2015 Medicare Advantage Plan Details | |||||||||||||||||||||||||||||
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Medicare Plan Name: | SeniorCare Sr Preferred - Basic Rx (Cost) | ||||||||||||||||||||||||||||
Location: | Schleicher, Texas Click to see other locations | ||||||||||||||||||||||||||||
Plan ID: | H4564 - 002 - 0 Click to see other plans | ||||||||||||||||||||||||||||
Member Services: | 1-866-334-3141 TTY users 1-800-735-2989 | ||||||||||||||||||||||||||||
— 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 |
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Email a copy of the SeniorCare Sr Preferred - Basic Rx (Cost) benefit details
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— Medicare Plan Features — | |||||||||||||||||||||||||||||
Monthly Premium: | $145.50 (see Plan Premium Details below) | ||||||||||||||||||||||||||||
Annual Deductible: | $0 | ||||||||||||||||||||||||||||
Annual Initial Coverage Limit (ICL): | $2,960 | ||||||||||||||||||||||||||||
Health Plan Type: | Cost | ||||||||||||||||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||||||||||||||||||||||||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||||||||||||||||||||||||||
Total Number of Formulary Drugs: | 3,110 drugs | Browse the SeniorCare Sr Preferred - Basic Rx (Cost) Formulary | |||||||||||||||||||||||||||
This plan has 5 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 | ||||||||||||||||||||||||
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $4.00 | $15.00 | $45.00 | $85.00 | 33% | ||||||||||||||||||||||||
• Number of Drugs per Tier: | 296 | 1403 | 448 | 681 | 282 | ||||||||||||||||||||||||
Plan's Pharmacy Search: | http://www.swhp.org | ||||||||||||||||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||||||||||||||||
Number of Members enrolled in this plan in Schleicher, Texas: | less than 10 members | ||||||||||||||||||||||||||||
Number of Members enrolled in this plan in (H4564 - 002): | 5,953 members | ||||||||||||||||||||||||||||
Plan’s Summary Star Rating: | 4 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 — | |||||||||||||||||||||||||||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |||||||||||||||||||||||||
Monthly Part D Premium with LIS: | $31.20 | $38.00 | $44.80 | $51.70 | |||||||||||||||||||||||||
— Plan Health Benefits — | |||||||||||||||||||||||||||||
** Cost ** | |||||||||||||||||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||||||||||||||||
$145.5 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||||||||
This plan does not have a deductible. | |||||||||||||||||||||||||||||
Yes. 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: | |||||||||||||||||||||||||||||
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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. | |||||||||||||||||||||||||||||
No. There are no limits on how much our plan will pay. | |||||||||||||||||||||||||||||
** 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: You pay nothing | |||||||||||||||||||||||||||||
Other Part B drugs1: You pay nothing | |||||||||||||||||||||||||||||
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
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Standard Mail Order Cost-Sharing
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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. | |||||||||||||||||||||||||||||
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:
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** Important Information ** | |||||||||||||||||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||||||||||||||||
$145.5 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||||||||
This plan does not have a deductible. | |||||||||||||||||||||||||||||
Yes. 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: | |||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||
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. | |||||||||||||||||||||||||||||
No. There are no limits on how much our plan will pay. | |||||||||||||||||||||||||||||
** Outpatient Care and Services ** | |||||||||||||||||||||||||||||
Acupuncture and Other Alternative Therapies | |||||||||||||||||||||||||||||
Not covered | |||||||||||||||||||||||||||||
Ambulance Services | |||||||||||||||||||||||||||||
$75 copay | |||||||||||||||||||||||||||||
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): $15 copay | |||||||||||||||||||||||||||||
Dental Services | |||||||||||||||||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||||||||||||||||||||||||||
Diabetes Supplies and Services | |||||||||||||||||||||||||||||
Diabetes monitoring supplies: 20% of the cost | |||||||||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||||||||
Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||||||||||||||||||||||||||
Diagnostic radiology services (such as MRIs CT scans): $0-15 copay depending on the service | |||||||||||||||||||||||||||||
Diagnostic tests and procedures: $0-15 copay depending on the service | |||||||||||||||||||||||||||||
Lab services: $0-15 copay depending on the service | |||||||||||||||||||||||||||||
Outpatient x-rays: $0-15 copay depending on the service | |||||||||||||||||||||||||||||
Therapeutic radiology services (such as radiation treatment for cancer): $0-15 copay depending on the service | |||||||||||||||||||||||||||||
Doctor’s Office Visits | |||||||||||||||||||||||||||||
Primary care physician visit: $15 copay | |||||||||||||||||||||||||||||
Specialist visit: $15 copay | |||||||||||||||||||||||||||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||||||||||||||||||||||||||
