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

2015 iCare Medicare Plan (HMO SNP) in Waupaca, Wisconsin

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the iCare Medicare Plan (HMO SNP) (H2237 - 001) in Waupaca, Wisconsin .

This plan is administered by INDEPENDENT CARE HEALTH PLAN, INC..  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the iCare Medicare Plan (HMO SNP) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
The iCare Medicare Plan (HMO SNP) has a monthly premium of $35.30. That is $423.60 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 $35.30 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 iCare Medicare Plan (HMO SNP) (H2237 - 001) currently has 5,618 members. There are 18 members enrolled in this plan in Waupaca, Wisconsin, and 5,548 members in Wisconsin.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 3.5 stars. The detail CMS plan carrier ratings are as follows:
  • Customer Service Rating not available
  • Member Experience Rating of 4 out of 5 stars
  • Drug Cost Information Accuracy Rating of 3 out of 5 stars
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $320 deductible. So, you are 100% responsible for the first $320 in medication costs. After you have met the deductible, the iCare Medicare Plan (HMO SNP) will share the costs of your medications with you -- see cost-sharing below. $320 is the maximum deductible for 2015. 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 iCare Medicare Plan (HMO SNP) formulary (or drug list). There are 3161 drugs on the iCare Medicare Plan (HMO SNP) formulary. Click here to browse the iCare Medicare Plan (HMO SNP) 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 $320, 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 iCare Medicare Plan (HMO SNP)’s formulary is divided into 3 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 (Generic) contains 2,200 drugs and has a co-payment of $0.00.
  • Tier 2 (Brand) contains 688 drugs and has a co-payment of $0.00.
  • Tier 3 (Specialty Tier) contains 477 drugs and has a co-payment of $0.00.
    •    
Click here to browse the iCare Medicare Plan (HMO SNP) 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 (iCare Medicare Plan (HMO SNP)) offers No Coverage during the Coverage Gap phase.

The iCare Medicare Plan (HMO SNP) 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
$35.3 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical 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.
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
Your yearly limit(s) in this plan:
  • $6 700 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 drugs1:  0% or 20% of the cost
Other Part B drugs1:  0% or 20% of the cost
Our plan does not have a deductible for Part D prescription drugs.
You pay the following:
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 (Generic)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.
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.
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)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.
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.
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 (Specialty Tier)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.
Not OfferedNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Generic)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.
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.
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)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.
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.
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 (Specialty Tier)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.
Not 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.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$35.3 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical 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.
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.
Your yearly limit(s) in this plan:
  • $6 700 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
0% or 20% of the cost
Chiropractic Care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  0% or 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):  0% or 20% of the cost
Diabetes Supplies and Services
Diabetes monitoring supplies:  You pay nothing
Diabetes self-management training:  0% or 20% of the cost
Therapeutic shoes or inserts:  0% or 20% of the cost
Diagnostic Tests, Lab and Radiology Services, and X-Rays
Diagnostic radiology services (such as MRIs CT scans):  0% or 20% of the cost
Diagnostic tests and procedures:  0% or 20% of the cost
Lab services:  0% or 20% of the cost
Outpatient x-rays:  0% or 20% of the cost
Therapeutic radiology services (such as radiation treatment for cancer):  0% or 20% of the cost
Doctor’s Office Visits
Primary care physician visit:  0% or 20% of the cost
Specialist visit:  0% or 20% of the cost
Durable Medical Equipment (wheelchairs, oxygen, etc.)
0% or 20% of the cost
Emergency Care
$0 or $65 copay
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:  0% or 20% of the cost
Hearing Services
Exam to diagnose and treat hearing and balance issues:  0% or 20% of the cost
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.
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
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:  0% or 20% of the cost
Outpatient individual therapy visit:  0% or 20% 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):  0% or 20% of the cost
Occupational therapy visit:  0% or 20% of the cost
Physical therapy and speech and language therapy visit:  0% or 20% of the cost
Outpatient Substance Abuse
Group therapy visit:  0% or 20% of the cost
Individual therapy visit:  0% or 20% of the cost
Outpatient Surgery
Ambulatory surgical center:  0% or 20% of the cost
Outpatient hospital:  0% or 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:  0% or 20% of the cost
Related medical supplies:  0% or 20% of the cost
Renal Dialysis
0% or 20% of the cost
Transportation
Not covered
Urgently Needed Care
0% or 20% of the cost
Vision Services
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  0% or 20% of the cost
Eyeglasses or contact lenses after cataract surgery:  0% or 20% of the cost
** 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.
Annual physical exam:  You pay nothing
** Inpatient Care **
Inpatient Hospital Care
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
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.
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:  0% or 20% of the cost
Other Part B drugs1:  0% or 20% of the cost
Our plan does not have a deductible for Part D prescription drugs.
You pay the following:
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 (Generic)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.
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.
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)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.
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.
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 (Specialty Tier)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.
Not OfferedNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Generic)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.
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.
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)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.
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.
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 (Specialty Tier)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.
Not 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.
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 700 you pay nothing for all drugs.
** Outpatient Care **
Diabetes Supplies and Services
Diabetes monitoring supplies:  You pay nothing
Diabetes self-management training:  0% or 20% of the cost
Therapeutic shoes or inserts:  0% or 20% of the cost
Foot Care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  0% or 20% of the cost
Hearing Services
Exam to diagnose and treat hearing and balance issues:  0% or 20% of the cost
** Outpatient Medical Services and Supplies **
Outpatient Substance Abuse
Group therapy visit:  0% or 20% of the cost
Individual therapy visit:  0% or 20% of the cost
Prosthetic Devices (braces, artificial limbs, etc.)
Prosthetic devices:  0% or 20% of the cost
Related medical supplies:  0% or 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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  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • 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.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • 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.
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