2015 First Plus Advantage Plus (PPO) - H4011-003-0 in PR Plan Benefits Details

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2015 Medicare Advantage Plan Benefit Details for the First Plus Advantage Plus (PPO) - H4011-003-0

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2015 Medicare Advantage Plan Details

Medicare Plan Name:

First+Plus Advantage Plus (PPO)

Location:

Aguadilla, Puerto Rico Click to see other locations

Plan ID:

H4011 - 003 - 0 Click to see other plans

Member Services:

1-888-767-7717 TTY users 1-877-672-4242

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 First+Plus Advantage Plus (PPO) benefit details

Monthly Premium:

$0.00 (see Plan Premium Details below)

Annual Deductible:

Annual Initial Coverage Limit (ICL):

$2,960

Health Plan Type:

Local PPO

Maximum Out-of-Pocket Limit for Parts A & B (MOOP):

$6,700

Additional Gap Coverage?

Yes, some additional gap coverage.

Total Number of Formulary Drugs:

3,207 drugs

Browse the First+Plus Advantage Plus (PPO) Formulary

This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.

Formulary Drug Details:

Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

• Preferred Pharmacy
Cost-Sharing during
initial coverage phase:

$6.00

$14.00

$40.00

$65.00

33%

• Number of Drugs per
Tier:

761

1205

175

644

422

Plan's Pharmacy Search:

http://www.firstpluspr.com

Plan Offers Mail Order?

Yes

Number of Members enrolled in this plan in Aguadilla, Puerto Rico:

29 members

Number of Members enrolled in this plan in (H4011 - 003):

936 members

Plan’s Summary Star Rating:

2.5 out of 5 Stars.

• Customer Service Rating:

Insufficient data to rate this plan.

• Member Experience Rating:

2 out of 5 Stars.

• Drug Cost Accuracy Rating:

3 out of 5 Stars.

The Monthly Premium is Split as Follows: ❔

Total
Premium

Part C
Premium

Part D Base
Premium

Part D Supplemental
Premium

$0.00

Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔

100%
Subsidy

75%
Subsidy

50%
Subsidy

25%
Subsidy

Monthly Part D Premium with LIS:

$0.00

Total Monthly Premium with LIS (Parts C & D):

$0.00

** Cost **

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

$0 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:

$6 700 for services you receive from in-network providers.

$10 000 for services you receive from any provider.

Your limit for services received from in-network providers will count toward this limit.

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

Not covered

** 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

Out-of-network: 20% of the cost

Other Part B drugs¹:

In-network: 20% of the cost

Out-of-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

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$6 copay	$18 copay
Tier 2 (Non-Preferred Generic)	$14 copay	$42 copay
Tier 3 (Preferred Brand)	$40 copay	$120 copay
Tier 4 (Non-Preferred Brand)	$65 copay	$195 copay
Tier 5 (Specialty Tier)	33% of the cost	33% of the cost

Standard Mail Order Cost-Sharing

Tier	Three-month supply
Tier 1 (Preferred Generic)	$12 copay
Tier 2 (Non-Preferred Generic)	$28 copay
Tier 3 (Preferred Brand)	$80 copay
Tier 4 (Non-Preferred Brand)	$130 copay

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 at the same cost as 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

Tier	Drugs Covered	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	All	$6 copay	$18 copay
Tier 2 (Non-Preferred Generic)	All	$14 copay	$42 copay

Standard Mail Order Cost-Sharing

Tier	Drugs Covered	Three-month supply
Tier 1 (Preferred Generic)	All	$12 copay
Tier 2 (Non-Preferred Generic)	All	$28 copay

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

$0 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:

$6 700 for services you receive from in-network providers.

$10 000 for services you receive from any provider.

Your limit for services received from in-network providers will count toward this limit.

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

Not covered

Ambulance Services

In-network: $75 copay

Out-of-network: 20% of the cost

If you are admitted to the hospital you do not have to pay for the ambulance services.

