2017 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Amerivantage Dual Coordination (HMO SNP) | ||||
Location: | Rhea, Tennessee Click to see other locations | ||||
Plan ID: | H7200 - 006 - 0 Click to see other plans | ||||
Member Services: | 1-866-805-4589 TTY users 711 | ||||
— 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 Amerivantage Dual Coordination (HMO SNP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 for people who qualify for both Medicare and Medicaid. | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,700 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Dual-Eligible | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,770 drugs | Browse the Amerivantage Dual Coordination (HMO SNP) Formulary | |||
This plan has 6 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: | $0.00 | $4.00 | $40.00 | $93.00 | 25% |
• Number of Drugs per Tier: | 234 | 534 | 896 | 1399 | 635 |
Plan's Pharmacy Search: | http://www.myamerigroup.com/medicare | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Tennessee: | 4,843 members | ||||
Number of Members enrolled in this plan in (H7200 - 006): | 8,787 members | ||||
Plan’s Summary Star Rating: | 3 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 Basic Premium | Part D Supplemental Premium | |
$31.80 | $0.00 | $31.80 | $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: $0 | |||||
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: You pay nothing | |||||
Doctor's office visits:
| |||||
Durable medical equipment (wheelchairs, oxygen, etc.): You pay nothing | |||||
Emergency care: You pay nothing | |||||
Home health care: You pay nothing | |||||
Mental health care: You pay nothing | |||||
Outpatient hospital: You pay nothing | |||||
Renal dialysis: You pay nothing | |||||
** Inpatient Care ** | |||||
Inpatient hospital care: You pay nothing | |||||
Optional Supplemental Benefits?: No | |||||
Skilled Nursing Facility (SNF): You pay nothing | |||||
Prescription Drugs Covered?: Yes | |||||
** Additional Benefits ** | |||||
Optional Supplemental Benefits?: No |