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

2013 Simply Complete (HMO SNP) in MIAMI-DADE, Florida 33142

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Simply Complete (HMO SNP) (H5471 - 001) in MIAMI-DADE, Florida 33142.

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

Plan Premium
The Simply Complete (HMO SNP) has a monthly premium of $24.80. That is $297.60 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 $24.80 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 and Plan Ratings
The Simply Complete (HMO SNP) (H5471 - 001) currently has 4,004 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 (Simply Complete (HMO SNP)) has no deductible.

The following information is about the Simply Complete (HMO SNP) formulary (or drug list). There are 3165 drugs on the Simply Complete (HMO SNP) formulary. Click here to browse the Simply Complete (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. 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 Simply Complete (HMO SNP)’s formulary is divided into 5 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 (Preferred Generic) contains 1,307 drugs and has a co-payment of $0.00.
  • Tier 2 (Non-Preferred Generic) contains 681 drugs and has a co-payment of $0.00.
  • Tier 3 (Preferred Brand) contains 256 drugs and has a co-payment of $45.00.
  • Tier 4 (Non-Preferred Brand) contains 815 drugs and has a co-payment of $75.00.
  • Tier 5 (Specialty Tier) contains 374 drugs and has a co-insurance of 33% of the drug cost.
    •  
Click here to browse the Simply Complete (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 (Simply Complete (HMO SNP))offers Coverage for during the Coverage Gap phase.

The Simply Complete (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.*
$500 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 each one-way trip to plan-approved location.
** 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.*
$500 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.
$0 copay
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.
$0 copay for SNF 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
$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 52 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
    Authorization rules may apply.
    $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 copay for each Medicare-covered outpatient hospital facility visit*
    Ambulance Services
    Authorization rules may apply.
    $0 copay for Medicare-covered ambulance benefits.*
    Emergency Care
    $0 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.
    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 copay for Medicare-covered durable medical equipment*
    Prosthetic Devices
    Authorization rules may apply.
    $0 copay for Medicare-covered prosthetic devices*
    Diabetes Programs and Supplies
    Authorization rules may apply.
    $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*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • 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
    $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
  • Nutritional Education
  • Health Club Membership/Fitness Classes
    • $0 copay for Simply Aide. Contact plan for details.
    Kidney Disease and Conditions
    Authorization rules may apply.
    $0 copay 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 $0 to $50 copay for Medicare Part B drugs (not including Part B chemotherapy drugs).*
    0% or 0% to 20% of the cost for Medicare Part B chemotherapy drugs.*
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.simplyhealthcareplans.com/medicare/pharmacy/formulary/index.html 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 you the plan and Medicare.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from Simply Complete (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 Simply Complete (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.
    Supplemental drugs don’t count toward your out-of-pocket drug costs.
    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.
    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 Simply Complete (HMO SNP).
    Depending on your income and institutional status you will be reimbursed by Simply Complete (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 Medicare-covered dental benefits*
    $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
    • Plan offers additional comprehensive dental benefits.
    Hearing Services
    Authorization rules may apply.
    $0 copay for Medicare-covered diagnostic hearing exams*
    $0 copay for :
    • 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:
    • up to 2 inner-ear hearing aid(s) every year
  • up to 2 outer-ear hearing aid(s) every year
  • up to 2 over-the-ear hearing aid(s) every year
    • $1 500 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 1 supplemental routine eye exam(s) every year
    $0 copay for
    • one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
    • up to 1 pair(s) of glasses every year
  • contacts
  • up to 1 pair(s) of lenses every year
  • up to 1 frame(s) every year
    • $350 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
    $0 copay for each one-way trip to plan-approved location.
    Acupuncture
    This plan does not cover Acupuncture.
    ** 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 copay for each Medicare-covered outpatient hospital facility visit*
    Ambulance Services
    Authorization rules may apply.
    $0 copay for Medicare-covered ambulance benefits.*
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    Authorization rules may apply.
    $0 copay 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*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • 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
    $0 copay for each one-way trip to plan-approved location.




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