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2015 Medicare Advantage Plan Benefit Details for the Virginia Premier Health Plan, Inc. (Medicare-Medicaid Plan) - H3067-001-0
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:Virginia Premier Health Plan, Inc. (Medicare-Medicaid Plan)
Location:Powhatan, Virginia     Click to see other locations
Plan ID:H3067 - 001 - 0     Click to see other plans
Member Services:1-800-727-7536 TTY users 1-800-828-1120
— 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 Virginia Premier Health Plan, Inc. (Medicare-Medicaid Plan) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Health Plan Type:Medicare-Medicaid Plan
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,635 drugsBrowse the Virginia Premier Health Plan, Inc. (Medicare-Medicaid Plan) Formulary
This plan has 3 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$0.00$0.00  
• Number of Drugs per
  Tier:		24651170
Plan's Pharmacy Search:http://www.vapremier.com
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Powhatan, Virginia:17 members
Number of Members enrolled in this plan in Virginia:5,575 members
Number of Members enrolled in this plan in (H3067 - 001):5,838 members
Plan’s Summary Star Rating: New plan - No summary rating as of yet.
• Customer Service Rating: New plan - not yet rated.
• Member Experience Rating: New plan - not yet rated.
• Drug Cost Accuracy Rating: New plan - not yet rated.
— 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:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Some services may require a monthly payment amount.
You pay nothing
No. This plan does not have any limits.
In this plan you will pay nothing for services from any provider.
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 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 may get your drugs at network retail pharmacies and mail order pharmacies.
You pay the following:
Standard Retail Cost-Sharing
TierYour cost
Tier 1 (Generic Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 2 (Brand Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 3 (Non-Medicare Rx/OTC Drugs)$0
Standard Mail Order Cost-Sharing
TierYour cost
Tier 1 (Generic Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 2 (Brand Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 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.
You pay the following:
TierYour cost
Tier 1 (Generic Drugs)$0
Tier 2 (Brand Drugs)$0
Tier 3 (Non-Medicare Rx/OTC Drugs)$0
Institutional Care
Case management (long term care):   You pay nothing
Nursing home services:   You pay nothing
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
Some services may require a monthly payment amount.
You pay nothing
No. This plan does not have any limits.
In this plan you will pay nothing for services from any provider.
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 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
Additional Home Care Services
Personal care services:   You pay nothing
Self-directed personal assistance services:   You pay nothing
Additional Services
Case management:   You pay nothing
Respite Care Services (for up to 480 hours every year):   You pay nothing
Adult Day Health Care:   You pay nothing
Personal Emergency/Medication Monitoring System:   You pay nothing
Transition Services:   You pay nothing (there is a limit to how much our plan will pay)
Additional Skilled Nursing Facility Days:   You pay nothing
Community Mental Health Rehabilitative Services:   You pay nothing
Additional Outpatient Mental Health Services:   You pay nothing
Telemedicine Services:   You pay nothing
HIV Testing and Treatment Counseling (Prenatal):   You pay nothing
High Risk Prenatal Services:   You pay nothing
Additional Outpatient Substance Abuse Treatment Services:   You pay nothing
Nutrition Education for Pregnant Women (for up to 3 sessions):   You pay nothing
Health Education for Pregnant Women (for up to 12 sessions):   You pay nothing
Day and Residental Treatment for Pregnant Women:   You pay nothing
Federal Qualified Health Center Services/Rural Health Clinic Services:   You pay nothing
Emergency Custody Orders/Temporary Detention Orders (TDOs):   You pay nothing
Court Ordered Services:   You pay nothing
Service Facililation:   You pay nothing
Ambulance Services
You pay nothing
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  You pay nothing
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:  You pay nothing
Diabetes self-management training:  You pay nothing
Therapeutic shoes or inserts:  You pay nothing
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):  You pay nothing
Diagnostic tests and procedures:  You pay nothing
Lab services:  You pay nothing
Outpatient x-rays:  You pay nothing
Therapeutic radiology services (such as radiation treatment for cancer):  You pay nothing
Doctor’s Office Visits
Primary care physician visit:  You pay nothing
Specialist visit:  You pay nothing
Durable Medical Equipment (wheelchairs, oxygen, etc.)
