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2015 Medicare Advantage Plan Benefit Details for the Advocare Essence Rx (HMO-POS) - H5211-002-0
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:Advocare Essence Rx (HMO-POS)
Location:Waupaca, Wisconsin     Click to see other locations
Plan ID:H5211 - 002 - 0     Click to see other plans
Member Services:1-877-998-0998 TTY users 1-877-727-2232
— 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 Advocare Essence Rx (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$77.00 (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):$3,400
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:5,150 drugsBrowse the Advocare Essence Rx (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:		$6.00$19.00$45.00$95.0033%
• Number of Drugs per
  Tier:		17320937211836316
Plan's Pharmacy Search:http://www.securityhealth.org/advocarepharmacies
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Waupaca, Wisconsin:37 members
Number of Members enrolled in this plan in Wisconsin:17,325 members
Number of Members enrolled in this plan in (H5211 - 002):17,359 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
$77.00$34.60$42.40$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:$7.10$15.90$24.70$33.60
Total Monthly Premium with LIS (Parts C & D):$41.70$50.50$59.30$68.20
— Plan Health Benefits —
** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$77 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$1 500 per year for out-of-network services.
This plan does not have a deductible for Part D prescription drugs.
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:
  • $3 400 for services you receive from in-network providers.
  • $3 500 for services you receive from out-of-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.
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 drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost after you pay your deductible
Other Part B drugs:
  • In-network:  0-20% of the cost depending on the drug
  • Out-of-network:  20% of the cost after you pay your deductible
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 supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$12 copay$18 copay
Tier 2 (Non-Preferred Generic)$19 copay$38 copay$57 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
Tier 6 (Vaccines)$0Not OfferedNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$6 copay$12 copay$18 copay
Tier 2 (Non-Preferred Generic)$19 copay$38 copay$57 copay
Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the costNot OfferedNot 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 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.

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
$77 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$1 500 per year for out-of-network services.
This plan does not have a deductible for Part D prescription drugs.
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:
  • $3 400 for services you receive from in-network providers.
  • $3 500 for services you receive from out-of-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.
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
  • In-network:  $200 copay
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 after you pay your deductible
Routine chiropractic visit:
  • In-network:  $20 copay
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
Diabetes Supplies and Services
Diabetes monitoring supplies:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Therapeutic shoes or inserts:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):
  • In-network:  $200 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Diagnostic tests and procedures:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Lab services:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Outpatient x-rays:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Doctor’s Office Visits
Primary care physician visit:
  • In-network:  $20 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Specialist visit:
  • In-network:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Durable Medical Equipment (wheelchairs, oxygen, etc.)
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost after you pay your deductible
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:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Hearing Services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Routine hearing exam:
  • In-network:  $50 copay. You are covered for up to 1 every year.
  • Out-of-network:  20% of the cost after you pay your deductible.  There may be a limit to how often these services are covered.
Home Health Care
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital stay.
  • In-network:  
    • $300 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:  
        • $1 500 deductible for inpatient hospital and mental health care
        • 20% of the cost per stay
          • Outpatient group therapy visit:
          • In-network:  $40 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient individual therapy visit:
          • In-network:  $40 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          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 after you pay your deductible
          Occupational therapy visit:
          • In-network:  $20 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Physical therapy and speech and language therapy visit:
          • In-network:  $20 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient Substance Abuse
          Group therapy visit:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Individual therapy visit:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient Surgery
          Ambulatory surgical center:
          • In-network:  $0-150 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient hospital:
          • In-network:  $0-400 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Over-the-Counter Items
          Not Covered
          Prosthetic Devices (braces, artificial limbs, etc.)
          Prosthetic devices:
          • In-network:  20% of the cost
          • Out-of-network:  20% of the cost after you pay your deductible
          Related medical supplies:
          • In-network:  0-20% of the cost depending on the supply
          • Out-of-network:  20% of the cost after you pay your deductible
          Renal Dialysis
          • In-network:  You pay nothing
          Transportation
          Not covered
          Urgently Needed Care
          $20-50 copay depending on the service
          Vision Services
          Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Routine eye exam:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Eyeglasses or contact lenses after cataract surgery:
          • In-network:  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
          • In-network:  You pay nothing
          • Out-of-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:  
            • $300 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:  
                • $1 500 deductible for inpatient hospital and mental health care
                • 20% of the cost per 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.
                  • In-network:  
                      • $0 copay per day for days 1 through 6
                      • $40 copay per day for days 7 through 45
                      • $0 copay per day for days 46 through 100
                      • Out-of-network:  
                        • $1 500 deductible
                        • 20% of the cost per stay
                          • Outpatient Prescription Drugs
                          For Part B drugs such as chemotherapy drugs:
                          • In-network:  20% of the cost
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Other Part B drugs:
                          • In-network:  0-20% of the cost depending on the drug
                          • Out-of-network:  20% of the cost after you pay your deductible
                          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 supplyTwo-month supplyThree-month supply
                          Tier 1 (Preferred Generic)$6 copay$12 copay$18 copay
                          Tier 2 (Non-Preferred Generic)$19 copay$38 copay$57 copay
                          Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
                          Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
                          Tier 5 (Specialty Tier)33% of the costNot OfferedNot Offered
                          Tier 6 (Vaccines)$0Not OfferedNot Offered
                          Standard Mail Order Cost-Sharing
                          TierOne-month supplyTwo-month supplyThree-month supply
                          Tier 1 (Preferred Generic)$6 copay$12 copay$18 copay
                          Tier 2 (Non-Preferred Generic)$19 copay$38 copay$57 copay
                          Tier 3 (Preferred Brand)$45 copay$90 copay$135 copay
                          Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
                          Tier 5 (Specialty Tier)33% of the costNot OfferedNot 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 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.

                          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:  You pay nothing
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Diabetes self-management training:
                          • In-network:  You pay nothing
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Therapeutic shoes or inserts:
                          • In-network:  You pay nothing
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Foot Care (podiatry services)
                          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                          • In-network:  $50 copay
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Hearing Services
                          Exam to diagnose and treat hearing and balance issues:
                          • In-network:  $50 copay
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Routine hearing exam:
                          • In-network:  $50 copay. You are covered for up to 1 every year.
                          • Out-of-network:  20% of the cost after you pay your deductible.  There may be a limit to how often these services are covered.
                          ** Outpatient Medical Services and Supplies **
                          Outpatient Substance Abuse
                          Group therapy visit:
                          • In-network:  $0-50 copay depending on the service
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Individual therapy visit:
                          • In-network:  $0-50 copay depending on the service
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Prosthetic Devices (braces, artificial limbs, etc.)
                          Prosthetic devices:
                          • In-network:  20% of the cost
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Related medical supplies:
                          • In-network:  0-20% of the cost depending on the supply
                          • Out-of-network:  20% of the cost after you pay your deductible
                          ** Additional Benefits **
                          Inpatient Mental Health Care
                          For inpatient mental health care see the "Mental Health Care" section.




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                          • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
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                          • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
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                          • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
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                          • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
                          • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
                          • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
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                          • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.
                          .