20% of the cost | |||||||||||||||||||||||||||||
Emergency Care | |||||||||||||||||||||||||||||
$200 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: $15 copay | |||||||||||||||||||||||||||||
Hearing Services | |||||||||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $15 copay | |||||||||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $15 copay | |||||||||||||||||||||||||||||
Home Health Care | |||||||||||||||||||||||||||||
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. | |||||||||||||||||||||||||||||
Outpatient group therapy visit: $15 copay | |||||||||||||||||||||||||||||
Outpatient individual therapy visit: $15 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): $15 copay | |||||||||||||||||||||||||||||
Occupational therapy visit: $15 copay | |||||||||||||||||||||||||||||
Physical therapy and speech and language therapy visit: $15 copay | |||||||||||||||||||||||||||||
Outpatient Substance Abuse | |||||||||||||||||||||||||||||
Group therapy visit: $15 copay | |||||||||||||||||||||||||||||
Individual therapy visit: $15 copay | |||||||||||||||||||||||||||||
Outpatient Surgery | |||||||||||||||||||||||||||||
Ambulatory surgical center: $100 copay | |||||||||||||||||||||||||||||
Outpatient hospital: $15 copay | |||||||||||||||||||||||||||||
Over-the-Counter Items | |||||||||||||||||||||||||||||
Not Covered | |||||||||||||||||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||||||||
Prosthetic devices: 20% of the cost | |||||||||||||||||||||||||||||
Related medical supplies: 20% of the cost | |||||||||||||||||||||||||||||
Renal Dialysis | |||||||||||||||||||||||||||||
$15 copay | |||||||||||||||||||||||||||||
Transportation | |||||||||||||||||||||||||||||
Not covered | |||||||||||||||||||||||||||||
Urgently Needed Care | |||||||||||||||||||||||||||||
$40 copay | |||||||||||||||||||||||||||||
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section for other costs. | |||||||||||||||||||||||||||||
Vision Services | |||||||||||||||||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $15 copay | |||||||||||||||||||||||||||||
Routine eye exam (for up to 1 every year): $15 copay | |||||||||||||||||||||||||||||
Eyeglasses (frames and lenses) (for up to 1 every two years): $15 copay | |||||||||||||||||||||||||||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||||||||||||||||||||||||||
** 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 | |||||||||||||||||||||||||||||
You pay nothing | |||||||||||||||||||||||||||||
Our plan covers many preventive services including:
| |||||||||||||||||||||||||||||
** Inpatient Care ** | |||||||||||||||||||||||||||||
Inpatient Hospital Care | |||||||||||||||||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||||||||||||||||
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. | |||||||||||||||||||||||||||||
Outpatient Prescription Drugs | |||||||||||||||||||||||||||||
For Part B drugs such as chemotherapy drugs1: You pay nothing | |||||||||||||||||||||||||||||
Other Part B drugs1: You pay nothing | |||||||||||||||||||||||||||||
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
| |||||||||||||||||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||||||||||||||||
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. | |||||||||||||||||||||||||||||
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:
| |||||||||||||||||||||||||||||
** Outpatient Care ** | |||||||||||||||||||||||||||||
Diabetes Supplies and Services | |||||||||||||||||||||||||||||
Diabetes monitoring supplies: 20% of the cost | |||||||||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||||||||
Foot Care (podiatry services) | |||||||||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay | |||||||||||||||||||||||||||||
Hearing Services | |||||||||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $15 copay | |||||||||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $15 copay | |||||||||||||||||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||||||||||||||||
Outpatient Substance Abuse | |||||||||||||||||||||||||||||
Group therapy visit: $15 copay | |||||||||||||||||||||||||||||
Individual therapy visit: $15 copay | |||||||||||||||||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||||||||
Prosthetic devices: 20% of the cost | |||||||||||||||||||||||||||||
Related medical supplies: 20% of the cost | |||||||||||||||||||||||||||||
** Additional Benefits ** | |||||||||||||||||||||||||||||
Inpatient Mental Health Care | |||||||||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||||||||||||||||
** Cost ** | |||||||||||||||||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||||||||||||||||
Package 1: Dental Services | |||||||||||||||||||||||||||||
Benefits include:
| |||||||||||||||||||||||||||||
Additional $12 per month. You must keep paying your Medicare Part B premium and your $145.50 monthly plan premium. | |||||||||||||||||||||||||||||
This package does not have a deductible. | |||||||||||||||||||||||||||||
Our plan pays up to $1000 every year. | |||||||||||||||||||||||||||||
** Important Information ** | |||||||||||||||||||||||||||||
Package 1: Dental Services | |||||||||||||||||||||||||||||
Benefits include:
| |||||||||||||||||||||||||||||
Additional $12 per month. You must keep paying your Medicare Part B premium and your $145.50 monthly plan premium. | |||||||||||||||||||||||||||||
This package does not have a deductible. | |||||||||||||||||||||||||||||
Our plan pays up to $1000 every year. |