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: 20% of the cost

Routine chiropractic visit (for up to 2 every year):

In-network: $20 copay

Out-of-network: 20% of the cost

Dental Services

Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):

In-network: You pay nothing

Out-of-network: 20% of the cost

Preventive dental services:

Cleaning (for up to 2 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Dental x-ray(s) (for up to 1 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Fluoride treatment (for up to 2 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Oral exam (for up to 2 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Diabetes Supplies and Services

Diabetes monitoring supplies:

In-network: 0-20% of the cost depending on the supply

Out-of-network: 20% of the cost

Diabetes self-management training:

In-network: You pay nothing

Out-of-network: You pay nothing

Therapeutic shoes or inserts:

In-network: 0-20% of the cost depending on the supply

Out-of-network: 20% of the cost

Diagnostic Tests, Lab and Radiology Services, and X-Rays

Diagnostic radiology services (such as MRIs CT scans):

In-network: 10-20% of the cost depending on the service

Out-of-network: 20% of the cost

Diagnostic tests and procedures:

In-network: 10-20% of the cost depending on the service

Out-of-network: 20% of the cost

Lab services:

In-network: $5 copay

Out-of-network: 20% of the cost

Outpatient x-rays:

In-network: $10-20 copay depending on the service

Out-of-network: 20% of the cost

Therapeutic radiology services (such as radiation treatment for cancer):

In-network: 10-20% of the cost depending on the service

Out-of-network: 20% of the cost

Doctor’s Office Visits

Primary care physician visit:

In-network: $8 copay

Out-of-network: 20% of the cost

Specialist visit:

In-network: $20 copay

Out-of-network: 20% of the cost

Durable Medical Equipment (wheelchairs, oxygen, etc.)

In-network: 10-20% of the cost depending on the equipment

Out-of-network: 20% of the cost

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: $20 copay

Out-of-network: 20% of the cost

Routine foot care (for up to 2 visit(s) every year):

In-network: $20 copay

Out-of-network: 20% of the cost

Hearing Services

Exam to diagnose and treat hearing and balance issues:

In-network: You pay nothing

Out-of-network: 20% of the cost

Routine hearing exam (for up to 1 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Hearing aid fitting/evaluation:

In-network: You pay nothing

Out-of-network: 20% of the cost

Hearing aid:

In-network: You pay nothing

Out-of-network: You pay nothing

Our plan pays up to $300 every three years for hearing aids from any provider.

Home Health Care

In-network: You pay nothing

Out-of-network: 20% of the cost

Mental Health Care

Inpatient visit:

Our plan covers an unlimited number of days for an inpatient hospital stay.

Your costs may vary depending on your hospital's tier (or group).

Tier 1

In-network:

$75 copay per stay

You pay nothing per day for days 91 and beyond

Out-of-network:

$300 copay per stay

Tier 2

In-network:

$150 copay per stay

You pay nothing per day for days 91 and beyond

Out-of-network:

$300 copay per stay

Outpatient group therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

Outpatient individual therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

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: You pay nothing

Out-of-network: 20% of the cost

Occupational therapy visit:

In-network: $40 copay

Out-of-network: 20% of the cost

Physical therapy and speech and language therapy visit:

In-network: $40 copay

Out-of-network: 20% of the cost

Outpatient Substance Abuse

Group therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

Individual therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

Outpatient Surgery

Ambulatory surgical center:

In-network: $50-100 copay depending on the service

Out-of-network: 20% of the cost

Outpatient hospital:

In-network: $50-100 copay depending on the service

Out-of-network: 20% of the cost

Over-the-Counter Items

Please visit our website to see our list of covered over-the-counter items.

Prosthetic Devices (braces, artificial limbs, etc.)

