2020 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Optimum Diamond Rewards COPD (HMO C-SNP) | ||||
Location: | Seminole, Florida Click to see other locations | ||||
Plan ID: | H5594 - 031 - 0 Click to see other plans | ||||
Member Services: | 1-866-245-5360 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 Optimum Diamond Rewards COPD (HMO C-SNP) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $4,020 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Chronic Lung Disorders | ||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||
Total Number of Formulary Drugs: | 3,365 drugs | Browse the Optimum Diamond Rewards COPD (HMO C-SNP) Formulary | |||
This plan has 4 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: | $0.00 | $30.00 | $80.00 | 33% | |
• Number of Drugs per Tier: | 1339 | 702 | 641 | 683 | |
Plan's Pharmacy Search: | http://www.youroptimumhealthcare.com | ||||
Plan Offers Mail Order? | Yes | ||||
Medicare Plan Pharmacy Numbers: | BIN: 610011 PCN: OPH See BIN/PCNs for all plans | ||||
Number of Members enrolled in this plan in Seminole, Florida: | less than 10 members | ||||
Number of Members enrolled in this plan in (H5594 - 031): | 245 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 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 Base Premium | Part D Supplemental Premium | |
$0.00 | $0.00 | $0.00 | $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 | $0.00 | $0.00 | $0.00 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $0.00 | $0.00 | $0.00 |
— Plan Health Benefits — | |||||
** Base Plan ** | |||||
Premium | |||||
• Health plan premium: $0 | |||||
• Drug plan premium: $0 | |||||
• You must continue to pay your Part B premium. | |||||
• Part B premium reduction: $50 | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
• Drug plan deductible: No annual deductible | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $5,000 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $30 copay per visit (authorization and referral required) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0-200 copay or 20% coinsurance (authorization and referral required) | |||||
• Lab services: $0-50 copay (authorization and referral required) | |||||
• Diagnostic radiology services (e.g., MRI): $25-200 copay (authorization and referral required) | |||||
• Outpatient x-rays: $0-200 copay (authorization and referral required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $75 copay per visit (always covered) | |||||
• Urgent care: $10 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• $195 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization and referral required) | |||||
Outpatient hospital coverage | |||||
• $200 copay per visit (authorization and referral required) | |||||
Skilled Nursing Facility | |||||
• $0 per day for days 1 through 20 $150 per day for days 21 through 100 (authorization and referral required) | |||||
Preventive care | |||||
• $0 copay (authorization and referral required) | |||||
Ground ambulance | |||||
• $150 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $30 copay (authorization and referral required) | |||||
• Physical therapy and speech and language therapy visit: $30 copay (authorization and referral required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $195 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization and referral required) | |||||
• Outpatient group therapy visit with a psychiatrist: $30 copay (authorization and referral required) | |||||
• Outpatient individual therapy visit with a psychiatrist: $30 copay (authorization and referral required) | |||||
• Outpatient group therapy visit: $30 copay (authorization and referral required) | |||||
• Outpatient individual therapy visit: $30 copay (authorization and referral required) | |||||
Opioid treatment program services | |||||
• In-network: 20% coinsurance or $0.00-$200.00 copay (authorization and referral required) | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required) | |||||
• Diabetes supplies: 0-20% coinsurance per item (authorization required) | |||||
Dialysis | |||||
• 20% coinsurance (authorization and referral required) | |||||
Hearing | |||||
• Hearing exam: $0 copay | |||||
• Fitting/evaluation: $0 copay (limits apply) | |||||
• Hearing aids: $0 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam: $0 copay (limits apply) | |||||
• Cleaning: $0 copay (limits apply) | |||||
• Fluoride treatment: $0 copay (limits apply) | |||||
• Dental x-ray(s): $0 copay (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: $0 copay (limits apply, authorization required) | |||||
• Endodontics: Not covered | |||||
• Periodontics: $0 copay (limits apply, authorization required) | |||||
• Extractions: $0 copay (limits apply, authorization required) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: $0 copay (limits apply) | |||||
• Other: Not covered | |||||
• Contact lenses: $10 copay (limits apply) | |||||
• Eyeglasses (frames and lenses): $10 copay (limits apply) | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: $30 copay (limits apply) | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• $0 copay (limits apply) | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $30 copay (authorization and referral required) | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% coinsurance (authorization required) | |||||
• Other Part B drugs: 20% coinsurance (authorization required) | |||||
Medically-approved non-opioid pain management services | |||||
• Chiropractic services: Not covered | |||||
• Acupuncture: Not covered | |||||
• Therapeutic Massage: Not covered | |||||
• Alternative Therapies: Not covered | |||||
More benefits | |||||
• Transportation services: Some coverage | |||||
• Transportation services for non-emergency care: Plan-approved locations: Not covered | |||||
• Over-the-counter drug benefits: Some coverage | |||||
• Meals for short duration: Some coverage | |||||
• Annual physical exams: Not covered | |||||
• Telehealth: Not covered | |||||
• WorldWide emergency transportation: Some coverage | |||||
• WorldWide emergency coverage: Some coverage | |||||
• WorldWide emergency urgent care: Some coverage | |||||
• Fitness Benefit: Some coverage | |||||
• In-Home Support Services: Not covered | |||||
• Bathroom Safety Devices: Not covered | |||||
• Health Education: Not covered | |||||
• In-Home Safety Assessment: Not covered | |||||
• Personal Emergency Response System (PERS): Not covered | |||||
• Medical Nutrition Therapy (MNT): Not covered | |||||
• Post discharge In-Home Medication Reconciliation: Not covered | |||||
• Re-admission Prevention: Not covered | |||||
• Wigs for Hair Loss Related to Chemotherapy: Not covered | |||||
• Weight Management Programs: Not covered | |||||
• Adult Day Health Services: Not covered | |||||
• Nutritional/Dietary Benefit: Not covered | |||||
• Home-Based Palliative Care: Not covered | |||||
• Support for Caregivers of Enrollees: Not covered | |||||
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered | |||||
• Enhanced Disease Management: Not covered | |||||
• Telemonitoring Services: Not covered | |||||
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage | |||||
• Counseling Services: Not covered |