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2015 Medicare Advantage Plan Benefit Details for the MVP Preferred Gold with Part D (HMO-POS) - H9859-002-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2015 Medicare Advantage Plan Details
Medicare Plan Name:MVP Preferred Gold with Part D (HMO-POS)
Location:Warren, New York     Click to see other locations
Plan ID:H9859 - 002 - 0     Click to see other plans
Member Services:1-800-665-7924 TTY users 1-800-662-1220
— 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 MVP Preferred Gold with Part D (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$167.40 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$2,960
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$4,500
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,899 drugsBrowse the MVP Preferred Gold with Part D (HMO-POS) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$10.00$35.00$90.0033%
• Number of Drugs per
  Tier:		19419602811004449
Plan's Pharmacy Search:http://www.mvphealthcare.com/medicare/2013PartD/partd_index.html
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Warren, New York:247 members
Number of Members enrolled in this plan in (H9859 - 002):4,012 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: Insufficient data to rate this plan.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$167.40$86.50$57.90$23.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$44.00$53.20$62.40$71.70
Total Monthly Premium with LIS (Parts C & D):$130.50$139.70$148.90$158.20
— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$167.4 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $4 500 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture and Other Alternative Therapies
  • In-network:  50% of the cost. You are covered for up to 10 visit(s) every year.
** Extra Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0
Tier 2 (Non-Preferred Generic)$10 copay$30 copay
Tier 3 (Preferred Brand)$35 copay$105 copay
Tier 4 (Non-Preferred Brand)$90 copay$270 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost
Tier 6 (Vaccines)$0Not Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0
Tier 2 (Non-Preferred Generic)$10 copay$20 copay
Tier 3 (Preferred Brand)$35 copay$70 copay
Tier 4 (Non-Preferred Brand)$90 copay$180 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost
Tier 6 (Vaccines)$0Not Offered
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
Standard Retail Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$0$0
Tier 6 (Vaccines)All$0Not Offered
Standard Mail Order Cost-Sharing
TierDrugs CoveredOne-month supplyThree-month supply
Tier 1 (Preferred Generic)All$0$0
Tier 6 (Vaccines)All$0Not Offered
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
  • 5% of the cost or
  • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$167.4 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $4 500 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture and Other Alternative Therapies
  • In-network:  50% of the cost. You are covered for up to 10 visit(s) every year.
Ambulance Services
  • In-network:  $75 copay
  • Out-of-network:  $75 copay.  There is a limit to how much our plan will pay.
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  $20 copay
  • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $30 copay
  • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
  • Dental x-ray(s):
    • In-network:  You pay nothing. You are covered for up to 2 every year.
  • Oral exam:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
    • Our plan pays up to $240 every year for preventive dental services from an in-network provider.
    Diabetes Supplies and Services
    Diabetes monitoring supplies:
    • In-network:  10-20% of the cost depending on the supply
    Diabetes self-management training:
    • In-network:  You pay nothing
    Therapeutic shoes or inserts:
    • In-network:  20% of the cost
    Diagnostic Tests, Lab and Radiology Services, and X-Rays
    Diagnostic radiology services (such as MRIs CT scans):
    • In-network:  $60 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Diagnostic tests and procedures:
    • In-network:  You pay nothing
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Lab services:
    • In-network:  $10 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Outpatient x-rays:
    • In-network:  $30 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  You pay nothing
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Doctor’s Office Visits
    Primary care physician visit:
    • In-network:  $15 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Specialist visit:
    • In-network:  $30 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Durable Medical Equipment (wheelchairs, oxygen, etc.)
    • In-network:  20% of the cost
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
    Emergency Care
    $65 copay
    If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot Care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
    • In-network:  $30 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Hearing Services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $30 copay
    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
    Home Health Care
    • In-network:  You pay nothing
    Mental Health Care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • In-network:  
      • $150 copay per day for days 1 through 5
      • You pay nothing per day for days 6 through 90
        • Outpatient group therapy visit:
        • In-network:  $30 copay
        Outpatient individual therapy visit:
        • In-network:  $30 copay
        Outpatient Rehabilitation Services
        Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
        • In-network:  $30 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Occupational therapy visit:
        • In-network:  $30 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Physical therapy and speech and language therapy visit:
        • In-network:  $30 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Outpatient Substance Abuse
        Group therapy visit:
        • In-network:  $30 copay
        Individual therapy visit:
        • In-network:  $30 copay
        Outpatient Surgery
        Ambulatory surgical center:
        • In-network:  $100 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Outpatient hospital:
        • In-network:  $225 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Over-the-Counter Items
        Not Covered
        Prosthetic Devices (braces, artificial limbs, etc.)
        Prosthetic devices:
        • In-network:  20% of the cost
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Related medical supplies:
        • In-network:  You pay nothing
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Renal Dialysis
        • In-network:  You pay nothing
        Transportation
        Not covered
        Urgently Needed Care
        $30 copay
        Vision Services
        Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
        • In-network:  $30 copay
        • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
        Routine eye exam:
        • In-network:  $30 copay. You are covered for up to 1 every year.
        Contact lenses:
        • In-network:  You pay nothing. You are covered for up to 1 every two years.
        Eyeglasses (frames and lenses):
        • In-network:  You pay nothing. You are covered for up to 1 every two years.
        Eyeglasses or contact lenses after cataract surgery:
        • In-network:  20% of the cost
        Our plan pays up to $100 every two years for contact lenses and eyeglasses (frames and lenses) from an in-network provider.
        ** Hospice **
        Hospice
        You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
        ** Preventive Care **
        Preventive Care
        • In-network:  You pay nothing
        Our plan covers many preventive services including:
        • Abdominal aortic aneurysm screening
        • Alcohol misuse counseling
        • Bone mass measurement
        • Breast cancer screening (mammogram)
        • Cardiovascular disease (behavioral therapy)
        • Cardiovascular screenings
        • Cervical and vaginal cancer screening
        • Colonoscopy
        • Colorectal cancer screenings
        • Depression screening
        • Diabetes screenings
        • Fecal occult blood test
        • Flexible sigmoidoscopy
        • HIV screening
        • Medical nutrition therapy services
        • Obesity screening and counseling
        • Prostate cancer screenings (PSA)
        • Sexually transmitted infections screening and counseling
        • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
        • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
        • "Welcome to Medicare" preventive visit (one-time)
        • Yearly "Wellness" visit
        Any additional preventive services approved by Medicare during the contract year will be covered.
        ** Inpatient Care **
        Inpatient Hospital Care
        Our plan covers an unlimited number of days for an inpatient hospital stay.
        • In-network:  
          • $150 copay per day for days 1 through 5
          • You pay nothing per day for days 6 through 90
          • You pay nothing per day for days 91 and beyond
            • Out-of-network:  
              • 30% of the cost per stay
              • There is a limit to how much our plan will pay
                • Inpatient Mental Health Care
                For inpatient mental health care see the "Mental Health Care" section.
                Skilled Nursing Facility (SNF)
                Our plan covers up to 100 days in a SNF.
                • In-network:  
                  • You pay nothing per day for days 1 through 20
                  • $150 copay per day for days 21 through 100
                    • Outpatient Prescription Drugs
                    For Part B drugs such as chemotherapy drugs1:
                    • In-network:  20% of the cost
                    Other Part B drugs1:
                    • In-network:  20% of the cost
                    You pay the following until your total yearly drug costs reach $2 960. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
                    You may get your drugs at network retail pharmacies and mail order pharmacies.
                    Standard Retail Cost-Sharing
                    TierOne-month supplyThree-month supply
                    Tier 1 (Preferred Generic)$0$0
                    Tier 2 (Non-Preferred Generic)$10 copay$30 copay
                    Tier 3 (Preferred Brand)$35 copay$105 copay
                    Tier 4 (Non-Preferred Brand)$90 copay$270 copay
                    Tier 5 (Specialty Tier)33% of the cost33% of the cost
                    Tier 6 (Vaccines)$0Not Offered
                    Standard Mail Order Cost-Sharing
                    TierOne-month supplyThree-month supply
                    Tier 1 (Preferred Generic)$0$0
                    Tier 2 (Non-Preferred Generic)$10 copay$20 copay
                    Tier 3 (Preferred Brand)$35 copay$70 copay
                    Tier 4 (Non-Preferred Brand)$90 copay$180 copay
                    Tier 5 (Specialty Tier)33% of the cost33% of the cost
                    Tier 6 (Vaccines)$0Not Offered
                    If you reside in a long-term care facility you pay the same as at a retail pharmacy.
                    You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
                    Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $2 960.

