of the cost for Medicare-covered prosthetic devices*
Diabetes Programs and Supplies
$0 copay for Medicare-covered Diabetes self-management training*
0% or 20% of the cost for Medicare-covered Diabetes monitoring supplies*
Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies.
0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts*
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of 0% or 0% to 20% of the cost may apply*
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
Authorization rules may apply.
$0 copay for Medicare-covered:
  • lab services*
0% or 0% to 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*
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 0% to 20% of the cost may apply*
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost may apply*
** Preventive Services **
Cardiac and Pulmonary Rehabilitation Services
Authorization rules may apply.
0% or 0% to 20% of the cost for Medicare-covered Cardiac Rehabilitation Services*
0% or 0% to 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services*
0% or 0% to 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.
The plan covers the following supplemental education/wellness programs:
  • Nursing Hotline
Kidney Disease and Conditions
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.*
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.sunshinestatehealth.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.
Your in-network prescription coverage may be limited to the plan’s service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details.
Total yearly drug costs are the total drug costs paid by you the plan and Medicare.
Some drugs have quantity limits.
Your provider must get prior authorization from Sunshine State Health Plan (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.
If you request a formulary exception for a drug and Sunshine State Health Plan (HMO SNP) approves the exception you will pay the generic cost share for generic drugs and the brand cost share for brand drugs.
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:
  • A $0 copay or
  • A $1.15 copay or
  • A $2.65 copay
For all other drugs either:
  • A $0 copay or
  • A $3.50 copay or
  • A $6.60 copay.
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.
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 Sunshine State Health Plan (HMO SNP).
Depending on your income and institutional status you will be reimbursed by Sunshine State Health Plan (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:
  • A $0 copay or
  • A $1.15 copay or
  • A $2.65 copay
For all other drugs purchased out-of-network either:
  • A $0 copay or
  • A $3.50 copay or
  • A $6.60 copay.
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
Authorization rules may apply.
$0 copay for the following preventive 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
    • 0% or 0% to 20% of the cost for Medicare-covered dental benefits*
    Plan offers additional comprehensive dental benefits.
    $500 plan coverage limit for comprehensive dental benefits every year
    Hearing Services
    Authorization rules may apply.
    • up to 1 supplemental routine hearing exam(s) every year
  • up to 1 fitting-evaluation(s) for a hearing aid every year
    • $0 copay for hearing aids.
    0% or 0% to 20% of the cost for Medicare-covered diagnostic hearing exams*
    $500 plan coverage limit for hearing aids every year.
    ** Additional Benefits **
    Vision Services
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    • up to 1 pair(s) of glasses every year
  • up to 1 pair(s) of contacts every year
  • 0% or 20% of the cost for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.*
  • 0% or 0% to 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.*
    • $200 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 up to 12 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.
    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% or 0% to 20% of the cost 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 0% to 20% of the cost for each Medicare-covered ambulatory surgical center visit*
    0% or 0% to 20% of the cost for each Medicare-covered outpatient hospital facility visit*
    Ambulance Services
    Authorization rules may apply.
    0% or 0% to 20% of the cost 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*
    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 copay for Medicare-covered:
    • lab services*
    0% or 0% to 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*
    If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 0% to 20% of the cost may apply*
    If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of 0% or 20% of the cost 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
    Authorization rules may apply.
    $0 copay for up to 12 one-way trip(s) to plan-approved location every year




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