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2019 Medicare Advantage Plan Benefit Details for the SeniorCare Advantage Platinum (PPO) - H2032-003-0

2019 Medicare Advantage Plan Details
Medicare Plan Name:SeniorCare Advantage Platinum (PPO)
Location:Fayette, Texas
Plan ID:H2032 - 003 - 0     Click to see other plans
Member Services:1-866-334-3141 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Email a copy of the SeniorCare Advantage Platinum (PPO) benefit details
— Medicare Plan Features —
Monthly Premium:$150.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$3,820
Health Plan Type:Local PPO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,500
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:4,283 drugsBrowse the SeniorCare Advantage Platinum (PPO) 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:
Number of Drugs per
Plan's Pharmacy Search:https://portal.swhp.org/#/search
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Fayette, Texas:less than 10 members
Number of Members enrolled in this plan in (H2032 - 003):369 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:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS):100%
Monthly Part D Premium with LIS:$31.00$37.00$43.00$49.00
Total Monthly Premium with LIS (Parts C & D):$126.00$132.00$138.00$144.00
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible $0
Other health plan deductibles? In-Network:  No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $10,000 In and Out-of-network
$3,500 In-network
$10,000 Out-of-network
Optional supplemental benefits No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? In-Network:  No
Inpatient hospital coverage In-Network:  $200 per day for days 1 through 4
$0 per day for days 5 through 90
  Out-of-Network:  25% per day for days 1 through 5
25% per day for days 6 through 90
Outpatient hospital coverage In-Network:  $100 or 20% per visit
  Out-of-Network:  25% per visit
Doctor visits Primary:  In-Network:  $0 copay
  Primary:  Out-of-Network:  25% per visit
  Specialist:  In-Network:  $20 per visit
  Specialist:  Out-of-Network:  25% per visit
Preventive care In-Network:  $0 copay
  Out-of-Network:  25%
Emergency care/Urgent care Emergency:  $90 per visit (always covered)
  Urgent care:  $50 per visit (always covered)
Vision Routine eye exam:  In-Network:  $0 copay
  Routine eye exam:  Out-of-Network:  25%
  Other:  Not covered
  Contact lenses:  In-Network:  $0 copay
  Contact lenses:  Out-of-Network:  25%
  Eyeglasses (frames and lenses):  In-Network:  $0 copay
  Eyeglasses (frames and lenses):  Out-of-Network:  25%
  Eyeglass frames:  In-Network:  $0 copay
  Eyeglass frames:  Out-of-Network:  25%
  Eyeglass lenses:  In-Network:  $0 copay
  Eyeglass lenses:  Out-of-Network:  25%
  Upgrades:  Not covered
Mental health services Inpatient hospital - psychiatric:  In-Network:  $200 per day for days 1 through 5
$0 per day for days 6 through 90
  Inpatient hospital - psychiatric:  Out-of-Network:  25% per day for days 1 through 5
25% per day for days 6 through 90
  Outpatient group therapy visit with a psychiatrist:  In-Network:  $20
  Outpatient group therapy visit with a psychiatrist:  Out-of-Network:  25%
  Outpatient individual therapy visit with a psychiatrist:  In-Network:  $20
  Outpatient individual therapy visit with a psychiatrist:  Out-of-Network:  25%
  Outpatient group therapy visit:  In-Network:  $20
  Outpatient group therapy visit:  Out-of-Network:  25%
  Outpatient individual therapy visit:  In-Network:  $20
  Outpatient individual therapy visit:  Out-of-Network:  25%
Skilled Nursing Facility In-Network:  $0 per day for days 1 through 20
$50 per day for days 21 through 100
  Out-of-Network:  25% per stay
25% per day for days 1 through 20
25% per day for days 21 through 100
Rehabilitation services Occupational therapy visit:  In-Network:  $25
  Occupational therapy visit:  Out-of-Network:  25%
  Physical therapy and speech and language therapy visit:  In-Network:  $25
  Physical therapy and speech and language therapy visit:  Out-of-Network:  25%
Ground ambulance In-Network:  $75
  Out-of-Network:  25%
Transportation Not covered
Foot care (podiatry services) Foot exams and treatment:  In-Network:  $45
  Foot exams and treatment:  Out-of-Network:  25%
  Routine foot care:  Not covered
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:  25% per item
  Prosthetics (e.g., braces, artificial limbs):  In-Network:  20% per item
  Prosthetics (e.g., braces, artificial limbs):  Out-of-Network:  25% per item
  Diabetes supplies:  In-Network:  $0 copay
  Diabetes supplies:  Out-of-Network:  25% per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy:  In-Network:  20%
  Chemotherapy:  Out-of-Network:  25%
  Other Part B drugs:  In-Network:  20%
  Other Part B drugs:  Out-of-Network:  25%
** Benefits Services **
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures:  In-Network:  $0 copay
  Diagnostic tests and procedures:  Out-of-Network:  25%
  Lab services:  In-Network:  $0 copay
  Lab services:  Out-of-Network:  25%
  Diagnostic radiology services (e.g., MRI):  In-Network:  $20-200
  Diagnostic radiology services (e.g., MRI):  Out-of-Network:  25%
  Outpatient x-rays:  In-Network:  $0 copay
  Outpatient x-rays:  Out-of-Network:  25%
Hearing Hearing exam:  In-Network:  $20
  Hearing exam:  Out-of-Network:  25%
  Fitting/evaluation:  In-Network:  $0 copay
  Fitting/evaluation:  Out-of-Network:  25%
  Hearing aids:  In-Network:  $0 copay
  Hearing aids:  Out-of-Network:  25%
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:  Not covered
  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:  In-Network:  $0 copay
  Diagnostic services:  Out-of-Network:  50%
  Restorative services:  Not covered
  Endodontics:  Not covered
  Periodontics:  Not covered
  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%

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