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2018 Medicare Advantage Plan Benefit Details for the HealthPartners Freedom Ultimate with Enhanced Rx (Cost)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2018 Medicare Advantage Plan Details
Medicare Plan Name:HealthPartners Freedom Ultimate with Enhanced Rx (Cost)
Location:Wadena, Minnesota     Click to see other locations
Plan ID:H2462 - 012 - 0     Click to see other plans
Member Services:1-800-233-9645 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
Email a copy of the HealthPartners Freedom Ultimate with Enhanced Rx (Cost) benefit details
— Medicare Plan Features —
Monthly Premium:$375.90 (see Plan Premium Details below)
Annual Rx Deductible:$115
Annual Rx Initial Coverage Limit (ICL):$3,750
Health Plan Type:Cost
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,000
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Rx Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,387 drugsBrowse the HealthPartners Freedom Ultimate with Enhanced Rx (Cost) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$5.00$14.00$47.0050%29%
• Number of Drugs per
  Tier:		305651709947775
Plan's Pharmacy Search:http://healthpartners.com/medicare
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Minnesota:284 members
Number of Members enrolled in this plan in (H2462 - 012):716 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 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
$375.90$0.00$119.90$91.20
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$177.10$185.60$194.10$202.60
Total Monthly Premium with LIS (Parts C & D):$177.10$185.60$194.10$202.60
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible
• $0
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,000 In-network
Optional supplemental benefits
• Yes
Inpatient hospital coverage
• $100 per stay
Outpatient hospital coverage
• $0-50 per visit
Preventive care
• $0 copay
Other health plan deductibles?
• In-Network:  Yes
Doctor visits
• Primary:  $0 copay
• Specialist:  $0 copay
Emergency care/Urgent care
• Emergency:  $50 per visit (always covered)
• Urgent care:  $0 copay
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures:  $0 copay
• Lab services:  $0 copay
• Diagnostic radiology services (e.g., MRI):  $0 copay
• Outpatient x-rays:  $0 copay
Ambulance
• $0 copay
Skilled Nursing Facility
• $0 copay
Mental health services
• $100 per stay
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Mental health services
• Outpatient group therapy visit with a psychiatrist:  $0 copay
• Outpatient individual therapy visit with a psychiatrist:  $0 copay
• Outpatient group therapy visit:  $0 copay
• Outpatient individual therapy visit:  $0 copay
Rehabilitation services
• Occupational therapy visit:  $0 copay
• Physical therapy and speech and language therapy visit:  $0 copay
Foot care (podiatry services)
• Foot exams and treatment:  $0 copay
• Routine foot care:  Not covered
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen):  20% per item
• Prosthetics (e.g., braces, artificial limbs):  20% per item
• Diabetes supplies:  20% per item
Medicare Part B drugs
• Chemotherapy:  0-20%
• Other Part B drugs:  0-20%
** Benefits Services **
Hearing
• Hearing exam:  $0 copay
• Fitting/evaluation:  Not covered
• Hearing aids - inner ear:  Not covered
• Hearing aids - outer ear:  Not covered
• Hearing aids - over the ear:  Not covered
Preventive dental
• Oral exam:  $0 copay
• Cleaning:  $0 copay
• Fluoride treatment:  Not covered
• Dental x-ray(s):  $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:  $0 copay
• Other:  Not covered
• Contact lenses:  Not covered
• Eyeglasses (frames and lenses):  Not covered
• Eyeglass frames:  Not covered
• Eyeglass lenses:  Not covered
• Upgrades:  Not covered
** Optional Supplemental Benefits **
Package #1
• Comprehensive dental services, Preventive dental services
• Monthly Premium:  $41.50
• Deductible:  $50.00




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