2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Good Samaritan Insurance Plan ND (HMO SNP) | ||||
Location: | Dickey, North Dakota Click to see other locations | ||||
Plan ID: | H8967 - 001 - 0 Click to see other plans | ||||
Member Services: | |||||
— 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 Good Samaritan Insurance Plan ND (HMO SNP) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $33.90 (see Plan Premium Details below) | ||||
Annual Deductible: | $405 | ||||
Annual Initial Coverage Limit (ICL): | $3,750 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Institutional | ||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 4,093 drugs | Browse the Good Samaritan Insurance Plan ND (HMO SNP) Formulary | |||
This plan has 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: | cost-sharing data not available. | ||||
• Number of Drugs per Tier: | |||||
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in Dickey, North Dakota: | less than 10 members | ||||
Number of Members enrolled in this plan in North Dakota: | 95 members | ||||
Number of Members enrolled in this plan in (H8967 - 001): | 179 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 Base Premium | Part D Supplemental Premium | |
$33.90 | $0.00 | $33.90 | $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 | $8.50 | $16.90 | $25.40 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $8.50 | $16.90 | $25.40 |
— Plan Health Benefits — |