2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Select (HMO-POS SNP) | ||||
Location: | Faulkner, Arkansas Click to see other locations | ||||
Plan ID: | H1587 - 003 - 0 Click to see other plans | ||||
Member Services: | 1-877-372-1033 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 Select (HMO-POS SNP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $128.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Institutional | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,717 drugs | Browse the Select (HMO-POS SNP) 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: | $2.00 | $8.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 861 | 1012 | 596 | 574 | 674 |
Plan's Pharmacy Search: | http://www.tributehealthplans.com | ||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in Faulkner, Arkansas: | less than 10 members | ||||
Number of Members enrolled in this plan in Arkansas: | less than 10 members | ||||
Number of Members enrolled in this plan in (H1587 - 003): | less than 10 members | ||||
Plan’s Summary Star Rating: | Insufficient data to rate this plan. | ||||
• Customer Service Rating: | Insufficient data to rate this plan. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• 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 | |
$128.00 | $64.30 | $63.70 | $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: | $41.10 | $46.80 | $52.40 | $58.10 | |
Total Monthly Premium with LIS (Parts C & D): | $105.40 | $111.10 | $116.70 | $122.40 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $4,500 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Outpatient hospital coverage | |||||
• In-Network: 20% per visit | |||||
Inpatient hospital coverage | |||||
• In-Network: $110 for days 1 through 8 $0 for days 9 through 90 | |||||
• Out-of-Network: Not Applicable | |||||
Doctor visits | |||||
• Primary: In-Network: $0 copay | |||||
• Specialist: In-Network: $25 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $75 per visit (always covered) | |||||
• Urgent care: $25 per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: 20% | |||||
• Lab services: In-Network: $0 copay | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $75 | |||||
• Outpatient x-rays: In-Network: $15 | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Not covered | |||||
Transportation | |||||
• Not covered | |||||
Mental health services | |||||
• In-Network: $110 for days 1 through 8 $0 for days 9 through 90 | |||||
Ambulance | |||||
• In-Network: $200 | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 for days 1 through 20 $160 for days 21 through 100 | |||||
Mental health services | |||||
• Out-of-Network: Not Applicable | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: Not Applicable | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $25 | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $25 | |||||
• Outpatient group therapy visit: In-Network: $25 | |||||
• Outpatient individual therapy visit: In-Network: $25 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $25 | |||||
• Physical therapy and speech and language therapy visit: In-Network: $25 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $35 | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Diabetes supplies: In-Network: 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 20% | |||||
• Other Part B drugs: In-Network: 20% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: In-Network: 20% | |||||
• Fitting/evaluation: In-Network: $0 copay | |||||
• Fitting/evaluation: Out-of-Network: $0 copay | |||||
• Hearing aids: In-Network: $0 copay | |||||
• Hearing aids: Out-of-Network: $0 copay | |||||
Preventive dental | |||||
• Oral exam: In-Network: $0 copay | |||||
• Oral exam: Out-of-Network: $0 copay | |||||
• Cleaning: In-Network: $0 copay | |||||
• Cleaning: Out-of-Network: $0 copay | |||||
• Fluoride treatment: In-Network: $0 copay | |||||
• Fluoride treatment: Out-of-Network: $0 copay | |||||
• Dental x-ray(s): In-Network: $0 copay | |||||
• Dental x-ray(s): Out-of-Network: $0 copay | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: In-Network: $0 copay | |||||
• Routine eye exam: Out-of-Network: $0 copay | |||||
• Other: Not covered | |||||
• Contact lenses: Not covered | |||||
• Eyeglasses (frames and lenses): In-Network: $0 copay | |||||
• Eyeglasses (frames and lenses): Out-of-Network: $0 copay | |||||
• Eyeglass frames: In-Network: $0 copay | |||||
• Eyeglass frames: Out-of-Network: $0 copay | |||||
• Eyeglass lenses: In-Network: $0 copay | |||||
• Eyeglass lenses: Out-of-Network: $0 copay | |||||
• Upgrades: Not covered |