2017 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | CareSource Advantage Zero Premium (HMO) | ||||
Location: | Mercer, Kentucky Click to see other locations | ||||
Plan ID: | H1493 - 004 - 0 Click to see other plans | ||||
Member Services: | 1-800-833-3239 TTY users 1-800-648-6056 | ||||
— 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 CareSource Advantage Zero Premium (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $250 (Tier 1 and 2 excluded from the Deductible.) | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,700 | ||||
Health Plan Type: | Local HMO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,195 drugs | Browse the CareSource Advantage Zero Premium (HMO) Formulary | |||
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $6.00 | $15.00 | $47.00 | $100.00 | 28% |
• Number of Drugs per Tier: | 414 | 1560 | 275 | 374 | 572 |
Plan's Pharmacy Search: | http://caresource.com/ | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Mercer, Kentucky: | less than 10 members | ||||
Number of Members enrolled in this plan in Kentucky: | 1 members | ||||
Number of Members enrolled in this plan in (H1493 - 004): | 118 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 — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic 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 — | |||||
** General Plan Information ** | |||||
Choice of Doctors?: Plan Doctors for Most Services | |||||
** Cost ** | |||||
Monthly Health Plan Premium: $0.00 | |||||
Monthly Drug Plan Premium: $0.00 | |||||
Health Plan Deductible: $400 In-network | |||||
Other Health Plan Deductibles?: No | |||||
Maximum Out-of-Pocket Enrollee Responsibility (does not include prescription drugs) : $6,700 In-network | |||||
** Extra Benefits ** | |||||
Prescription Drugs Covered?: Yes | |||||
Optional Supplemental Benefits?: No | |||||
** Outpatient Care and Services ** | |||||
Ambulance: $275 | |||||
Doctor's office visits:
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Durable medical equipment (wheelchairs, oxygen, etc.): 20% per item | |||||
Emergency care: $75 per visit (always covered) | |||||
Home health care: You pay nothing | |||||
Mental health care:
| |||||
Outpatient hospital: 20% per visit | |||||
Renal dialysis: 20% per visit | |||||
** Inpatient Care ** | |||||
Inpatient hospital care:
| |||||
Optional Supplemental Benefits?: No | |||||
Skilled Nursing Facility (SNF):
| |||||
Prescription Drugs Covered?: Yes | |||||
** Additional Benefits ** | |||||
Optional Supplemental Benefits?: No |