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2020 Medicare Advantage Plan Benefit Details for the Allwell Medicare (HMO) in LA - H5117-003-0


2020 Medicare Advantage Plan Details
Medicare Plan Name:Allwell Medicare (HMO)
Location:Acadia, Louisiana
Plan ID:H5117 - 003 - 0     Click to see other plans
Member Services:1-855-766-1572 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Email a copy of the Allwell Medicare (HMO) benefit details
— 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
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:4,030 drugsBrowse the Allwell Medicare (HMO) Formulary
This plan has 6 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:
$0.00$10.00$37.00$90.0033%
Number of Drugs per
  Tier:
2799098351133740
Plan's Pharmacy Search:http://allwell.louisianahealthconnect.com/findadoctor
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 004336   PCN: MEDDADV   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Acadia, Louisiana:21 members
Number of Members enrolled in this plan in Louisiana:476 members
Number of Members enrolled in this plan in (H5117 - 003):480 members
Plan’s Summary Star Rating: Insufficient data to rate this plan.
Customer Service Rating: Insufficient data to rate this plan.
Member Experience Rating: Insufficient data to rate this plan.
Drug Cost Accuracy Rating: Does not apply.
— 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: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: Yes
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6,700 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: $40 copay per visit
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $125 copay (authorization required)
• Outpatient x-rays: $40 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $35 copay per visit (always covered)
Inpatient hospital coverage
• $90 per day for days 1 through 10
$0 per day for days 11 through 90 (authorization required)
Outpatient hospital coverage
• $160 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$170 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $250 copay
Rehabilitation services
• Occupational therapy visit: $15 copay (authorization required)
• Physical therapy and speech and language therapy visit: $15 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $199 per day for days 1 through 8
$0 per day for days 9 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay
• Outpatient individual therapy visit with a psychiatrist: $40 copay
• Outpatient group therapy visit: $40 copay
• Outpatient individual therapy visit: $40 copay
Opioid treatment program services
• In-network: $40.00 copay
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay
Dialysis
• 20% coinsurance
Hearing
• Hearing exam: $40 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0-1,580 copay (limits apply)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: 20% coinsurance (limits apply)
• Diagnostic services: $0 copay (limits apply)
• Restorative services: 20% coinsurance (limits apply)
• Endodontics: 30% coinsurance (limits apply)
• Periodontics: 30% coinsurance (limits apply)
• Extractions: 30% coinsurance (limits apply)
• Prosthodontics, other oral/maxillofacial surgery, other services: 30% coinsurance (limits apply)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $40 copay
• 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: Some coverage
• Telehealth: Not covered
• WorldWide emergency: Not covered
• 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): Some coverage
• 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


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