2016 Medicare Advantage Plan Details | |||||||||||||||||||||||
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Medicare Plan Name: | AAA0 Vantage ZERO (HMO-POS) | ||||||||||||||||||||||
Location: | Avoyelles, Louisiana Click to see other locations | ||||||||||||||||||||||
Plan ID: | H5576 - 017 - 2 Click to see other plans | ||||||||||||||||||||||
Member Services: | 1-866-704-0109 TTY users 1-866-524-5144 | ||||||||||||||||||||||
— 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 AAA0 Vantage ZERO (HMO-POS) benefit details
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— Medicare Plan Features — | |||||||||||||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||||||||||||
Annual Deductible: | $200 | ||||||||||||||||||||||
Annual Initial Coverage Limit (ICL): | $3,310 | ||||||||||||||||||||||
Health Plan Type: | Local HMO | ||||||||||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||||||||||||||||||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||||||||||||||||||||
Total Number of Formulary Drugs: | 3,879 drugs | Browse the AAA0 Vantage ZERO (HMO-POS) 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 | $10.00 | $47.00 | $100.00 | 28% | ||||||||||||||||||
• Number of Drugs per Tier: | 472 | 1822 | 537 | 519 | 529 | ||||||||||||||||||
Plan's Pharmacy Search: | http://www.VantageMedicare.com | ||||||||||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||||||||||
Number of Members enrolled in this plan in Avoyelles, Louisiana: | 59 members | ||||||||||||||||||||||
Number of Members enrolled in this plan in Louisiana: | 8,416 members | ||||||||||||||||||||||
Number of Members enrolled in this plan in (H5576 - 017): | 8,451 members | ||||||||||||||||||||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||||||||||||||||||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||||||||||||||||||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||||||||||||||||||||
• Drug Cost Accuracy Rating: | 3 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 | |||||||||||||||||||
$0.00 | $0.00 | $0.00 | $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: | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||||||||||||
Total Monthly Premium with LIS (Parts C & D): | $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 | |||||||||||||||||||||||
$0 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||
This plan has deductibles for some hospital and medical services and Part D prescription drugs. | |||||||||||||||||||||||
$250 per year for out-of-network services. | |||||||||||||||||||||||
$200 per year for Part D prescription drugs except for drugs listed on Tier 1 Tier 2 and Tier 3 which are excluded from the deductible. | |||||||||||||||||||||||
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: | |||||||||||||||||||||||
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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. | |||||||||||||||||||||||
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. | |||||||||||||||||||||||
** Doctor and Hospital Choice ** | |||||||||||||||||||||||
Acupuncture | |||||||||||||||||||||||
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:
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Other Part B drugs1:
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After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. 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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Preferred 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 $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 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 $4 850 you pay the greater of:
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** Important Information ** | |||||||||||||||||||||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||||||||||||||||||||
$0 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||
This plan has deductibles for some hospital and medical services and Part D prescription drugs. | |||||||||||||||||||||||
$250 per year for out-of-network services. | |||||||||||||||||||||||
$200 per year for Part D prescription drugs except for drugs listed on Tier 1 Tier 2 and Tier 3 which are excluded from the deductible. | |||||||||||||||||||||||
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: | |||||||||||||||||||||||
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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. | |||||||||||||||||||||||
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. | |||||||||||||||||||||||
** Outpatient Care and Services ** | |||||||||||||||||||||||
Acupuncture | |||||||||||||||||||||||
Not covered | |||||||||||||||||||||||
Ambulance | |||||||||||||||||||||||
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Chiropractic care | |||||||||||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
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Dental services | |||||||||||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
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Preventive dental services: | |||||||||||||||||||||||
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Our plan pays up to $100 every six months for preventive dental services from an in-network provider. There is a limit to how much our plan will pay from an out-of-network provider. | |||||||||||||||||||||||
Diabetes supplies and services | |||||||||||||||||||||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting) | |||||||||||||||||||||||
Diagnostic radiology services (such as MRIs CT scans):
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Diagnostic tests and procedures:
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Lab services:
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Outpatient x-rays:
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Therapeutic radiology services (such as radiation treatment for cancer):
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Doctor's office visits | |||||||||||||||||||||||
Primary care physician visit:
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Specialist visit:
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Durable medical equipment (wheelchairs, oxygen, etc.) | |||||||||||||||||||||||
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Emergency care | |||||||||||||||||||||||
$75 copay | |||||||||||||||||||||||
If you are admitted to the hospital within 72 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:
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Hearing services | |||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam:
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Our plan pays up to $40 every year for routine hearing exams from an in-network provider. There is a limit to how much our plan will pay from an out-of-network provider. | |||||||||||||||||||||||
Home health care | |||||||||||||||||||||||
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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:
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Outpatient individual therapy visit:
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Outpatient rehabilitation | |||||||||||||||||||||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
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Occupational therapy visit:
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Physical therapy and speech and language therapy visit:
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Outpatient substance abuse | |||||||||||||||||||||||
Group therapy visit:
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Individual therapy visit:
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Outpatient surgery | |||||||||||||||||||||||
Ambulatory surgical center:
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Outpatient hospital:
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Over-the-counter items | |||||||||||||||||||||||
Not Covered | |||||||||||||||||||||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||
Prosthetic devices:
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Related medical supplies:
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Renal dialysis | |||||||||||||||||||||||
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Transportation | |||||||||||||||||||||||
Not covered | |||||||||||||||||||||||
Urgently needed services | |||||||||||||||||||||||
$65 copay | |||||||||||||||||||||||
Vision services | |||||||||||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
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Routine eye exam:
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Contact lenses:
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Eyeglasses (frames and lenses):
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Eyeglasses or contact lenses after cataract surgery:
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Our plan pays up to $100 every year for contact lenses and eyeglasses (frames and lenses) from an in-network provider. There is a limit to how much our plan will pay from an out-of-network provider. | |||||||||||||||||||||||
** 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 | |||||||||||||||||||||||
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Our plan covers many preventive services including:
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** 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:
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Other Part B drugs1:
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After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. 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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Preferred 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 $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 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 $4 850 you pay the greater of:
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** Outpatient Care ** | |||||||||||||||||||||||
Diabetes supplies and services | |||||||||||||||||||||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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Foot care (podiatry services) | |||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
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Hearing services | |||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam:
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Our plan pays up to $40 every year for routine hearing exams from an in-network provider. There is a limit to how much our plan will pay from an out-of-network provider. | |||||||||||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||||||||||
Outpatient substance abuse | |||||||||||||||||||||||
Group therapy visit:
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Individual therapy visit:
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Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||
Prosthetic devices:
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Related medical supplies:
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** Additional Benefits ** | |||||||||||||||||||||||
Inpatient mental health care | |||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. |