Prosthetic devices:

In-network: 10-20% of the cost depending on the device

Out-of-network: 20% of the cost

Related medical supplies:

In-network: 10-20% of the cost depending on the supply

Out-of-network: 20% of the cost

Renal Dialysis

In-network: You pay nothing

Out-of-network: You pay nothing

Transportation

Not covered

Urgently Needed Care

You pay nothing

Vision Services

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):

In-network: You pay nothing

Out-of-network: 20% of the cost

Routine eye exam (for up to 1 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Eyeglasses (frames and lenses) (for up to 1 every year):

In-network: You pay nothing

Out-of-network: 50% of the cost

Eyeglasses or contact lenses after cataract surgery:

In-network: You pay nothing

Out-of-network: 20% of the cost

Our plan pays up to $100 every year for eyeglasses (frames and lenses) from any 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

Out-of-network: 20% of the cost

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.

Your costs may vary depending on your hospital's tier (or group).

Tier 1

In-network:

$75 copay per stay

You pay nothing per day for days 91 and beyond

Out-of-network:

$300 copay per stay

Tier 2

In-network:

$150 copay per stay

You pay nothing per day for days 91 and beyond

Out-of-network:

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

Out-of-network:

$25 copay per stay

You pay nothing per day for days 1 through 20

$25 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

Out-of-network: 20% of the cost

Other Part B drugs¹:

In-network: 20% of the cost

Out-of-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

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$6 copay	$18 copay
Tier 2 (Non-Preferred Generic)	$14 copay	$42 copay
Tier 3 (Preferred Brand)	$40 copay	$120 copay
Tier 4 (Non-Preferred Brand)	$65 copay	$195 copay
Tier 5 (Specialty Tier)	33% of the cost	33% of the cost

Standard Mail Order Cost-Sharing

Tier	Three-month supply
Tier 1 (Preferred Generic)	$12 copay
Tier 2 (Non-Preferred Generic)	$28 copay
Tier 3 (Preferred Brand)	$80 copay
Tier 4 (Non-Preferred Brand)	$130 copay

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 at the same cost as an in-network pharmacy.

Standard Retail Cost-Sharing

Tier	Drugs Covered	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	All	$6 copay	$18 copay
Tier 2 (Non-Preferred Generic)	All	$14 copay	$42 copay

Standard Mail Order Cost-Sharing

Tier	Drugs Covered	Three-month supply
Tier 1 (Preferred Generic)	All	$12 copay
Tier 2 (Non-Preferred Generic)	All	$28 copay

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: 0-20% of the cost depending on the supply

Out-of-network: 20% of the cost

Diabetes self-management training:

In-network: You pay nothing

Out-of-network: You pay nothing

Therapeutic shoes or inserts:

In-network: 0-20% of the cost depending on the supply

Out-of-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: $20 copay

Out-of-network: 20% of the cost

Routine foot care (for up to 2 visit(s) every year):

In-network: $20 copay

Out-of-network: 20% of the cost

Hearing Services

Exam to diagnose and treat hearing and balance issues:

In-network: You pay nothing

Out-of-network: 20% of the cost

Routine hearing exam (for up to 1 every year):

In-network: You pay nothing

Out-of-network: 20% of the cost

Hearing aid fitting/evaluation:

In-network: You pay nothing

Out-of-network: 20% of the cost

Hearing aid:

In-network: You pay nothing

Out-of-network: You pay nothing

Our plan pays up to $300 every three years for hearing aids from any provider.

** Outpatient Medical Services and Supplies **

Outpatient Substance Abuse

Group therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

Individual therapy visit:

In-network: $20 copay

Out-of-network: 50% of the cost

Prosthetic Devices (braces, artificial limbs, etc.)

Prosthetic devices:

In-network: 10-20% of the cost depending on the device

Out-of-network: 20% of the cost

Related medical supplies:

In-network: 10-20% of the cost depending on the supply

Out-of-network: 20% of the cost

** Additional Benefits **

Inpatient Mental Health Care

For inpatient mental health care see the "Mental Health Care" section.

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