                    After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 65% of the plan's cost for covered generic drugs until your costs total $4 700 which is the end of the coverage gap. Not everyone will enter the coverage gap.

                    Under this plan you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you.
                    Standard Retail Cost-Sharing
                    TierDrugs CoveredOne-month supplyThree-month supply
                    Tier 1 (Preferred Generic)All$0$0
                    Tier 6 (Vaccines)All$0Not Offered
                    Standard Mail Order Cost-Sharing
                    TierDrugs CoveredOne-month supplyThree-month supply
                    Tier 1 (Preferred Generic)All$0$0
                    Tier 6 (Vaccines)All$0Not Offered
                    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay the greater of:
                    • 5% of the cost or
                    • $2.65 copay for generic (including brand drugs treated as generic) and a $6.60 copayment for all other drugs.
                    ** Outpatient Care **
                    Diabetes Supplies and Services
                    Diabetes monitoring supplies:
                    • In-network:  10-20% of the cost depending on the supply
                    Diabetes self-management training:
                    • In-network:  You pay nothing
                    Therapeutic shoes or inserts:
                    • In-network:  20% of the cost
                    Foot Care (podiatry services)
                    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                    • In-network:  $30 copay
                    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
                    Hearing Services
                    Exam to diagnose and treat hearing and balance issues:
                    • In-network:  $30 copay
                    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
                    ** Outpatient Medical Services and Supplies **
                    Outpatient Substance Abuse
                    Group therapy visit:
                    • In-network:  $30 copay
                    Individual therapy visit:
                    • In-network:  $30 copay
                    Prosthetic Devices (braces, artificial limbs, etc.)
                    Prosthetic devices:
                    • In-network:  20% of the cost
                    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
                    Related medical supplies:
                    • In-network:  You pay nothing
                    • Out-of-network:  30% of the cost.  There is a limit to how much our plan will pay.
                    ** Additional Benefits **
                    Inpatient Mental Health Care
                    For inpatient mental health care see the "Mental Health Care" section.




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                    .