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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2015 Gundersen Senior Preferred Value (w/Rx) (HMO) in Fayette, Iowa

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Gundersen Senior Preferred Value (w/Rx) (HMO) (H5262 - 003) in Fayette, Iowa .

This plan is administered by GUNDERSEN HEALTH PLAN.  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Gundersen Senior Preferred Value (w/Rx) (HMO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The Gundersen Senior Preferred Value (w/Rx) (HMO) has a monthly premium of $64.20. That is $770.40 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $64.20 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings
The Gundersen Senior Preferred Value (w/Rx) (HMO) (H5262 - 003) currently has 3,876 members. There are 26 members enrolled in this plan in Fayette, Iowa, and 202 members in Iowa.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 5 stars.   Therefore, this plan qualifies for the 5-star rating Special Enrollment period ( Read more). The detail CMS plan carrier ratings are as follows:
  • Customer Service Rating not available
  • Member Experience Rating of 5 out of 5 stars
  • Drug Cost Information Accuracy Rating of 4 out of 5 stars
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $195 deductible. So, you are 100% responsible for the first $195 in medication costs. After you have met the deductible, the Gundersen Senior Preferred Value (w/Rx) (HMO) will share the costs of your medications with you (see cost-sharing below). The maximum deductible for 2015 is $320, but this plan (Gundersen Senior Preferred Value (w/Rx) (HMO)) has a $195. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the Gundersen Senior Preferred Value (w/Rx) (HMO) formulary (or drug list). There are 3117 drugs on the Gundersen Senior Preferred Value (w/Rx) (HMO) formulary. Click here to browse the Gundersen Senior Preferred Value (w/Rx) (HMO) Formulary.
 
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $195, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The Gundersen Senior Preferred Value (w/Rx) (HMO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 1,098 drugs and has a co-payment of $9.00.
  • Tier 2 (Non-Preferred Generic) contains 796 drugs and has a co-payment of $30.00.
  • Tier 3 (Preferred Brand) contains 444 drugs and has a co-payment of $45.00.
  • Tier 4 (Non-Preferred Brand) contains 732 drugs and has a co-payment of $95.00.
  • Tier 5 (Specialty Tier) contains 493 drugs and has a co-insurance of 28% of the drug cost.
    •  
Click here to browse the Gundersen Senior Preferred Value (w/Rx) (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 35% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 55% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (Gundersen Senior Preferred Value (w/Rx) (HMO)) offers No Coverage during the Coverage Gap phase.

The Gundersen Senior Preferred Value (w/Rx) (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$64.2 per month. In addition you must keep paying your Medicare Part B premium.
$195 per year 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.
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 drugs:  You pay nothing
Other Part B drugs:  You pay nothing
After you pay your yearly 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.
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$9 copay$18 copay$27 copay
Tier 2 (Non-Preferred Generic)$30 copay$60 copay$90 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)28% 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 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:
  • 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
$64.2 per month. In addition you must keep paying your Medicare Part B premium.
$195 per year 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.
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
Not covered
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):  $15 copay
Routine chiropractic visit:  $15 copay
Dental Services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  $35 copay
Diabetes Supplies and Services
Diabetes monitoring supplies:  5-25% of the cost depending on the supply
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):  10% of the cost
Diagnostic tests and procedures:  0-10% of the cost depending on the service
Lab services:  0-10% of the cost depending on the service
Outpatient x-rays:  10% of the cost
Therapeutic radiology services (such as radiation treatment for cancer):  10% of the cost
Doctor’s Office Visits
Primary care physician visit:  $35 copay
Specialist visit:  $35 copay
Durable Medical Equipment (wheelchairs, oxygen, etc.)
20% of the cost
Emergency Care
$0-50 copay depending on the service
If you are admitted to the hospital within 3 days 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:  $35 copay
Hearing Services
Exam to diagnose and treat hearing and balance issues:  You pay nothing
Routine hearing exam (for up to 1 every year):  You pay nothing
Home Health Care
You pay nothing
Mental Health Care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital stay.
  • $500 copay per stay
  • You pay nothing per day for days 91 and beyond
    • Outpatient group therapy visit:  $35 copay
    Outpatient individual therapy visit:  $35 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.  Additional visits are covered but your cost may be more.
    Occupational therapy visit:  $35 copay
    Physical therapy and speech and language therapy visit:  $35 copay
    Outpatient Substance Abuse
    Group therapy visit:  $35 copay
    Individual therapy visit:  $35 copay
    Outpatient Surgery
    Ambulatory surgical center:  $0-75 copay or 0-10% of the cost depending on the service
    Outpatient hospital:  $0-75 copay or 0-10% of the cost depending on the service
    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
    20% of the cost
    Transportation
    Not covered
    Urgently Needed Care
    $35 copay
    Vision Services
    Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $0-35 copay depending on the service
    Routine eye exam:  $0-35 copay depending on the service
    Eyeglasses (frames and lenses):  You pay nothing
    Eyeglass frames:  You pay nothing
    Eyeglass lenses:  You pay nothing
    Eyeglasses or contact lenses after cataract surgery:  You pay nothing
    Our plan pays up to $100 every year for eyeglasses (frames and lenses) eyeglass lenses and eyeglass frames.
    ** 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.
    ** Inpatient Care **
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital stay.
    • $200 copay per day for days 1 through 17
    • You pay nothing per day for days 18 through 90
    • You pay nothing per day for days 91 and beyond
      • 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.
      • You pay nothing per day for days 1 through 20
      • $125 copay per day for days 21 through 100
        • Outpatient Prescription Drugs
        For Part B drugs such as chemotherapy drugs:  You pay nothing
        Other Part B drugs:  You pay nothing
        After you pay your yearly 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.
        Standard Retail Cost-Sharing
        TierOne-month supplyTwo-month supplyThree-month supply
        Tier 1 (Preferred Generic)$9 copay$18 copay$27 copay
        Tier 2 (Non-Preferred Generic)$30 copay$60 copay$90 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)28% 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 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:
        • 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:  5-25% of the cost depending on the supply
        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:  $35 copay
        Hearing Services
        Exam to diagnose and treat hearing and balance issues:  You pay nothing
        Routine hearing exam (for up to 1 every year):  You pay nothing
        ** Outpatient Medical Services and Supplies **
        Outpatient Substance Abuse
        Group therapy visit:  $35 copay
        Individual therapy visit:  $35 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.




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