You pay nothing
Durable Medical Equipment (non-specific e.g. outside home):  You pay nothing
Medical supplies:  You pay nothing
Emergency Care
You pay nothing
Foot Care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
Routine foot care (for up to 1 visit(s) every three months):  You pay nothing
Hearing Services
Exam to diagnose and treat hearing and balance issues:  You pay nothing
Home Health Care
You pay nothing
Additional hours of care:  You pay nothing
Home Health Aide (for up to 32 visits every year):  You pay nothing.
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital stay.
You pay nothing
Outpatient group therapy visit:  You pay nothing
Outpatient individual therapy visit:  You pay nothing
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):  You pay nothing.  Additional visits are covered but your cost may be more.
Respiratory care services:  You pay nothing
Occupational therapy visit:  You pay nothing
Additional Acute and Non-Acute Occupational Therapy:  You pay nothing
Physical therapy and speech and language therapy visit:  You pay nothing
Additional Acute and Non-Acute Physical Therapy:  You pay nothing
Additional Acute and Non-Acute Speech Therapy:  You pay nothing
Outpatient Substance Abuse
Group therapy visit:  You pay nothing
Individual therapy visit:  You pay nothing
Outpatient Surgery
Ambulatory surgical center:  You pay nothing
Outpatient hospital:  You pay nothing
Over-the-Counter Items
Not Covered
Prosthetic Devices (braces, artificial limbs, etc.)
Prosthetic devices:  You pay nothing
Related medical supplies:  You pay nothing
Prosthetics/Orthotics:  You pay nothing
Renal Dialysis
You pay nothing
Transportation
  You pay nothing
Urgently Needed Care
You pay nothing
Vision Services
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  You pay nothing
Routine eye exam (for up to 1 every two years):  You pay nothing
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:
  • 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.
Family planning services:  You pay nothing
Tobacco cessation counseling for pregnant women:  You pay nothing
** Inpatient Care **
Inpatient Hospital Care
Our plan covers an unlimited number of days for an inpatient hospital stay.
You pay nothing
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Institutional Care
Case management (long term care):   You pay nothing
Nursing home services:   You pay nothing
Skilled Nursing Facility (SNF)
Our plan covers an unlimited number of days in a SNF.
You pay nothing
Outpatient Prescription Drugs
For Part B drugs such as chemotherapy drugs1:  You pay nothing
Other Part B drugs1:  You pay nothing
You may get your drugs at network retail pharmacies and mail order pharmacies.
You pay the following:
Standard Retail Cost-Sharing
TierYour cost
Tier 1 (Generic Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 2 (Brand Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 3 (Non-Medicare Rx/OTC Drugs)$0
Standard Mail Order Cost-Sharing
TierYour cost
Tier 1 (Generic Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 copay.
Tier 2 (Brand Drugs)For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.65 copay

For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $6.60 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.
You pay the following:
TierYour cost
Tier 1 (Generic Drugs)$0
Tier 2 (Brand Drugs)$0
Tier 3 (Non-Medicare Rx/OTC Drugs)$0
Additional Home Care Services
Personal care services:   You pay nothing
Self-directed personal assistance services:   You pay nothing
** Outpatient Care **
Diabetes Supplies and Services
Diabetes monitoring supplies:  You pay nothing
Diabetes self-management training:  You pay nothing
Therapeutic shoes or inserts:  You pay nothing
Foot Care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  You pay nothing
Routine foot care (for up to 1 visit(s) every three months):  You pay nothing
Hearing Services
Exam to diagnose and treat hearing and balance issues:  You pay nothing
** Outpatient Medical Services and Supplies **
Outpatient Substance Abuse
Group therapy visit:  You pay nothing
Individual therapy visit:  You pay nothing
Prosthetic Devices (braces, artificial limbs, etc.)
Prosthetic devices:  You pay nothing
Related medical supplies:  You pay nothing
Prosthetics/Orthotics:  You pay nothing
** Additional Benefits **
Inpatient Mental Health Care
For inpatient mental health care see the "Mental Health Care" section.
Institutional Care
Case management (long term care):   You pay nothing
Nursing home services:   You pay nothing




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