2019 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Advantra Gold (PPO) | ||||
Location: | Marshall, West Virginia Click to see other locations | ||||
Plan ID: | H1608 - 026 - 0 Click to see other plans | ||||
Member Services: | 1-888-365-6052 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 Advantra Gold (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $42.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,820 | ||||
Health Plan Type: | Local PPO | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Additional Rx Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,948 drugs | Browse the Advantra Gold (PPO) 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: | $0.00 | $0.00 | $47.00 | $100.00 | 33% |
• Number of Drugs per Tier: | 388 | 554 | 902 | 1452 | 652 |
Plan's Pharmacy Search: | http://www.coventry-medicare.com/findpharmacy | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Marshall, West Virginia: | 115 members | ||||
Number of Members enrolled in this plan in West Virginia: | 1,822 members | ||||
Number of Members enrolled in this plan in (H1608 - 026): | 1,846 members | ||||
Plan’s Summary Star Rating: | 3.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 3 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 | |
$42.00 | $17.30 | $24.70 | $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: | $0.00 | $6.20 | $12.30 | $18.50 | |
Total Monthly Premium with LIS (Parts C & D): | $17.30 | $23.50 | $29.60 | $35.80 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $10,000 In and Out-of-network $6,700 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Health plan deductible | |||||
• $750 annual deductible | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-Network: No | |||||
Inpatient hospital coverage | |||||
• In-Network: $325 per stay | |||||
Outpatient hospital coverage | |||||
• In-Network: $275 per visit | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Inpatient hospital coverage | |||||
• Out-of-Network: 20% per stay | |||||
Outpatient hospital coverage | |||||
• Out-of-Network: 20% per visit | |||||
Preventive care | |||||
• Out-of-Network: 0-20% | |||||
Doctor visits | |||||
• Primary: In-Network: $5 per visit | |||||
• Primary: Out-of-Network: 20% per visit | |||||
• Specialist: In-Network: $35 per visit | |||||
• Specialist: Out-of-Network: 20% per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $90 per visit (always covered) | |||||
• Urgent care: $50 per visit (always covered) | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 per day for days 1 through 20 $167.50 per day for days 21 through 100 | |||||
Ground ambulance | |||||
• In-Network: $255 | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: 20% per stay | |||||
Ground ambulance | |||||
• Out-of-Network: $255 | |||||
Vision | |||||
• Routine eye exam: In-Network: $0 copay | |||||
• Routine eye exam: Out-of-Network: 20% | |||||
• Other: Not covered | |||||
• Contact lenses: In-Network: $0 copay | |||||
• Contact lenses: Out-of-Network: $0 copay | |||||
• 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: In-Network: $0 copay | |||||
• Upgrades: Out-of-Network: $0 copay | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: In-Network: $176 per day for days 1 through 9 $0 per day for days 10 through 90 | |||||
• Inpatient hospital - psychiatric: Out-of-Network: 30% per stay | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: 45% | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: 45% | |||||
• Outpatient group therapy visit: In-Network: $40 | |||||
• Outpatient group therapy visit: Out-of-Network: 45% | |||||
• Outpatient individual therapy visit: In-Network: $40 | |||||
• Outpatient individual therapy visit: Out-of-Network: 45% | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $35 | |||||
• Occupational therapy visit: Out-of-Network: 20% | |||||
• Physical therapy and speech and language therapy visit: In-Network: $35 | |||||
• Physical therapy and speech and language therapy visit: Out-of-Network: 20% | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $35 | |||||
• Foot exams and treatment: Out-of-Network: 20% | |||||
• Routine foot care: In-Network: $35 | |||||
• Routine foot care: Out-of-Network: 20% | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 30% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 30% per item | |||||
• Diabetes supplies: In-Network: 0-20% per item | |||||
• Diabetes supplies: Out-of-Network: 0-20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 20% | |||||
• Chemotherapy: Out-of-Network: 20% | |||||
• Other Part B drugs: In-Network: 20% | |||||
• Other Part B drugs: Out-of-Network: 20% | |||||
** Benefits Services ** | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: $5 | |||||
• Diagnostic tests and procedures: Out-of-Network: 20% | |||||
• Lab services: In-Network: $5 | |||||
• Lab services: Out-of-Network: 20% | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $225 | |||||
• Diagnostic radiology services (e.g., MRI): Out-of-Network: 20% | |||||
• Outpatient x-rays: In-Network: $20 | |||||
• Outpatient x-rays: Out-of-Network: 20% | |||||
Hearing | |||||
• Hearing exam: In-Network: $35 | |||||
• Hearing exam: Out-of-Network: $0 copay | |||||
• 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: 30% | |||||
• Cleaning: In-Network: $0 copay | |||||
• Cleaning: Out-of-Network: 30% | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): In-Network: $0 copay | |||||
• Dental x-ray(s): Out-of-Network: 30% | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: In-Network: 50% | |||||
• Restorative services: Out-of-Network: 50% | |||||
• Endodontics: In-Network: 50% | |||||
• Endodontics: Out-of-Network: 50% | |||||
• Periodontics: In-Network: 50% | |||||
• Periodontics: Out-of-Network: 50% | |||||
• Extractions: In-Network: 50% | |||||
• Extractions: Out-of-Network: 50% | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: In-Network: 50% | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Out-of-Network: 50% |